LAKESIDE REHABILITATION AND CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the resident's free of physical and chemical restraints that were not medically indicated for 1 of 15 residents (Resident #1) observed for physical restraints in that; The facility failed to ensure Resident #1 had a physician order, consent and evaluation for a chest restraint used for positioning and mobility. This failure could place residents at risk of injuries or entrapment. Findings include: Review of Resident #1's admission record, dated 10/09/25, revealed he was a 25 -year-old male admitted on [DATE] with the following diagnoses: spastic quadriplegic cerebral palsy (a type of cerebral palsy that affects all four limbs, causing stiffness, tightness, and difficulty with movement) and a history of falling. Review of Resident #1's quarterly MDS assessment, dated 08/29/25 revealed staff performed an assessment for mental status and Resident #1's cognitive skills for daily decision making were moderately impaired. The MDS further revealed Resident #1 required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with positioning, mobility and transfers. The MDS revealed Resident #1 did no use a trunk restraint, limb restraint, chair that prevents rising or other restraint in his chair. Record review of Resident #1's comprehensive care plan, undated, revealed he did not have a care plan for restraints or a care plan for the chest harness used. The care plan further revealed Resident #1 was totally dependent on staff for activities of daily living and transfers. Record review of Resident #1's order summary report dated 10/09/25 revealed no physician order for a chest harness or chest restraint. Record review Resident #1's medical record revealed no consent or completed evaluation of need for a chest harness or chest restraint. Record review of a facility document titled, Social Services Assessment for Resident #1, dated 06/17/25, revealed: Section B - Physical Functional Status:3. Are restraints currently being used with this resident?Answer - yes3b. If yes, describe type and reason for restraint use:Answer - [Resident #1] utilizes a stability device across his wheelchair to prevent slipping out of his chair. Observation on 10/09/25 at 10:33 AM revealed Resident #1 sitting up in his wheelchair in the TV area. Resident #1 was noted to have a specialized chair and a chest harness was noted across Resident #1's chest and strapped to the back of the chair. A buckle was noted on the chest harness and was currently buckled. During an interview on 10/09/25 at 4:20 PM, LVN A stated Resident #1 used the chest harness to help prevent him from falling. LVN A stated she did not think Resident #1 could remove the chest harness by himself. LVN A stated Resident #1 would be able to answer yes or no questions from the surveyor. During an observation and interview on 10/09/25 at 4:21 PM, Resident #1 was sitting in his wheelchair in front of the nurse's station by LVN A. Resident #1 was asked if staff put the chest harness on him daily and Resident #1 nodded yes. Resident #1 was asked if he could unbuckle the chest harness and Resident #1 shook his head no. During an interview on 10/09/25 at 4:23 PM, the ADM and the DON stated the chest harness on Resident #1 was used as a position changing device. The ADM stated the chest harness was made specifically for Resident #1's chair and it was his understanding that the chest harness was not a restraint. The ADM stated Resident #1 would fall if he did not have the chest harness due to Resident #1's spasticity (when muscles become abnormally stiff and tight, leading to involuntary muscle spasms, jerking, and difficulty with movement). Attempted phone interview on 10/09/25 at 5:20 PM with the physician for Resident #1 revealed no answer. During an interview on 10/09/25 at 5:25 PM, the DON stated all of the nursing staff were responsible for ensuring residents had a physician order for a position changing device. The DON stated he was ultimately responsible if a resident had a restraint. The DON stated Resident #1 did not have a restraint, he had a position changing device. The DON stated if a resident had any type of restraint, it would need a risk assessment, consent and physician order. The DON stated the residents would also need physician orders to check placement and the skin around the restraint. The DON stated Resident #1 would fall if the chest harness was not used for him. During an interview on 10/09/25 at 5:37 PM, the ADM stated he was ultimately responsible for ensuring residents had a physician order, consent and assessment for any restraint used. The ADM stated the facility did not consider the chest harness for Resident #1 to be a restraint. The ADM stated Resident #1 used the chest harness as a position changing device. The ADM stated a potential negative outcome to the residents if they did not have a physician order for a restraint was a risk of being physically harmed because it was a device. Record review of the facility's policy titled, Use of Restraints with a revised date of April 2017, reflected the following: Policy Statement: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation:1. Physical Restraints are defined as any manual method or physical mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition , and this restricts his/her typical ability to change position or place, that device is considered a restraint.9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:a. The specific reason for the restraint (as it relates to the resident's medical symptoms);b. How the restraint will be used to benefit the resident's medical symptom; andc. The type of restraint, and period of time for the use of the restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure dignity was maintained for 1 of 14 residents (Resident #1) reviewed for respect and dignity. The Administrator failed to respect and ensure Resident #1's dignity when he made an obscene hand gesture towards the resident. This failure placed residents at risk for loss of self-worth and emotional distress and failed to ensure the residents' right to be treated with dignity and respect.Findings included: Record review of Resident #1's Transfer/Discharge Report dated 08/27/25 reflected the [AGE] year-old male resident was re-admitted to the facility on [DATE] with a diagnosis of paraplegia. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was admitted to the facility on [DATE]. He was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated cognitively intact). In an interview on 08/27/25 at 8:18 AM, the SW stated she began her employment at the facility in April 2025. She stated there was staff turnover around May 2025. She stated on 05/08/25 she was asked to conduct Safe Surveys with the residents due to complaints about the Administrator's inappropriate comments to staff and the residents. She stated the Administrator was suspended 2-3 days while the investigation was conducted by the RNC, but she did not know the specifics. She stated none of the residents she interviewed reported any complaints or concerns regarding the Administrator. In a telephone interview on 08/27/25 at 8:48 AM, the former DON stated Resident #1 informed her the Administrator made an obscene gesture, the middle finger which the resident found to be disrespectful. She stated the obscene gesture and unprofessional comments the Administrator had made to staff and residents to the RDO. She stated about a week after she made the comments the RNC came to investigate. She stated the RNC suspended the Administrator a few days while she conducted the investigation. She stated the RNC did not report the allegations to the State Agency but should have been as required. The former DON stated Resident #1 was not interviewed by the RNC about the specific allegations regarding the Administrator and she believed. She stated the RNC terminated her employment and brought the Administrator back the day after her termination. She stated she believes her termination was retaliation for reporting the Administrator. Record review of the former DON's Disciplinary Action Form dated 05/12/25 revealed, a statement from the former DON, which read, in part, this is done in retaliation to me reporting Administrator, who not only verbally abuse - but also emotionally abused a resident. The form was signed by the former DON and RNC on 05/12/25. Record review of an email from the former DON to the RDO dated 04/30/25 at 7:42 PM which read, in part, I am writing to you today to inform you about something that has been going on in the facility since the Administrator has arrived to the facility. Today a resident by the name of Resident #1 came into my office to explain to me that he felt like he was being mistreated by the administrator. This is not the first time that the resident has voiced to me ill treatment from the Administrator. In this particular instance, the resident came into my office and informed me that yesterday (04/29/25) while he was in the smoking room, the Administrator came up to him in front of an employee and stated Hey Resident #1, I have something for you. At that time the Administrator went into his pocket and pulled out his fist and flipped him off. The resident then informed me that former Housekeeper A saw him do this. He said he felt like this was inappropriate and at no time have he and the Administrator had a relationship in which they would joke around with each other the resident went on to tell me that he and the Administrator do not have a relationship in which it would ever be ok to do those things. In a telephone interview on 08/27/25 at 9:27 AM, the RNC stated the RDO received an email from the former DON alleging the Administrator had verbally abused Resident #1. She stated she suspended the Administrator 3 days, maybe more, while she interviewed the staff who all denied the allegations. She stated she did not interview Resident #1 about the allegations, but she had the SW conduct Safe Surveys and none of the residents, including Resident #1 reported any issues. She stated the decision was made to treat the incident internally and not report the incident to the State Agency. When the RNC was asked by the Investigator if the facility policy was followed regarding reporting, she stated that's a tricky one because everyone denied the allegations. Record review of the RNC's investigation conducted on 05/08/25 reflected a copy of the email from the former DON to the RDO dated 04/30/25, the Safe Surveys conducted by the SW with the residents on 05/08/25 and the RDO's interviews with staff: - The Administrator denied the allegation. - An interview with former Housekeeper B on 5/8/2025 at 2:49 PM reflected, Have you ever been witness to any administrative staff saying or doing anything to a resident/or other staff member that would be considered out of a professional role? If so, can you tell me when, by whom and directed towards who? I was in the smoke room at the same time with Resident #1 when the Administrator came in and spoke with all of us and then told Resident #1, I have something for you and then the Administrator pulled out his hand and flipped Resident #1 off but then tell him he was just playing and then Resident #1 said boy and then they both laughed. Did you report that to anyone? No ma'am I did not I thought they were just playing. - The SW conducted Safe Surveys with 46 residents on 05/08/25, the questions included general questions regarding which included if they were comfortable asking for assistance, if staff treated them with dignity and respect, if they felt safe in the facility, if they felt comfortable telling staff about concerns, if staff had ever physically harmed them and if staff member ever yelled or cursed at them. Resident #1 responded he did not feel comfortable asking staff for assistance; however, there was no further documentation regarding his response. Resident #1 reported no other issues during the Safe Survey. Record review of the Grievances from May 2025 - August 2025 reflected no grievances regarding Resident #1 or the Administrator. In an interview on 08/27/25 at 9:55 AM, the Administrator stated he was informed by the RNC of the allegations made against him and he was interviewed by the RNC. He stated he denied all the allegations in the former DON's email. He stated he did not want to discuss specifics because of legal action taken by the former DON and ADON. He stated he was suspended for an abuse allegation and was off 3 to 4 days pending the outcome of the investigation. He stated he was not privy to whether the incident was reported to the State Agency. He said the facility follows the Provider Letter as the policy regarding investigating and reporting abuse allegations. He stated he feels Corporate probably looked at the Provider Letter and made decisions based on it. He stated the facility had no other policy besides the Provider Letter. Record review of the Long-Term Care Regulation Provider Letter Number: PL 2024-14 dated 08/29/25 reflected a nursing facility must report to the State Agency Abuse, in accordance with applicable state and federal requirements. Allegations of abuse were to be reported immediately, but no later than two hours after the incident occurs or is suspected. During an observation on 08/27/25 at 11:14 AM, Resident #1 was asleep in bed with the covers over his head. In a telephone interview on 08/27/25 at 12:12 PM, former Housekeeper A stated she and former Housekeeper B were on a break out smoking and Resident #1 was outside with them. She stated she heard the Administrator tell Resident #1 he had something for him, but she did not see the hand gesture. She stated former Housekeeper B heard and saw the gesture. She stated Resident #1 said he thought the Administrator was taking things too far with the hand gesture. She stated the RNC came to the facility to investigate the allegations, but the RNC did not interview her. She stated former Housekeeper B did report the incident to the RNC because former Housekeeper B was bothered by the incident. In a telephone interview on 08/27/25 at 12:36 PM, former Housekeeper B stated she was outside on a smoke break with former Housekeeper A and Resident #1. She stated she hear the Administrator tell Resident #1 I have something for you, and then she saw the Administrator take his hand out of his pocket and flip Resident #1 off. She stated Resident #1 told the Administrator Don't disrespect me like that. She stated the Administrator told Resident #1 he was just playing. She stated the Administrator went back inside and Resident #1 said to her, did you see what he did that isn't cool. She stated she reported the incident to the DON and the ADON. She stated she was interviewed by the RNC and told the RNC about the incident. She stated she told the RNC the Administrator was making her and Resident #1 uncomfortable with his inappropriate comments. She stated after she reported the incident the Administrator began kissing Resident #1's ass. In a telephone interview on 08/27/25 at 12:50 PM, former ADON said the former DON sent corporate an email regarding the allegation about the Administrator. She stated Resident #1 came into the office with the former DON to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, the Administrator went into his pocket, pulled out his hand, and then flipped the resident off. She stated the RNC came to conduct the investigation but did not even interview Resident #1. She stated the Safe Surveys were done but were not specific to allegations regarding the Administrator. She stated, after the DON was terminated, she believed the allegations were not really investigated by the RNC, so she sent the RDO an email and he responded to her email and stated she was terminated. Record review of the email exchange between the former ADON and the RDO dated 05/15/25 reflected at 8:28 AM the former ADON sent the RDO an email entitled URGENT CRITICAL MATTER which read in part, around about on April 29th when Resident #1 came into the office with the DON and myself to express to us that while he was in the smoke room, the Administrator came in and told him he had something for him, went into his pocket, pulled out his hand, and then flipped him off. Resident #1 asked the DON to make the Administrator stop talking to him because he did not like him and they did not have a relationship in which it was considered ok to do those things to him. During the RNC's investigation it was brought to my attention that she failed to talk to half the nursing staff (she only spoke with the staff that worked that date), and she never spoke with the resident (Resident #1) with the compliant. At 2:18 PM the RDO responded via email, thank you for bringing this to our attention. I appreciate your concern, and for sharing these details, I am placing you on a temporary suspension while we conduct an investigation into this matter. Please do not consider this a punitive action but a necessary step in order to conduct a full and fair investigation into these allegations. In an interview on 08/27/25 at 1:54 PM, the SW stated, regarding the Safe Surveys dated 05/08/25, she did not ask the residents anything specifically about the Administrator. She stated she asked the residents the general questions on the Safe Survey sheet. In an interview and observation on 08/27/25 at 2:30 PM, Resident #1 was in bed in his room, his roommate was out of the room. He stated he was reluctant to speak to the investigator because the incident had been a long time ago, the Administrator apologized, and everything had been fine since. He stated the Administrator did flip him off when he was in the smoking area, and he just looked at the Administrator and did not respond. Resident #1 stated he was fine, and the incident did not affect him negatively. He stated he did not feel intimidated and had not changed his usual patterns in the facility. He stated he likes to stay up late and sleep late and staff accommodate him and let him do the things he wants to do. In a telephone interview on 08/27/25 at 4:05 PM, the RNC stated Housekeeper B told her about the incident with Resident #1 and the Administrator's hand gesture. She stated she did not speak to Resident #1, but he did not report any issues in the Safe Survey. She stated she did not feel it was a reportable incident of abuse because a lot of time had passed (from 04/29/25 - 05/08/25 ten days). She stated the Administrator was verbally counseled regarding the incident, but it was not a written counseling. She stated in response to the incident and residents' responses on the Safe Surveys dated 05/08/25 an in-service on abuse was conducted, but no further investigations were conducted into any of the allegations on the surveys. In a telephone interview on 08/27/25 at 4:09 PM, the RDO stated he over saw 20 facility's and it had been sometime since the incidents so he might not remember all the details or the timeline. He stated the former DON and ADON's complaints about theAdministrator were emailed to him. He stated the RNC was tasked with investigating the DON's complaint. He stated he could not remember the details of the complaint or the timeline to say if the allegation was reportable. He stated he believed the RNC shared the results of her investigation with him. He stated the finger gesture was bordering on reportable but sounded like it was reportable. He stated he was not aware Resident #1 was not interviewed by the RNC. He stated he was not sure what action was taken regarding the incident, but he thinks the Administrator was counseled. In a confidential telephone interview it was stated they heard about the Administrator flipping Resident #1 off. They stated they heard Resident #1 tell the former ADON, I don't know why he would feel comfortable doing that with me because we don't have a relationship like that. During the exit conference on 08/28/25 at 1:04 PM the Administrator stated he disagrees with findings. He adamantly denied the allegation he flipped Resident #1 off. He stated he was not counseled by the RNC and all she said was, if you did it don't do it again. Record review of the facility's Resident Rights policy dated December 2016 reflected employees shall treat all residents with kindness respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 2 of 5 (Resident #1 and Resident #2) reviewed for neglect. <BR/>The ADM and DON failed to report Resident #1 fall that resulted in the resident sustaining 2 head laceration and being transported to a local emergency room. <BR/>The ADM and DON failed to report Resident #2 fall that resulted in a Compression fracture of lumbar vertebra .<BR/>These failures could place residents at risk of allegations not being reported and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators.<BR/>Findings Included: <BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling).<BR/>Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/> Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #1's care plane revealed the following:<BR/>[DATE] <BR/>Problem:<BR/>Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand.<BR/>Intervention:<BR/>Anticipate and meet Resident #1 needs<BR/>Review past falls and attempt to determine cause of the falls.<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #1 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] 9:55 AM<BR/>Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C<BR/>Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. <BR/>Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. <BR/>Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. <BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck.<BR/>Physical Exam<BR/>Constitutional: She is in acute distress<BR/>Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound.<BR/>Neck: Patient is in a c-collar<BR/>Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed.<BR/>Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness <BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. <BR/>Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #2's care plan revealed the following:<BR/>[DATE]<BR/>Problem:<BR/>Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Resident #2encouraged to utilize call light and wait for assistance.<BR/>Intervention:<BR/>o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE]<BR/>Problem:<BR/>The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 states she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE]<BR/>Intervention:<BR/>[DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. <BR/>Date Initiated: [DATE]<BR/>Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not<BR/>want to go to the ER states, I barely hit my head. Date Initiated: [DATE]<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #2 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] <BR/>Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D<BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>Chief Complaint: Fall<BR/>Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]).<BR/>Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back.<BR/>During a confidential interview, it was stated that the CNA was suspended on [DATE]. They stated that the incident was not reported regarding Resident #1 until [DATE] because the ADM said she wanted people to shut up about it. They stated the incident/fall with Resident #1 and with Resident #2 was not reported. They stated that the person responsible for reporting was the ADM. She said the ADM was the abuse coordinator. After Resident #1 fell out of her wheelchair, the Regional Clinical Director completed an in-service about wheelchair safety. They stated they had been trained to report unwitnessed falls, misappropriation of property, injuries, and anything dealing with abuse to the state entity. They said not reporting makes the facility appear to be hiding something. They said not reporting and not investigating incidents could result in a decrease in the level of care. They said the injury could progress into something worse if they do not thoroughly look into it. They said it could make the residents involved and other residents feel unsafe if they were cognitive enough to know the facility did not address it. They stated they did not know much about Resident #2's fall but that it had happened at night, and it was also not reported. <BR/>During a confidential interview, it was stated It was their understanding that the only reason Resident #2 incident/fall was reported was because there had been an uproar made. The uproar was staff talking about it and questioning the death of the resident and why the incident with Resident #1 was not reported. They stated they had expressed to the DON that something was not right. They indicated that the DON had reassured them that everything was ok, that Resident #1 was checked at the hospital, and that the facility had done everything they were supposed to do. They said because of the response they were getting, it made them not want to talk about it anymore. They stated that due to the staff talking about Resident #1, the ADM would speak with them separately and tell them the gossiping needed to stop. They said that during their turn with the ADM, they expressed that they felt something was not right with the incident with Resident #1. They stated the Regional Clinical Director told them that because of the staff talking and not letting it go, the facility had to self-report the incident with Resident #1's fall. They stated that once it was reported, they were relieved. They stated regarding Resident #2 fall, she was told that she went to the hospital, and during updates, we were told that she had broken her back. They said they did not know if Resident #2 fall/injury had been reported. They stated that failure to report and investigate could make the residents scared and unsure of their care. They stated the abuse coordinator was the ADM. They stated they understood that the ADM had to be the one to call the incidents in. They said they do not know why Resident #1's incident was not called in, nor Resident #2. <BR/>During a confidential interview, they stated they asked the DON if Resident #1's fall/incident had been reported. The DON told them it had not been reported. They said they were confused, especially since CNA A had been suspended, confirmed, and terminated. They stated they knew they had a 2-hour window to report it to the state. They said they knew that if there was no injury, they had 24 hours. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They stated they asked the DON if Resident #2's fall had been reported, and again, they were told it had not been reported. They said they were told by the ADM that the incident with Resident #1 and Resident #2 was not reported because they knew what happened in both instances. They stated that they were concerned that both falls should have been reported. They said they reported their concerns about the ADM not reporting the falls and other concerns with how the staff were treated and were told that her supervisor would address it. They said many staff had concerns with fear of retaliation from the ADM, which was why they do not want to report or say anything. <BR/>During a Confidential Interview, it was stated that they heard CNA B yell stop. Before that, they heard Resident #1 yelling. They said Resident #1 yells, but this particular day ([DATE]), the yell was elongated. Resident #1's yell was abnormal. After that, we heard the fall. They said they went to assist. They stated there were two lacerations, and they were not able to get the bleeding to stop. They stated when the local ambulance arrived, one of the lacerations was still bleeding. They said the major laceration had 7 or 8 stitches. They stated that they were asked questions by the ADM and were told that CNA A would be suspended so that an investigation could be conducted. They said everything that was told in this interview was told to the ADM. They stated that they did not have any information about Resident #2's fall but that he heard it was bad. <BR/>During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They stated that it was her understanding that the fall was not reported because it was witnessed. They said they did not have any information on Resident #2 fall. <BR/>During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they did not know anything about Resident #2's fall. <BR/>During a confidential interview, they stated they were working with Resident #1 on the day that she fell. She said she was present on the day of the fall and saw everything. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. She stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him (CNA A) to stop, and CNA A kept pushing Resident #1. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. <BR/>During a confidential interview, they stated they were pulled to the floor to help the staff because another staff member was sick. They said it was near mealtime. They stated they observed Resident #1 yelling. She stated she observed Resident #1 feet under the chair. They stated they told CNA A that Resident #1's feet were under the chair and that he was dragging Resident #1's feet. They said they told CNA A that was why Resident #1 was yelling. They stated that the Activity Director called them, and when CNA A passed the door, they again told CNA that they were still dragging Resident #1 feet. They stated shortly after that moment, they heard the fall. They said when they told CNA A, he never readjusted her, checked her (Resident #1) feet, or even responded to them. They stated he kept pushing her. They stated they did not have any information about Resident #2 fall. <BR/>During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They said they did not know anything about Resident #2's fall. <BR/>During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days. She stated she did not call it in because it was not intentional on CNA A behalf. She stated she went ahead and called Resident #1 in because she had passed away, and staff were making a big deal about it. She said Resident #1 fell on [DATE], and she died on [DATE]. The ADM stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17.<BR/>During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at her son's home, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December.<BR/>During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing.<BR/>During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems.<BR/>During an interview on [DATE] at 2:38 PM, the Regional Clinical Director stated that she did not consider a laceration to be a serious injury. She stated a laceration was minor. She said serious was when surgical repair was needed. She stated urgent care was more. She stated she was unaware of Resident #2 injuries until the investigator was in the facility. She said that she did not feel that Resident #1 fall was reportable. She stated when she called the other regional nurse, she was instructed that if they were unsure, then the incident needed to be reported. She stated the ADM had initiated an investigation, and CNA A had already been terminated. She said they allow the DON and ADM to oversee the facility and have yet to read the self-report submitted regarding Resident #1. She said they did not report Resident #1 because it was perceived as a minor injury. She stated Resident #2 was unaware of it.<BR/>During an interview on [DATE] at 2:38 PM at 2:52 PM, CNA A stated he did not mean for Resident #1 to fall. He stated he did not know her feet were under the wheelchair. He stated he did not feel a difference in pushing her. He said he did not hear anyone tell him to stop. He stated that he was the only CNA on the side where Resident #1 resided. He stated that he believed this was why he did not pay attention. He said he was worried about getting everyone out of the dining room by himself. He stated there was no other staff in the dining room with him. He stated there were other residents in the dining room. He stated the kitchen staff was in the kitchen. He said he was unaware that Resident #1 would put her feet down. He stated that she had large legs and had previously inquired about leg rest for another resident. He said he had not asked for leg rest for Resident #1. He stated he was told by housekeeping staff that maintenance would get them. He said he brought this to maintenance attention and was told it would be taken care of. He stated he felt that he did not receive adequate training. He stated he was on the floor one day with another staff and that training did not include getting to know the other residents but instead included asking him to help with the larger residents and telling him to change people on his own. He was never informed that Resident #1 would drop her feet. He stated if he had been trained about Resident #1, he would have checked her feet. He said he pushed her, and she fell out of the chair. He stated he only stopped because he saw her fall forward. He stated he never stopped until she started falling forward.<BR/>Record review of the ADM witness statement dated [DATE] revealed the following:<BR/>On [DATE], she was in the hallway on station 1 when she heard someone yell, Stop !She stated she looked down the hallway and saw CNA A look back. She stated he turned his head. He stopped pushing the wheelchair, and at this time, Resident #1 fell forward. She was assessed and sent to the hospital for evaluation.<BR/>Record review of a confidential witness statement revealed the following:<BR/>They assisted in the assessment of Resident #1. During the course of providing care to Resident #1, they overheard the Activity director tell CNA A, We told you to stop pushing her; her legs were under her wheelchair. They stated they addressed the ADM about reporting the resident death to the state and were told by the ADM that they knew how and why she died. They said the ADM told them that when a resident was on hospice, they were filled with morphine, and then they die. <BR/>Record review of a confidential witness statement revealed the following:<BR/> They were not present the day Resident #1 fell but were notified that Resident #1 was being pushed by CNA A and, after being told to stop, failed to stop. She stated that while others rendered aid, 911 was called. Resident #1 was sent to the hospital and received 7-8 stitches. They said that during a meeting, Resident #1 death was brought up. They stated the ADM stated she would report it since there was a lot of discussion about it. They stated that the ADM said she would report it because if the Activity Director quits, she would ultimately report it. <BR/>Record review of a confidential witness statement revealed the following:<BR/>They heard Resident #1 screaming for at least 5 seconds. They stated they recognized her scream because when Resident #1 did not want to be moved, she would scream. They looked at another staff and then took a step where they could see out the door. They saw Resident #1 mid-fall. They stated Resident #1 hit her head first. They stated they heard CNA A say they

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 5 allegations reviewed for reporting alleged resident abuse (Resident #1 and Resident #2). <BR/>The facility failed to ensure an allegation of neglect for Resident #1 was thoroughly investigated. <BR/>The facility failed to ensure an allegation of neglect for Resident #2 was thoroughly investigated. these failures could place residents at risk of unidentified abuse due to allegations not being investigated as required.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling).<BR/>Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/> Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #1's care plane revealed the following:<BR/>[DATE] <BR/>Problem:<BR/>Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand.<BR/>Intervention:<BR/>Anticipate and meet Resident #1 needs<BR/>Review past falls and attempt to determine cause of the falls.<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #1 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] 9:55 AM<BR/>Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C<BR/>Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. <BR/>Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. <BR/>Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. <BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck.<BR/>Physical Exam<BR/>Constitutional: She is in cute distress<BR/>Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound.<BR/>Neck: Patient is in a c-collar<BR/>Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed.<BR/>Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness <BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. <BR/>Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #2's care plane revealed the following:<BR/>[DATE]<BR/>Problem:<BR/>Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Ms. [NAME] encouraged to utilize call light and wait for assistance.<BR/>Intervention:<BR/>o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE]<BR/>Problem:<BR/>The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 States she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE]<BR/>Intervention:<BR/>[DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. <BR/>Date Initiated: [DATE]<BR/>Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not<BR/>want to go to the ER states, I barely hit my head. Date Initiated: [DATE]<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #2 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] <BR/>Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D<BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>Chief Complaint: Fall<BR/>Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]).<BR/>Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back.<BR/>During a confidential interview, it was stated that they were standing in the doorway with another staff member. They observed CNA A go retrieve Resident #1. When CNA A and Resident #1 passed by, Resident #1 screamed, and CNA B yelled to CNA A, CNA A, her feet!. They stated they heard a noise, and they looked out, and Resident #1 was on her face. They said they heard the ADM tell CNA A to turn her over, and this was before any nurse had come. They stated the ladies from therapy may have witnessed it as well. There was a therapy staff on the floor keeping her calm, and nursing staff assessed her. They stated that what concerned them was that they were never interviewed or asked for a statement. They stated that it was customary that if something of this magnitude happened all staff were interviewed that were there that day. They stated this could not have happened since they were not interviewed. They said because of the response they were getting, it made them not want to talk about it anymore. They said they could not understand why they did not have to give a statement, and at this time, no one still had asked them what they knew or saw. They stated that failure to report and investigate could make the residents scared and unsure of their care. She said regarding Resident #1 fall, CNA A was the only CNA working on the floor on his side, and not investigating it, the facility may not see that this may have also been a factor. They stated the quality of care may decrease if not enough people are working. They said there were times when there was just one CNA, and there were unwitnessed falls. They stated the abuse coordinator was the ADM. They stated they did not feel that Resident #1's incident/fall was investigated because they were present that day, and no one asked them about the incident or took a statement. They stated they don't know much about Resident #2's fall. <BR/>During a confidential interview, they stated they interacted with Resident #1 before her fall. The resident was not acting abnormally. They said they were not present the day Resident #1 fell but were present the day after she had fallen. They stated that they observed the wound, and Resident #1 still had matted-up blood in her hair. They said Resident #1 was vocally crying and moaning but did not have tears. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They said they were never interviewed about Resident #2 fall. They stated they were not interviewed after both falls. <BR/>During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They said the ADM never interviewed them. <BR/>During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling and getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they never interviewed her to see what they saw or heard. <BR/>During a confidential interview, they stated they were not working with Resident #1 on the day that she fell. They said she was present on the day of the fall and saw everything. They stated they were not interviewed. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. They stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him to stop, and CNA A kept pushing her. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. <BR/>During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They stated that no one came and interviewed her about what she had seen. <BR/>During a confidential interview, it was stated that she was not present when Resident #2 fell when she broke her back. They said Resident #2 falls a lot. They stated they had never been questioned at all when Resident #2 fell. They stated that all they knew was Resident #2 was in the hospital. They said she was present often during the overnight shift. <BR/>During a confidential interview, it was stated that they were present the night Resident #2 fell and broke her back. They stated that they were not interviewed by anyone regarding the incident. They said Resident #2 hit the call light, and the resident was on the floor when they went in. They stated they asked Resident #2 what happened, and Resident #2 said she was trying to sit in her chair, and it moved. They stated Resident #2 hit her bottom. They stated they retrieved another staff to help and assess. They said Resident #2 was in pain. They stated they sent her out to the hospital, and she was gone for about a week. They stated that they had not been interviewed about Resident #2's fall when she broke her back, nor had she ever been interviewed about any of her falls. They stated Resident #2 falls a lot. <BR/>During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days She said Resident #1 fell on [DATE], and she died on [DATE]. The AD stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17.<BR/>During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at a family members home during the hoiday, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December.<BR/>During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing.<BR/>During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems.<BR/>Record review of an untitled, undated document provided by the DON on [DATE] revealed the following:<BR/>The DON was not involved in the self-report process. It stated that she was notified by LVN C about the incident with Resident #1. It said that on the date she terminated CNA A, it was at the ADM's request. It stated that she spoke with LVN P, LVN Q, the Activity Director, and CNA A on the same date. (The outcome of the interviews was not included in this document).<BR/>Record review of the facility policy titled abuse investigation and Reporting, revised [DATE], revealed the following: <BR/>Policy Statement<BR/>All reports of resident abuse, neglect, exploitation, misappropriation of rcsident property, mistreatment and/or<BR/>injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.<BR/>Role of the Investigator: <BR/>The individual conducting the investigation will, as a minimum:<BR/>a. Review the completed documentation forms;<BR/>b. Review the resident's medical record to determine events leading up to the incident;<BR/>c. Interview the person(s) reporting the incident;<BR/>d. Interview any witnesses to the incident;<BR/>e. Interview the resident (as medically appropriate);<BR/>f. Interview the resident's Attending Physician as needed to determine the resident's current level of<BR/>cognitive function and medical condition;<BR/>g. Interview staff members (on all shifts) who have had contact with the resident during the period of the<BR/>alleged incident;<BR/>h. Interview the resident's roommate, family members, and visitors;<BR/>i. Interview other residents to whom the accused employee provides care or services; and<BR/>j. Review all events leading up to the alleged incident.<BR/>The following guidelines will be used when conducting interviews:<BR/>a. Each interview will be conducted separately and in a private location.<BR/>b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved<BR/>in the interview process.<BR/>c. Should a person disclose information that may be self-incriminating, that individual will be informed<BR/>of his/her rights to terminate the interview until such time as his/her rights are protected (e.g.,<BR/>representation by legal counsel).<BR/>d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and<BR/>date it, or the investigator may obtain a statement, read it back to the member and have him/her sign<BR/>and date it.<BR/>3. The investigator will notify' the ombudsman that an abuse investigation is being conducted. The<BR/>ombudsman will be invited to participate in the review process. <BR/>a. If the ombudsman declines the invitation to participate in the investigation, that information will be<BR/>noted in the investigation record. The ombudsman will be notified of the results of the investigation as<BR/>well as any corrective measures taken.<BR/>4. The investigator will consult daily with the Administrator concerning the progress/findings of the<BR/>investigation.<BR/>5. Upon conclusion of the investigation, the investigator will record the results of the investigation on<BR/>approved documentation forms and provide the completed documentation to the Administrator.<BR/>Record review of the facility policy titled Accidents and Incidents-Investigating and reporting, revised [DATE], revealed the following: <BR/>Policy Statement<BR/>All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.<BR/>1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and<BR/>document investigation of the accident or incident.<BR/>2. The following data, as applicable, shall be included on the Report of Incident/Accident form:<BR/>a. The date and time the accident or incident took place;<BR/>b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);<BR/>c. The circumstances surrounding the accident or incident;<BR/>d. Where the accident or incident took place;<BR/>e. The name(s) of witnesses and their accounts of the accident or incident;<BR/>f. The injured person's account of the accident or incident;<BR/>g. The time the injured person's attending physician was notified, as well as the time the physician<BR/>responded and his or her instructions;<BR/>h. The date/time the injured person's family was notified and by whom;<BR/>1. The condition of the injured person, including his/her vital signs;<BR/>j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work,<BR/>etc.);<BR/>k. Any corrective action taken;<BR/>1. Follow-up information;<BR/>m. Other pertinent data as necessary or required; and<BR/>a. The signature and title of the person completing the report.<BR/>3. This facility is in compliance with current rules and regulations governing accidents and/or incidents<BR/>involving a medical device.<BR/>5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of<BR/>Incident/Accident form and submit the original to the director of nursing services within 24 hours of the<BR/>incident or accident.<BR/>6. The director of nursing services shall ensure that the administrator receives a copy of the Report of<BR/>Incident/Accident of form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. <BR/>This failure could place residents at risk for not receiving medications correctly. <BR/>Findings included: <BR/>Record Review of Resident #1's facesheet dated 01/08/2025 revealed that Resident #1 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #1 had a medical history of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), epilepsy (disorder in which nerves cell activity in the brain is disturbed, causing seizures), insomnia (makes it difficult to fall asleep or stay asleep), anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (loss of pleasure or interest in activities for long periods of time), dysphagia (swallowing difficulties), cerebral palsy (congenital disorder of movement, muscle, tone, or posture), and congenital hypertonia (overly toned muscles that cause muscles to be stiff and difficult to control).<BR/>Record review of Resident #1s MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 10 which indicated Resident #1 had a moderate cognitive impairment. Section GG- Functional Abilities: A. revealed a score of 2 for eating, which indicated Resident #1 needed substantial/maximal assistance. Section K- Swallowing/Nutritional Status C. revealed coughing or choking during meals or when swallowing medications. K0520 revealed mechanically altered diet. <BR/>Record review of Resident #1 s care plan dated 08/19/2020 revealed problem: Resident #1 has an ADL self-performance deficit related to cerebral palsy. Goal to maintain current level of function in ADL's through the review date. Date initiated 07/23/2022. Interventions: Eating: Resident #1 requires extensive assist x 1 with eating. 04/20/21 Resident #1 requires extensive assist x 1 with eating. She has a regular diet, foods cut up into bite size pieces. She has difficulty with swallowing, so requires attention. She has ROM deficits in upper extremities requiring assist with feeding. Initiated on 08/19/2020. Revision on 10/06/2023.<BR/>Record review of Resident #1s physician order dated 02/13/2024 for Resident #1 to receive ST skilled service 3 x week for 30 days for dysphagia management. <BR/>Record review of Resident #1s Nutritional Review assessment dated [DATE]: 8. Current Diet/Supplement Order: Regular pureed diet with nectar thicken liquids. 9. Appropriateness of Diet Order: Appropriate. 10. Ability to Chew/Swallow: Ok. 13. Ability to feed self: Dependent. 24. Comments: Resident #1 is alert to person and place and can communicate needs.<BR/>Record review of Resident #1's Nursing Monthly Summary dated 12/13/2024 revealed: Section A. Level of Consciousness/Orientation/Cognition: Resident #1 is alert and oriented to person and place, with episodic confusion. Section H. ADLs- Eating is total dependence of one person. Diet order: thickened liquids, pureed. <BR/>Record review of Resident #1's December 2024 Medication Administration Record revealed an order for Tylenol Extra Strength oral tablet 500 mg. Give one tablet by mouth every 6 hours as needed for pain. There is no documentation on 12/31/2024 that the medication was given. <BR/>During an interview on 01/08/2025 at 8:40 AM, the ADON stated that it had been a hectic day and she was running behind with the medication pass. ADON stated that her family member, CNA, came by and asked if she needed any help. ADON stated that she remembered it was during the morning med pass on 12/30/2024, and Resident #1 was crying out. ADON stated that she poured a Tylenol Extra Strength tablet into a medication cup and asked CNA to go administer the medication to Resident #1. ADON stated that CNA also does transportation for the facility and knows her residents very well. ADON stated it was just an OTC medication, and she would not have done that with any of the other medications. ADON stated that she would never to that again, it was just a spur of the moment decision. ADON revealed CNA is not certified to administer medications. <BR/>During an interview on 01/08/2025 at 9:34 AM, Confidential Person A stated that she observed the ADON give a medication cup to CNA. Confidential Person A stated they did not know what was in the cup, but they knew a CNA should not be giving medications. <BR/>During an observation on 01/08/2025 at 9:54 AM, Resident #1 was observed resting with eyes closed, head of bed up at 30 degrees, and had oxygen administering via nasal cannula. No signs or symptoms of distress. <BR/>During a phone interview on 01/08/2025 at 10:40 AM, Regional RN stated, oh no, they can not do that, regarding the ADON giving CNA a medication to administer to Resident #1. <BR/>During an interview on 01/08/2025 at 11:16 AM, CNA stated that Monday 12/30/2024 had been a crazy day, and she was checking with other staff to see if she could help them with anything. CNA stated her family member, ADON was passing medications, and CNA asked her if she needed her to do anything. ADON poured a Tylenol Extra Strength tablet into a medication cup and asked her to go administer it to Resident #1. Resident #1 took the medication without incident. CNA stated that she was just trying to help out, and it was just an OTC medication. Regarding the risks to a resident if someone did not know the resident had an order for thickened liquids, CNA stated that she had been certified for 10 years, and as a CNA she knows that about her residents. CNA stated that Resident #1's head of bed is always elevated. CNA stated that she did not have her certification to administer medications. CNA stated that she would never do it again and stated that she would not have done that if it had not been her family member. <BR/>During an interview on 01/08/2025 at 11:25 AM, Confidential Person B stated that they were concerned about an uncertified person giving medications, because they may not know what they are giving, or whether or not that resident has thickened liquids, or possibly the unlicensed person could give the medication to the wrong person. <BR/>During an interview on 01/08/2025 at 11:46 AM, LVN A revealed the risks to a resident that is administered medications by an uncertified person includes not knowing what medication they are giving, what the side effects are, if there are parameters that need to be checked prior to administration, or there might be possible drug interactions with other medications. LVN A stated that if a person is not certified in medication administration, they should not be giving medications. <BR/>During an interview on 01/08/2025 at 12:20 PM, ADON stated that a lot of things could happen to a resident with an uncertified person giving medications. ADON stated, I did it, but I will never do it again.<BR/>During an interview on 01/08/2025 at 12:30 PM, Resident #1 was awake, made eye contact and smiled. Investigator asked how she was doing. It took a little while for her to get her words out. Resident #1 voiced she was doing ok. Resident #1 denied any concerns regarding the staff or her care. Resident #1 could not recall what medications she had on 12/30/2024. <BR/>During an interview on 01/08/2025 at 1:47 PM, the Interim DON stated that the ADON had just told her about giving a medication to her family member, CNA, to administer to Resident #1. Interim DON stated, that is not good. Interim DON stated that the risks to a resident being given medication by an uncertified person could result in the resident choking or aspirating, or they may give the medication to the wrong person.<BR/>During an interview on 01/08/2025 at 2:27 PM, LVN B, stated that the risks of an uncertified person giving medications include they could give the medication to the wrong person, or they may not give the resident the medication and take it themselves, the uncertified person may not know what the medication is for, or know what the side effects might be. LVN B stated there could be a lot wrong with an uncertified person administering medications. <BR/>During an interview on 01/08/2025 at 3:15 PM, Physician stated that the risks of an uncertified person administering medications that they did not prepare, first you would be relying on what someone else was telling you the medication was. Physician stated, it is just not good practice.<BR/>Record review of Disciplinary Action Form dated 01/08/2025 for ADON. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by ADON and Interim DON. <BR/>Record review of Disciplinary Action Form dated 01/08/2025 for CNA. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by CNA and Interim DON. <BR/>Record review of in-service dated 01/08/2025: Medication Administration: Only licensed personnel or personnel permitted by the state to prepare, administer, and document the administration of medication can do so. <BR/>The following policy reviewed: Administering Medications, 2001 Med-Pass, Inc. (Revised April 2019)<BR/>Policy Statement: Medications are administered in a safe and timely manner, as prescribed. <BR/>Policy Interpretation and Implementation: <BR/>1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans.<BR/>This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails.<BR/>This failure could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Findings include:<BR/>Resident #9<BR/>Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). <BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #9 was understood and had a BIMS score of 00 indicating that the resident's cognition was severely impaired. <BR/>Record review of the current care plan for Resident #9, undated, revealed there was no specific care plan regarding bedrails. <BR/>Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have &frac14; side rails on right and left side of bed. <BR/>Resident #11<BR/>Record review of the admission record for Resident #11, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (problem in the brain), acute and chronic respiratory failure (lung disease), and pneumonia (lung infection).<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #11 was understood and had a BIMS score of 12 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #11, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #11, dated 02/27/24, revealed the following order: May use siderails for positioning and ease of mobility as an enabler every shift for siderails with an order start date of 09/29/22.<BR/>Resident #160<BR/>Record review of the admission record for Resident #160, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (motor disability), seizures (neurological disorder), and muscle weakness.<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #160 was usually understood and had a BIMS score of 15 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #160, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #160, dated 02/27/24, revealed the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20.<BR/>During an interview on 02/29/24 at 12:07 PM, the DON and the ADON stated they were both responsible for ensuring the care plans for the residents were completed. The DON and the ADON stated they were unsure why Residents #9, #11 and #160 were missing care plans for bed rails. The DON and ADON stated the care plans were audited last week but they did not look for bedrails in the care plan at that time. The DON stated the potential negative outcome to the residents was the bed rails would not be followed up on and assessed to see if they were still appropriate for the residents. <BR/>During an interview on 02/29/24 at 12:16 PM, the ADM stated the DON and ADON were responsible for ensuring the care plans were completed. The ADM stated the facility had a change in nursing management last year and ensuring bed rails were care planned fell through the cracks. The ADM stated the potential negative outcome to the residents was staff could not be aware and it could cause a possible injury of some sort. <BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following:<BR/>Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, the comprehensive person-centered care plan, and the residents' choices for 2 of 20 residents (Resident #15 and 23) with orders for psychotropic and/or antibiotic medications, in that:<BR/>1) The facility failed to have physician's orders, assessments, care plan, communication, and coordination of care with physician/pharmacist/staff/pain management physician in place for Resident #15 related to pain management. <BR/>2)The facility failed to ensure Resident #23 received physician ordered medications prescribed for anxiety and a UTI.<BR/>An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>These failures affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. Additionally, these failures could place residents at risk for an increase in behaviors and infection symptoms. <BR/>The findings include:<BR/>Resident #15:<BR/>Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle).<BR/>Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23.<BR/>Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023.<BR/>Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8:<BR/>7/7/22 at 7:34 AM - 7<BR/>7/23/22 at 19:22 (7:22 PM) - 8<BR/>8/7/22 at 14:32 (2:23 PM) -6<BR/>8/23/22 at 8:59 AM - 6<BR/>8/30/22 at 22:49 (10:49 PM) - 8<BR/>9/2/22 at 6:58 AM - 7<BR/>1/13/23 at 3:58 AM - 6<BR/>Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following:<BR/>Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . <BR/>Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 .<BR/>Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give &frac12; hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 .<BR/>Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: <BR/>Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus.<BR/>Tylenol extra strength 500mg every 8 hours as needed for MS.<BR/>Requip 0.25mg every day for Restless Leg Syndrome.<BR/>Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms.<BR/>Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. <BR/>An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10.<BR/>Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention.<BR/>Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump.<BR/>Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities.<BR/>Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed.<BR/>Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication.<BR/>Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following:<BR/>Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day.<BR/>Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. <BR/>Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. <BR/>Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. <BR/>Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). <BR/>Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations.<BR/>Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN.<BR/>Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. <BR/>Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. <BR/>Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations.<BR/>Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18.<BR/>Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following:<BR/>Steps in the procedure: <BR/>8. Skin: <BR/>A. Intactness.<BR/>B. Moisture.<BR/>C. Color.<BR/>D. Texture.<BR/>E. Presence of bruises, pressure, sores, redness, edema, rashes.<BR/>14. Pain:<BR/>Pain: a. F. Current medication and treatments for pain.<BR/>Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following:<BR/>The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain.<BR/>General guidelines:<BR/>1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management.<BR/>2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals.<BR/>3. Pain management is a multidisciplinary care process that includes the following:<BR/>F. Identifying and using specific strategies for different levels and sources of pain.<BR/>G. Monitoring for the effectiveness of interventions.<BR/>Steps in the procedure:<BR/>Assessing pain:<BR/>1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative):<BR/>A. History of pain and its treatment including pharmacological and non-pharmacological interventions.<BR/>Implementing Pain Management Strategies:<BR/>3. The physician and staff will establish a treatment regimen based on consideration of the following: <BR/>B. Current medication regimen.<BR/>4. Strategies that may be employed when establishing the medication regimen include:<BR/>C. Combining long-acting medication with PRN's for breakthrough pain.<BR/>5. Implement the medication regimen as ordered, carefully documenting the results of the interventions.<BR/>Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following:<BR/>Policy statement:<BR/>Orders for medication and treatments will be consistent with principles of safe and effective order riding<BR/>Policy, interpretation, and implementation:<BR/>3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.<BR/>Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following:<BR/>Policy statement:<BR/>All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care.<BR/>Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following:<BR/>Policy statement:<BR/>The attending physician will be responsible for the following:<BR/>1. Excepting responsibility for initial and subsequent resident care.<BR/>2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards.<BR/>Providing appropriate care:<BR/>9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions.<BR/>On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested.<BR/>The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following:<BR/>Request to remove immediate jeopardy dated 1/12/2023<BR/>How corrective action will be accomplished for those residents affected by the violation:<BR/>Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. <BR/>Completion date 1/12/2023.<BR/>LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. <BR/>Completion 1/12/2023<BR/>In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care.<BR/>Completion 1/12/ 2023<BR/>How the facility will identify other residents with the potential to be affected by the same violation:<BR/>Only one resident in the facility has an internal pain pump currently.<BR/>Completion 1/12/2023<BR/>What measures will be put into place or systematic changes made to ensure the violation will not reoccur.<BR/>admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information.<BR/>Completion 1/12/2023.<BR/>How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur.<BR/>Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved.<BR/>Completion 1/13/2023<BR/>Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023.<BR/>Addendum to request to remove immediate Jeopardy dated 1/12/2023<BR/>Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff.<BR/> Nursing staff was in-serviced included regarding the remote bolus PRN doses.<BR/>In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. <BR/>The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows:<BR/>Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's.<BR/>Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs.<BR/>During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. <BR/>During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. <BR/>During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. <BR/>Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. <BR/>The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan.<BR/>Resident #23:<BR/>Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 Residents (Resident #1) reviewed for catheter care in that: <BR/>The facility failed to ensure Resident #1 had physician orders for a urinary catheter. <BR/>This failure had the potential to affect residents by placing them at an increased risk of not receiving the appropriate care or services related to the urinary catheter. <BR/>Findings include: <BR/>Record review of the admission record for Resident #1, dated 01/31/25, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: unspecified sequelae of cerebral infarction (long-term effects of a stroke in the brain), type 2 diabetes (blood sugar problems), essential hypertension (high blood pressure), and urinary tract infection (bladder infection). <BR/>Record review of Resident #1's quarterly MDS assessment, dated 12/20/24 revealed Resident #1 had a BIMS score of 15 which indicated the resident's cognition was intact. The MDS revealed Resident #1 had an indwelling catheter. <BR/>Record review of Resident #1's order summary report, dated 01/31/25, revealed no physician order for a foley catheter.<BR/>Observation on 01/31/25 at 9:52 AM revealed Resident #1 in bed and a foley catheter bag was noted hanging on the side of the bed. <BR/>Interview on 01/31/25 at 10:50 AM, Resident #1 stated she has had a urinary catheter for about 2 weeks. Resident #1 stated she was unsure why she received a catheter. Resident #1 stated staff cleaned her catheter when they changed her brief and emptied the bag at least twice daily. <BR/>Interview on 01/31/25 at 11:14 AM, LVN A stated this was her first day working at the facility and she was not familiar with Resident #1's care. LVN A stated the floor nurse was responsible for ensuring residents had physician orders for urinary catheters. LVN A stated there could be a potential for infection concerns or the urinary catheter could need to be irrigated and the staff would not know without physician orders for catheter care. <BR/>Attempted phone interview on 01/31/25 at 11:25 AM with LVN B. No answer. Left a voice message with a call back number. <BR/>Interview on 01/31/25 at 11:35 AM, the DON stated her first day working at the facility was this past Tuesday (01/28/25) and she was still trying to audit and get everything in place. The DON stated it was unknown why the urinary catheter was placed on Resident #1 but she believes hospice nurses ordered and placed the catheter. The DON stated she was unsure if hospice would keep the urinary catheter for Resident #1 as she was unsure what the actual diagnosis was for Resident #1's urinary catheter. The DON stated a potential negative outcome for the resident was urosepsis (a bladder infection that spreads to the kidneys and enters the bloodstream), infection, and septicemia (blood poisoning).<BR/>Interview on 01/31/25 at 12:05 AM, the Interim ADM stated she expected the residents who had a urinary catheter to have a current physician's order for the catheter and catheter care. The Interim ADM stated the floor nurse was responsible for ensuring the residents on her hall had physician orders for urinary catheters if they had a urinary catheter. The Interim ADM stated the DON and ADON were also responsible for auditing the resident's charts to ensure the proper physician's orders were in place and being followed. The Interim ADM stated a potential negative outcome to the resident was not receiving catheter care or monitoring. <BR/>Record review of Resident #1's progress note, dated 12/16/24 at 05:20 AM, created by LVN B: Foley cath changed to 18 fr [French] with 10 cc [ml] bulb. Small amt [amount] of bloody urine noted when inserted and sent to lab for UA [Urinary Analysis]. Resident tolerated procedure well <BR/>Record review of Resident #1's progress note, dated 12/16/24 at 05:22 AM, created by LVN B: order to obtain UA with C/S [culture/sensitivity] after foley placed tonight. One time only for 1 day. 18FR [French] foley cath [catheter] changed per sterile technique. Resident tolerated well. Resident had very small amt [amount] of bloody urine noted. Small amt [amount] of urine sent to lab for UA.<BR/>Record review of the facility policy and procedure titled, Catheter Care, Urinary, with a revised date of August 2022 revealed the following: <BR/>Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.<BR/>Catheter Evaluation:<BR/>1. Review and document the clinical indications for catheter use prior to inserting.<BR/>2. Nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use a standardized tool for documenting clinical indications for catheter use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. <BR/>This failure could place residents at risk for not receiving medications correctly. <BR/>Findings included: <BR/>Record Review of Resident #1's facesheet dated 01/08/2025 revealed that Resident #1 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #1 had a medical history of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), epilepsy (disorder in which nerves cell activity in the brain is disturbed, causing seizures), insomnia (makes it difficult to fall asleep or stay asleep), anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (loss of pleasure or interest in activities for long periods of time), dysphagia (swallowing difficulties), cerebral palsy (congenital disorder of movement, muscle, tone, or posture), and congenital hypertonia (overly toned muscles that cause muscles to be stiff and difficult to control).<BR/>Record review of Resident #1s MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 10 which indicated Resident #1 had a moderate cognitive impairment. Section GG- Functional Abilities: A. revealed a score of 2 for eating, which indicated Resident #1 needed substantial/maximal assistance. Section K- Swallowing/Nutritional Status C. revealed coughing or choking during meals or when swallowing medications. K0520 revealed mechanically altered diet. <BR/>Record review of Resident #1 s care plan dated 08/19/2020 revealed problem: Resident #1 has an ADL self-performance deficit related to cerebral palsy. Goal to maintain current level of function in ADL's through the review date. Date initiated 07/23/2022. Interventions: Eating: Resident #1 requires extensive assist x 1 with eating. 04/20/21 Resident #1 requires extensive assist x 1 with eating. She has a regular diet, foods cut up into bite size pieces. She has difficulty with swallowing, so requires attention. She has ROM deficits in upper extremities requiring assist with feeding. Initiated on 08/19/2020. Revision on 10/06/2023.<BR/>Record review of Resident #1s physician order dated 02/13/2024 for Resident #1 to receive ST skilled service 3 x week for 30 days for dysphagia management. <BR/>Record review of Resident #1s Nutritional Review assessment dated [DATE]: 8. Current Diet/Supplement Order: Regular pureed diet with nectar thicken liquids. 9. Appropriateness of Diet Order: Appropriate. 10. Ability to Chew/Swallow: Ok. 13. Ability to feed self: Dependent. 24. Comments: Resident #1 is alert to person and place and can communicate needs.<BR/>Record review of Resident #1's Nursing Monthly Summary dated 12/13/2024 revealed: Section A. Level of Consciousness/Orientation/Cognition: Resident #1 is alert and oriented to person and place, with episodic confusion. Section H. ADLs- Eating is total dependence of one person. Diet order: thickened liquids, pureed. <BR/>Record review of Resident #1's December 2024 Medication Administration Record revealed an order for Tylenol Extra Strength oral tablet 500 mg. Give one tablet by mouth every 6 hours as needed for pain. There is no documentation on 12/31/2024 that the medication was given. <BR/>During an interview on 01/08/2025 at 8:40 AM, the ADON stated that it had been a hectic day and she was running behind with the medication pass. ADON stated that her family member, CNA, came by and asked if she needed any help. ADON stated that she remembered it was during the morning med pass on 12/30/2024, and Resident #1 was crying out. ADON stated that she poured a Tylenol Extra Strength tablet into a medication cup and asked CNA to go administer the medication to Resident #1. ADON stated that CNA also does transportation for the facility and knows her residents very well. ADON stated it was just an OTC medication, and she would not have done that with any of the other medications. ADON stated that she would never to that again, it was just a spur of the moment decision. ADON revealed CNA is not certified to administer medications. <BR/>During an interview on 01/08/2025 at 9:34 AM, Confidential Person A stated that she observed the ADON give a medication cup to CNA. Confidential Person A stated they did not know what was in the cup, but they knew a CNA should not be giving medications. <BR/>During an observation on 01/08/2025 at 9:54 AM, Resident #1 was observed resting with eyes closed, head of bed up at 30 degrees, and had oxygen administering via nasal cannula. No signs or symptoms of distress. <BR/>During a phone interview on 01/08/2025 at 10:40 AM, Regional RN stated, oh no, they can not do that, regarding the ADON giving CNA a medication to administer to Resident #1. <BR/>During an interview on 01/08/2025 at 11:16 AM, CNA stated that Monday 12/30/2024 had been a crazy day, and she was checking with other staff to see if she could help them with anything. CNA stated her family member, ADON was passing medications, and CNA asked her if she needed her to do anything. ADON poured a Tylenol Extra Strength tablet into a medication cup and asked her to go administer it to Resident #1. Resident #1 took the medication without incident. CNA stated that she was just trying to help out, and it was just an OTC medication. Regarding the risks to a resident if someone did not know the resident had an order for thickened liquids, CNA stated that she had been certified for 10 years, and as a CNA she knows that about her residents. CNA stated that Resident #1's head of bed is always elevated. CNA stated that she did not have her certification to administer medications. CNA stated that she would never do it again and stated that she would not have done that if it had not been her family member. <BR/>During an interview on 01/08/2025 at 11:25 AM, Confidential Person B stated that they were concerned about an uncertified person giving medications, because they may not know what they are giving, or whether or not that resident has thickened liquids, or possibly the unlicensed person could give the medication to the wrong person. <BR/>During an interview on 01/08/2025 at 11:46 AM, LVN A revealed the risks to a resident that is administered medications by an uncertified person includes not knowing what medication they are giving, what the side effects are, if there are parameters that need to be checked prior to administration, or there might be possible drug interactions with other medications. LVN A stated that if a person is not certified in medication administration, they should not be giving medications. <BR/>During an interview on 01/08/2025 at 12:20 PM, ADON stated that a lot of things could happen to a resident with an uncertified person giving medications. ADON stated, I did it, but I will never do it again.<BR/>During an interview on 01/08/2025 at 12:30 PM, Resident #1 was awake, made eye contact and smiled. Investigator asked how she was doing. It took a little while for her to get her words out. Resident #1 voiced she was doing ok. Resident #1 denied any concerns regarding the staff or her care. Resident #1 could not recall what medications she had on 12/30/2024. <BR/>During an interview on 01/08/2025 at 1:47 PM, the Interim DON stated that the ADON had just told her about giving a medication to her family member, CNA, to administer to Resident #1. Interim DON stated, that is not good. Interim DON stated that the risks to a resident being given medication by an uncertified person could result in the resident choking or aspirating, or they may give the medication to the wrong person.<BR/>During an interview on 01/08/2025 at 2:27 PM, LVN B, stated that the risks of an uncertified person giving medications include they could give the medication to the wrong person, or they may not give the resident the medication and take it themselves, the uncertified person may not know what the medication is for, or know what the side effects might be. LVN B stated there could be a lot wrong with an uncertified person administering medications. <BR/>During an interview on 01/08/2025 at 3:15 PM, Physician stated that the risks of an uncertified person administering medications that they did not prepare, first you would be relying on what someone else was telling you the medication was. Physician stated, it is just not good practice.<BR/>Record review of Disciplinary Action Form dated 01/08/2025 for ADON. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by ADON and Interim DON. <BR/>Record review of Disciplinary Action Form dated 01/08/2025 for CNA. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by CNA and Interim DON. <BR/>Record review of in-service dated 01/08/2025: Medication Administration: Only licensed personnel or personnel permitted by the state to prepare, administer, and document the administration of medication can do so. <BR/>The following policy reviewed: Administering Medications, 2001 Med-Pass, Inc. (Revised April 2019)<BR/>Policy Statement: Medications are administered in a safe and timely manner, as prescribed. <BR/>Policy Interpretation and Implementation: <BR/>1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 9 of 15 confidential residents. <BR/>The facility failed to ensure 9 of 15 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information in regard to who the facility grievance officer was, their contact information, and how to file an anonymous grievance. <BR/>This failure could place the residents at risk of unresolved grievances and decreased quality of life. <BR/>Findings include:<BR/>Interviews and Record Review during Resident Council on, 04/08/2025 at 2:30pm, 9 of confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. Nine Residents attended the meeting, the 9 Residents in attendance had all been Residents of the facility for 6 plus months. <BR/>Observed prominent postings on 4/09/2025 at 3:17pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. <BR/>Interview with the ADM on 4/10/2025 at 1:14pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station, the ADM's office, the Activity Director's Office, and all department heads should have Grievance forms. The ADM stated the Residents cannot obtain a Grievance form without asking staff for the form. The ADM stated staff complete Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated he assigned the grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. <BR/>Record Review of the Grievance Policy last updated in 2017.<BR/>Policy Statement:<BR/>All grievances filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. <BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>The facility will make available information on how to file a grievance available to residents, family, and staff. <BR/>2. <BR/>The Administrator or designed will assign the responsibility of investigating the grievance. <BR/>3. <BR/>Each Resident grievance form will include the date and time and details of the grievance.<BR/>4. <BR/>The Administrator or designee will record and maintain all grievances in the Grievance Log. <BR/>5. <BR/>The Resident Grievance form will be filed with the Administrator or designee and the resolution will be identified within three working days of the concern. <BR/>6. <BR/>The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance. <BR/>7. <BR/>If during the investigation abuse, neglect, misappropriation and/or injuries of unknown source are identified, the facility will refer to the Abuse Policy. <BR/>a. <BR/>Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and<BR/>b. <BR/>Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievances for period of no less than 3 years from the issuance of the grievance decision.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 breakfast meals from 1 of 1 kitchen.<BR/>1) The facility failed to provide food that was palatable for 1 of 1 breakfast meal observed (1/12/23). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings include:<BR/>Two of 7 residents confidentially interviewed, and ate in their rooms on Station 1, voiced concerns related to food palatability. One resident stated, Our food is cold, and my roommate gets cold eggs. Another resident stated her eggs were cold and that breakfast was cold often. <BR/>Record review of the Resident Council Minutes dated 12/7/22 revealed, under New Business, residents stated an issue of cold food at dinner time.<BR/>Record review of the Resident Council Minutes dated 1/4/23 revealed, under Old Business, Dietary - Cold food at dinner time.<BR/>During an interview on 1/12/22 at 7:07 AM, the Dietary Manager was informed of a test tray request.<BR/>During a kitchen observation on 1/12/23 at 7:30 AM, temperatures were taken of the foods on the steam table by the Dietary Manager. The temperatures were as follows:<BR/>Over Easy Eggs no temperature taken<BR/>Toast no temperature taken<BR/>Eggs scramble 174.2&deg;F <BR/>Oatmeal 198 3&deg;F<BR/>Sausage patty 192&deg;F.<BR/>Bacon no temperature taken<BR/>Pur&eacute;ed sausage 154&deg;F<BR/>Gravy 167&deg;F <BR/>Cream of wheat 181&deg;F <BR/>Pur&eacute;ed eggs, 160.1&deg;F<BR/>Pur&eacute;e bread 149&deg;F<BR/>On 1/12/23 at 7:44 AM an observation revealed the Dietary Manager started serving/preparing the Station 2 hall cart trays. The cart left the dining room at 7:58 AM. It was observed that the plates had insulated covers, but the cart was not heated. It was also observed that the over easy eggs were plated on the stove and covered with plates. At 7:58 AM preparation started for the Station 1 cart. The last tray was prepared for the Station 1 cart at 8:07 AM and preparation began for the test trays. The test tray preparation ended at 8:10 AM. The hall cart for Station 1 left the dining room at 8:11 AM and arrived on the Station 1 at 8:11 AM. At 8:12 AM two staff (CNAs B and D) started serving trays on Station 1. The last tray on the Station 1 cart was served to Resident #167 at 8:34 AM. The resident began eating at 8:35 AM. <BR/>Observation on 1/12/23 at 8:39 AM, the test trays were sampled by surveyors with the following results:<BR/>Pur&eacute;ed, eggs - lukewarm cold, 100.4&deg;F.<BR/>Pur&eacute;ed sausage with gravy - cold, salty, 97.5&deg;F.<BR/>Pur&eacute;ed bread - cold, 97.5&deg;F<BR/>Bacon- cold<BR/>Scrambled Eggs - lukewarm/cold, 106&deg;F<BR/>Sausage- cold, 92.1&deg;F<BR/>Toast - cold<BR/>Over easy eggs - cold, 99.4&deg;F <BR/> Oatmeal - warm, 135.8&deg;F <BR/>Cream of wheat - lukewarm, 119.6&deg;F <BR/>The test ended at 8:50 AM.<BR/>On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager regarding the cold and lukewarm foods on the test tray. She stated it took longer to serve; staff were late, and nurses delayed. She stated breakfast would get cold fast, and the facility had no heated carts. She stated staff encouraged dining room dining to ensure residents received meals that were at palatable temperatures. She stated they usually finished serving everyone by 8:00 AM and they have a new person working in the kitchen. She stated the dietary staff have met with the residents about menus and alternates. She stated she was responsible for ensuring foods were palatable. She stated residents would not eat the food if the foods were not palatable. A policy related to food palatability was requested at this time. <BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding food palatability. She stated staff were expected to serve food that was palatable. She stated residents could be unhappy if their food was not palatable.<BR/>A policy specific for food palatability was not provided at the time of the exit on 1/13/23 at 6:45 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control.<BR/>1. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32.<BR/>2. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. <BR/>3. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. <BR/>4. <BR/>CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. <BR/>5. <BR/>CNA B failed to change gloves and perform hand hygiene during incontinence care with Resident #40. <BR/>These failures could place residents at risk for cross contamination and infection. <BR/>The findings include: <BR/>During a medication administration observation on 4/09/2025 at 8:34AM MA A used the blood pressure cuff to take Resident #41's blood pressure. At 8:38 AM, MA A used the same blood pressure cuff to take Resident #32's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #41 or Resident #32. <BR/>During a medication administration observation on 4/09/2025 at 8:38AM MA A used the blood pressure cuff to take Resident #32's blood pressure. At 8:42 AM, MA A used the same blood pressure cuff to take Resident #98's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #32 or Resident #98. <BR/>During a medication administration observation on 4/09/2025 at 8:42AM MA A used the blood pressure cuff to take Resident #98's blood pressure. At 9:08 AM, MA A used the same blood pressure cuff to take Resident #38's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #98 or Resident #38. <BR/>Record review of Resident #195's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #195 had a past medical history of cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), type two diabetes, and urinary tract infection. <BR/>Record review of Resident #195's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 10:28 AM, CNA C cleaned Resident #195's buttocks, removed contaminated gloves, and donned clean gloves. CNA C failed to utilize hand hygiene between glove change. <BR/>Record review of Resident #40's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident 340 had a medical history of major depressive disorder, cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain), and retention of urine. <BR/>Record review of Resident #40's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 11:02 AM, CNA B cleaned Resident #40's buttocks, removed dirty brief and placed clean brief on Resident #40. CNA B failed to change gloves and utilize hand hygiene prior to placing clean brief on Resident #40. <BR/>During an interview on 4/10/2025 at 10:00AM with MA A, she stated the DON was the infection preventionist. She stated she had been rained on infection prevention earlier this year. She stated she had been trained to disinfect the blood pressure cuffs before and after use. She stated the potential negative outcome of not disinfection the BP cuff could be spreading infection between residents. She stated she knew she had to disinfect the BP cuff with the disinfecting wipes but forgot to do so. <BR/>During an interview on 4/10/2025 at 10:30AM with CNA C, she stated the ADM was the infection preventionist. She stated she had been trained on infection control and the last training occurred March 2025. She stated she had been trained to use hand hygiene between glove changes. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection. She stated the DON and ADON do competencies all the time and will check them off on hand hygiene. She stated she did notice she failed to wash her hands between glove changes but had forgotten to do so. <BR/>During an interview on 4/10/2025 at 10:36AM with CNA B, she stated the DON and ADON were the infection preventionist. She stated she had been trained on infection prevention and her last training was approximately a month and a half ago. She stated she had been trained to change gloves when going from dirty to clean. She stated the potential negative outcome of not changing gloves when going from an area of dirty to clean could be spreading bacteria. She stated she had changed her gloves once and forgot to change them again after she cleaned the resident's bottom. <BR/>During an interview on 4/10/2025 at 10:49 AM with the DON, she stated she was the infection preventionist. She stated staff were trained on infection control upon hire, quarterly and as needed. She stated she was unsure of the last training date due to having just started at this facility in January 2025. She stated there was an infection control training scheduled for this month. She stated she expected her staff to wash their hands immediately upon removing their gloves. She stated the potential negative outcome of not changing their gloves and performing hand hygiene could be the spread of infection and an outbreak. She stated staff had been trained to disinfect the blood pressure cuffs and she expects staff to disinfect the blood pressure cuffs before and after resident use. She stated the potential negative outcome of not disinfecting the blood pressure cuff between residents could be the spread of infection. <BR/>During an interview on 4/10/2025 at 11:27AM with the ADM, he stated the ADM, and DON were the infection preventionist. He stated staff were trained on infection control upon hire, annually and as needed. He stated there was an infection control in-service approximately six weeks ago. He stated staff had been trained on washing their hands when changing gloves. He stated the potential negative outcome of not performing hand hygiene between glove changes could be spreading infection. He stated staff had been trained to change gloves when going from a dirty area to a clean area. He stated the potential negative outcome of not changing gloves and performing hand hygiene could be the spread of infection and contaminants. He stated staff had been trained to disinfect the BP cuff between resident use. He stated the potential negative outcome of not disinfecting the BP cuff could be the spread of contaminants and infection. <BR/>Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment last revised October 2018 revealed: <BR/>Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. <BR/> .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. <BR/>(1.) <BR/>Non-critical resident care items include bedpans, blood pressure cuffs .<BR/>(2.) <BR/>Most non-critical reusable items can be decontaminated where they are used.<BR/>Record review of facility policy titled Handwashing/Hand Hygiene last revised August 2019 revealed:<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations:<BR/> .h. Before moving from a contaminated body site to a clean body site during resident care; .<BR/> .m. after removing gloves;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on obervation, interviews and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administration of drugs that meet the needs of all residents for 1 of 5 residents (Resident #1) reviewed for pharmacy services. <BR/>ADON failed to make sure that drugs and biologicals are prepared and given by the same person by preparing a medication and giving it to CNA to administer to Resident #1, on 12/30/2024 around 10:30 AM per anonymous complaint dated 12/31/2024. <BR/>This failure could place residents at risk for not receiving medications correctly. <BR/>Findings included: <BR/>Record Review of Resident #1's facesheet dated 01/08/2025 revealed that Resident #1 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #1 had a medical history of acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), epilepsy (disorder in which nerves cell activity in the brain is disturbed, causing seizures), insomnia (makes it difficult to fall asleep or stay asleep), anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (loss of pleasure or interest in activities for long periods of time), dysphagia (swallowing difficulties), cerebral palsy (congenital disorder of movement, muscle, tone, or posture), and congenital hypertonia (overly toned muscles that cause muscles to be stiff and difficult to control).<BR/>Record review of Resident #1s MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 10 which indicated Resident #1 had a moderate cognitive impairment. Section GG- Functional Abilities: A. revealed a score of 2 for eating, which indicated Resident #1 needed substantial/maximal assistance. Section K- Swallowing/Nutritional Status C. revealed coughing or choking during meals or when swallowing medications. K0520 revealed mechanically altered diet. <BR/>Record review of Resident #1 s care plan dated 08/19/2020 revealed problem: Resident #1 has an ADL self-performance deficit related to cerebral palsy. Goal to maintain current level of function in ADL's through the review date. Date initiated 07/23/2022. Interventions: Eating: Resident #1 requires extensive assist x 1 with eating. 04/20/21 Resident #1 requires extensive assist x 1 with eating. She has a regular diet, foods cut up into bite size pieces. She has difficulty with swallowing, so requires attention. She has ROM deficits in upper extremities requiring assist with feeding. Initiated on 08/19/2020. Revision on 10/06/2023.<BR/>Record review of Resident #1s physician order dated 02/13/2024 for Resident #1 to receive ST skilled service 3 x week for 30 days for dysphagia management. <BR/>Record review of Resident #1s Nutritional Review assessment dated [DATE]: 8. Current Diet/Supplement Order: Regular pureed diet with nectar thicken liquids. 9. Appropriateness of Diet Order: Appropriate. 10. Ability to Chew/Swallow: Ok. 13. Ability to feed self: Dependent. 24. Comments: Resident #1 is alert to person and place and can communicate needs.<BR/>Record review of Resident #1's Nursing Monthly Summary dated 12/13/2024 revealed: Section A. Level of Consciousness/Orientation/Cognition: Resident #1 is alert and oriented to person and place, with episodic confusion. Section H. ADLs- Eating is total dependence of one person. Diet order: thickened liquids, pureed. <BR/>Record review of Resident #1's December 2024 Medication Administration Record revealed an order for Tylenol Extra Strength oral tablet 500 mg. Give one tablet by mouth every 6 hours as needed for pain. There is no documentation on 12/31/2024 that the medication was given. <BR/>During an interview on 01/08/2025 at 8:40 AM, the ADON stated that it had been a hectic day and she was running behind with the medication pass. ADON stated that her family member, CNA, came by and asked if she needed any help. ADON stated that she remembered it was during the morning med pass on 12/30/2024, and Resident #1 was crying out. ADON stated that she poured a Tylenol Extra Strength tablet into a medication cup and asked CNA to go administer the medication to Resident #1. ADON stated that CNA also does transportation for the facility and knows her residents very well. ADON stated it was just an OTC medication, and she would not have done that with any of the other medications. ADON stated that she would never to that again, it was just a spur of the moment decision. ADON revealed CNA is not certified to administer medications. <BR/>During an interview on 01/08/2025 at 9:34 AM, Confidential Person A stated that she observed the ADON give a medication cup to CNA. Confidential Person A stated they did not know what was in the cup, but they knew a CNA should not be giving medications. <BR/>During an observation on 01/08/2025 at 9:54 AM, Resident #1 was observed resting with eyes closed, head of bed up at 30 degrees, and had oxygen administering via nasal cannula. No signs or symptoms of distress. <BR/>During a phone interview on 01/08/2025 at 10:40 AM, Regional RN stated, oh no, they can not do that, regarding the ADON giving CNA a medication to administer to Resident #1. <BR/>During an interview on 01/08/2025 at 11:16 AM, CNA stated that Monday 12/30/2024 had been a crazy day, and she was checking with other staff to see if she could help them with anything. CNA stated her family member, ADON was passing medications, and CNA asked her if she needed her to do anything. ADON poured a Tylenol Extra Strength tablet into a medication cup and asked her to go administer it to Resident #1. Resident #1 took the medication without incident. CNA stated that she was just trying to help out, and it was just an OTC medication. Regarding the risks to a resident if someone did not know the resident had an order for thickened liquids, CNA stated that she had been certified for 10 years, and as a CNA she knows that about her residents. CNA stated that Resident #1's head of bed is always elevated. CNA stated that she did not have her certification to administer medications. CNA stated that she would never do it again and stated that she would not have done that if it had not been her family member. <BR/>During an interview on 01/08/2025 at 11:25 AM, Confidential Person B stated that they were concerned about an uncertified person giving medications, because they may not know what they are giving, or whether or not that resident has thickened liquids, or possibly the unlicensed person could give the medication to the wrong person. <BR/>During an interview on 01/08/2025 at 11:46 AM, LVN A revealed the risks to a resident that is administered medications by an uncertified person includes not knowing what medication they are giving, what the side effects are, if there are parameters that need to be checked prior to administration, or there might be possible drug interactions with other medications. LVN A stated that if a person is not certified in medication administration, they should not be giving medications. <BR/>During an interview on 01/08/2025 at 12:20 PM, ADON stated that a lot of things could happen to a resident with an uncertified person giving medications. ADON stated, I did it, but I will never do it again.<BR/>During an interview on 01/08/2025 at 12:30 PM, Resident #1 was awake, made eye contact and smiled. Investigator asked how she was doing. It took a little while for her to get her words out. Resident #1 voiced she was doing ok. Resident #1 denied any concerns regarding the staff or her care. Resident #1 could not recall what medications she had on 12/30/2024. <BR/>During an interview on 01/08/2025 at 1:47 PM, the Interim DON stated that the ADON had just told her about giving a medication to her family member, CNA, to administer to Resident #1. Interim DON stated, that is not good. Interim DON stated that the risks to a resident being given medication by an uncertified person could result in the resident choking or aspirating, or they may give the medication to the wrong person.<BR/>During an interview on 01/08/2025 at 2:27 PM, LVN B, stated that the risks of an uncertified person giving medications include they could give the medication to the wrong person, or they may not give the resident the medication and take it themselves, the uncertified person may not know what the medication is for, or know what the side effects might be. LVN B stated there could be a lot wrong with an uncertified person administering medications. <BR/>During an interview on 01/08/2025 at 3:15 PM, Physician stated that the risks of an uncertified person administering medications that they did not prepare, first you would be relying on what someone else was telling you the medication was. Physician stated, it is just not good practice.<BR/>Record review of Disciplinary Action Form dated 01/08/2025 for ADON. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by ADON and Interim DON. <BR/>Record review of Disciplinary Action Form dated 01/08/2025 for CNA. Safety violation: Unsafe Practice. Detailed description of offense: Not following the policy for Medication Administration. Employee comments: Will follow the facility policy. Action taken: Written Warning. Signed and dated by CNA and Interim DON. <BR/>Record review of in-service dated 01/08/2025: Medication Administration: Only licensed personnel or personnel permitted by the state to prepare, administer, and document the administration of medication can do so. <BR/>The following policy reviewed: Administering Medications, 2001 Med-Pass, Inc. (Revised April 2019)<BR/>Policy Statement: Medications are administered in a safe and timely manner, as prescribed. <BR/>Policy Interpretation and Implementation: <BR/>1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, the comprehensive person-centered care plan, and the residents' choices for 2 of 20 residents (Resident #15 and 23) with orders for psychotropic and/or antibiotic medications, in that:<BR/>1) The facility failed to have physician's orders, assessments, care plan, communication, and coordination of care with physician/pharmacist/staff/pain management physician in place for Resident #15 related to pain management. <BR/>2)The facility failed to ensure Resident #23 received physician ordered medications prescribed for anxiety and a UTI.<BR/>An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>These failures affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. Additionally, these failures could place residents at risk for an increase in behaviors and infection symptoms. <BR/>The findings include:<BR/>Resident #15:<BR/>Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle).<BR/>Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23.<BR/>Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023.<BR/>Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8:<BR/>7/7/22 at 7:34 AM - 7<BR/>7/23/22 at 19:22 (7:22 PM) - 8<BR/>8/7/22 at 14:32 (2:23 PM) -6<BR/>8/23/22 at 8:59 AM - 6<BR/>8/30/22 at 22:49 (10:49 PM) - 8<BR/>9/2/22 at 6:58 AM - 7<BR/>1/13/23 at 3:58 AM - 6<BR/>Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following:<BR/>Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . <BR/>Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 .<BR/>Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give &frac12; hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 .<BR/>Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: <BR/>Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus.<BR/>Tylenol extra strength 500mg every 8 hours as needed for MS.<BR/>Requip 0.25mg every day for Restless Leg Syndrome.<BR/>Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms.<BR/>Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. <BR/>An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10.<BR/>Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention.<BR/>Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump.<BR/>Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities.<BR/>Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed.<BR/>Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication.<BR/>Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following:<BR/>Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day.<BR/>Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. <BR/>Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. <BR/>Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. <BR/>Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). <BR/>Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations.<BR/>Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN.<BR/>Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. <BR/>Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. <BR/>Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations.<BR/>Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18.<BR/>Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following:<BR/>Steps in the procedure: <BR/>8. Skin: <BR/>A. Intactness.<BR/>B. Moisture.<BR/>C. Color.<BR/>D. Texture.<BR/>E. Presence of bruises, pressure, sores, redness, edema, rashes.<BR/>14. Pain:<BR/>Pain: a. F. Current medication and treatments for pain.<BR/>Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following:<BR/>The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain.<BR/>General guidelines:<BR/>1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management.<BR/>2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals.<BR/>3. Pain management is a multidisciplinary care process that includes the following:<BR/>F. Identifying and using specific strategies for different levels and sources of pain.<BR/>G. Monitoring for the effectiveness of interventions.<BR/>Steps in the procedure:<BR/>Assessing pain:<BR/>1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative):<BR/>A. History of pain and its treatment including pharmacological and non-pharmacological interventions.<BR/>Implementing Pain Management Strategies:<BR/>3. The physician and staff will establish a treatment regimen based on consideration of the following: <BR/>B. Current medication regimen.<BR/>4. Strategies that may be employed when establishing the medication regimen include:<BR/>C. Combining long-acting medication with PRN's for breakthrough pain.<BR/>5. Implement the medication regimen as ordered, carefully documenting the results of the interventions.<BR/>Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following:<BR/>Policy statement:<BR/>Orders for medication and treatments will be consistent with principles of safe and effective order riding<BR/>Policy, interpretation, and implementation:<BR/>3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.<BR/>Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following:<BR/>Policy statement:<BR/>All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care.<BR/>Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following:<BR/>Policy statement:<BR/>The attending physician will be responsible for the following:<BR/>1. Excepting responsibility for initial and subsequent resident care.<BR/>2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards.<BR/>Providing appropriate care:<BR/>9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions.<BR/>On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested.<BR/>The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following:<BR/>Request to remove immediate jeopardy dated 1/12/2023<BR/>How corrective action will be accomplished for those residents affected by the violation:<BR/>Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. <BR/>Completion date 1/12/2023.<BR/>LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. <BR/>Completion 1/12/2023<BR/>In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care.<BR/>Completion 1/12/ 2023<BR/>How the facility will identify other residents with the potential to be affected by the same violation:<BR/>Only one resident in the facility has an internal pain pump currently.<BR/>Completion 1/12/2023<BR/>What measures will be put into place or systematic changes made to ensure the violation will not reoccur.<BR/>admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information.<BR/>Completion 1/12/2023.<BR/>How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur.<BR/>Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved.<BR/>Completion 1/13/2023<BR/>Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023.<BR/>Addendum to request to remove immediate Jeopardy dated 1/12/2023<BR/>Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff.<BR/> Nursing staff was in-serviced included regarding the remote bolus PRN doses.<BR/>In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. <BR/>The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows:<BR/>Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's.<BR/>Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs.<BR/>During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. <BR/>During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. <BR/>During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. <BR/>Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. <BR/>The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan.<BR/>Resident #23:<BR/>Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure Resident 1's Physician Ordered dressings for the left thigh, coccyx, and left hip, based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that:<BR/>1. Resident #1's pressure ulcer on his left thigh was observed being uncovered with no dressings. Resident #1's pressure ulcer on coccyx (a small bone at the base of the spinal column) was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcers being exposed. Resident #1's pressure ulcer to the coccyx was observed with the dressing soaked with drainage from the pressure ulcer. <BR/>These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection.<BR/>Findings included:<BR/>Findings include:<BR/>Record review of Resident #1 face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of lung cancer, anemia, low potassium, high blood pressure, hyperlipidemia, atherosclerotic heart disease, nicotine dependence, cancer in bone, tachycardia, congestive heart failure, acid reflux.<BR/>Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 9 which indicated Resident #1 is moderately impaired cognition. Under Bladder and Bowel Resident #1 is listed as always being incontinent with urinary and bowel. Under skin conditions Resident #1 is listed as being a risk of developing pressure ulcers but is not listed as having any pressure ulcers upon admission. <BR/>Record review of Resident #1's Care Plan date revealed: on 06/03/2024, Resident #1 was care planned for pressure ulcers care with interventions of: monitor ulcers for signs of infection, notify provider if no signs of improvement on current wound regimen, provide wound care per treatment orders. There is no care plan for Resident #1 removing his own dressings. <BR/>Record review of Resident #1's Order Summary, date received 06/04/2024, revealed: <BR/>On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>Record review of Resident #1's Treatment Administration Record for June 2024, date received of 06/04/2024, revealed:<BR/>Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Observation had been made of Resident #1 on 06/03/2024 at 8:37 PM, revealed the ADON went with the Surveyor to show Resident #1's pressure ulcers. The ADON gathered a few supplies to cover Resident #1's pressure ulcers when completed with observation. Resident #1 was lying on his back in his room, sleeping. Resident #1 awakened to interview and allowed observations of his pressure ulcers. It was observed that Resident #1's pressure ulcer on his left thigh was uncovered, and with no dressings. Resident #1's pressure ulcer on his coccyx was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcer being exposed, with the dressing being dated 06/02/2024 with initials. Resident #1's pressure ulcer to his coccyx was observed with a dressing soaked with drainage from the pressure ulcer. The dressing had a watery brown drainage from the pressure ulcer on the dressing that was hanging off the top of the pressure ulcer. Resident #1 had blood on the backside and side of his gown and bedding. Observed the ADON following physician's orders per cleaning all wounds and covered with foam dressings with date and initials. <BR/>Interview on 06/03/2024 at 8:32 PM with CNA A revealed she said that she checks the residents every 2 hours. The CNA C stated that she was not aware that Resident #1's pressure ulcers were uncovered but she had just come onto shift and had not had a chance to make her rounds. The CNA C stated that she had seen Resident #1's pressure ulcers uncovered before. The CNA C stated that she is not sure if Resident #1 had removed the dressing or if someone didn't cover the pressure ulcers. The CNA C stated that she had not witnessed staff not covering the pressure ulcers. The CNA C stated that if she had seen the pressure ulcers uncovered, she would report it to the LVN, the ADON, or DON. CNA C stated that she would check to make sure that the pressure ulcers were covered. <BR/>Interview on 06/03/2024 at 8:50 PM with ADON revealed she said that Resident #1's orders did call for the pressure ulcers to be cleaned and covered. The ADON stated that she did not know why the pressure ulcers were uncovered. The ADON stated that the pressure ulcers are scheduled to be cleaned and covered for night shift. The ADON stated that night shift begins at 6 pm to 6 am. The ADON stated that she would assume that the staff had not had time to cleanse and cover the pressure ulcers yet but as long as it had gotten completed before the end of the night shift, it would be fine. ADON stated that usually the staff will make rounds every 2 hours, so they would report to the nursing staff if pressure ulcers were uncovered. <BR/>Interview on 06/03/2024 at 9:18 PM with Resident #1 revealed that he said that he is pain because of the open pressure ulcers and them not being covered. Resident #1 stated that he had not taken off any bandages. Resident #1 stated that the nursing staff do treat his wounds and usually covers them but stated he could not tell that they were uncovered until he moves around a little. <BR/>Interview on 06/03/2024 at 9:10 PM with LVN B revealed he said that he was unaware of Resident #1's wounds because he is only PRN and had not worked in the facility for a while. The LVN B stated that he would get to the pressure ulcers when he finished medication pass. <BR/>Interview on 06/04/2024 at 5:32 PM with ADON revealed she said that she is not sure why there is not a dressing on the left leg wound. The ADON stated that the orders do state to put a dressing on all pressure ulcers for Resident #1. The ADON stated that all nursing staff are responsible for making sure that the dressings is on the pressure ulcers. The ADON stated, Resident #1 does take off the dressings sometimes. There was no dressing observed by Surveyor in the room on the bed or on the floor to show that the resident might have removed it from the pressure ulcer. The ADON stated that the negative potential outcome of the pressure ulcers being uncovered is that it could cause infection, bigger pressure ulcers, and potential to be hospitalized . <BR/>Interview on 06/04/2024 at 5:45 PM with DON revealed she said that she does agree with the physician's orders for pressure ulcers for Resident #1. The DON stated that she expects the staff to follow physician's orders. The DON stated that she did expect staff to let someone know when a pressure ulcer is uncovered so that staff could cover the pressure ulcer as soon as possible and not wait the whole shift. The DON stated that she and the ADON are responsible for training staff. The DON stated that she had provided training for pressure ulcers monthly by in-services. The DON stated that the negative potential outcome for not following physician's orders for Resident #1's uncovered pressure ulcers would be they could get worse and possibly get infected. <BR/>Interview on 06/04/2024 at 6:01 pm with the Administrator revealed she said that she expects the staff to follow physician orders and cover pressure ulcers. The Administrator stated that the DON is responsible for the training for the staff and the staff have been trained. The Administrator stated that the pressure ulcers could worsen or get infected if they are not treated according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control.<BR/>1. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32.<BR/>2. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. <BR/>3. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. <BR/>4. <BR/>CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. <BR/>5. <BR/>CNA B failed to change gloves and perform hand hygiene during incontinence care with Resident #40. <BR/>These failures could place residents at risk for cross contamination and infection. <BR/>The findings include: <BR/>During a medication administration observation on 4/09/2025 at 8:34AM MA A used the blood pressure cuff to take Resident #41's blood pressure. At 8:38 AM, MA A used the same blood pressure cuff to take Resident #32's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #41 or Resident #32. <BR/>During a medication administration observation on 4/09/2025 at 8:38AM MA A used the blood pressure cuff to take Resident #32's blood pressure. At 8:42 AM, MA A used the same blood pressure cuff to take Resident #98's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #32 or Resident #98. <BR/>During a medication administration observation on 4/09/2025 at 8:42AM MA A used the blood pressure cuff to take Resident #98's blood pressure. At 9:08 AM, MA A used the same blood pressure cuff to take Resident #38's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #98 or Resident #38. <BR/>Record review of Resident #195's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #195 had a past medical history of cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), type two diabetes, and urinary tract infection. <BR/>Record review of Resident #195's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 10:28 AM, CNA C cleaned Resident #195's buttocks, removed contaminated gloves, and donned clean gloves. CNA C failed to utilize hand hygiene between glove change. <BR/>Record review of Resident #40's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident 340 had a medical history of major depressive disorder, cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain), and retention of urine. <BR/>Record review of Resident #40's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 11:02 AM, CNA B cleaned Resident #40's buttocks, removed dirty brief and placed clean brief on Resident #40. CNA B failed to change gloves and utilize hand hygiene prior to placing clean brief on Resident #40. <BR/>During an interview on 4/10/2025 at 10:00AM with MA A, she stated the DON was the infection preventionist. She stated she had been rained on infection prevention earlier this year. She stated she had been trained to disinfect the blood pressure cuffs before and after use. She stated the potential negative outcome of not disinfection the BP cuff could be spreading infection between residents. She stated she knew she had to disinfect the BP cuff with the disinfecting wipes but forgot to do so. <BR/>During an interview on 4/10/2025 at 10:30AM with CNA C, she stated the ADM was the infection preventionist. She stated she had been trained on infection control and the last training occurred March 2025. She stated she had been trained to use hand hygiene between glove changes. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection. She stated the DON and ADON do competencies all the time and will check them off on hand hygiene. She stated she did notice she failed to wash her hands between glove changes but had forgotten to do so. <BR/>During an interview on 4/10/2025 at 10:36AM with CNA B, she stated the DON and ADON were the infection preventionist. She stated she had been trained on infection prevention and her last training was approximately a month and a half ago. She stated she had been trained to change gloves when going from dirty to clean. She stated the potential negative outcome of not changing gloves when going from an area of dirty to clean could be spreading bacteria. She stated she had changed her gloves once and forgot to change them again after she cleaned the resident's bottom. <BR/>During an interview on 4/10/2025 at 10:49 AM with the DON, she stated she was the infection preventionist. She stated staff were trained on infection control upon hire, quarterly and as needed. She stated she was unsure of the last training date due to having just started at this facility in January 2025. She stated there was an infection control training scheduled for this month. She stated she expected her staff to wash their hands immediately upon removing their gloves. She stated the potential negative outcome of not changing their gloves and performing hand hygiene could be the spread of infection and an outbreak. She stated staff had been trained to disinfect the blood pressure cuffs and she expects staff to disinfect the blood pressure cuffs before and after resident use. She stated the potential negative outcome of not disinfecting the blood pressure cuff between residents could be the spread of infection. <BR/>During an interview on 4/10/2025 at 11:27AM with the ADM, he stated the ADM, and DON were the infection preventionist. He stated staff were trained on infection control upon hire, annually and as needed. He stated there was an infection control in-service approximately six weeks ago. He stated staff had been trained on washing their hands when changing gloves. He stated the potential negative outcome of not performing hand hygiene between glove changes could be spreading infection. He stated staff had been trained to change gloves when going from a dirty area to a clean area. He stated the potential negative outcome of not changing gloves and performing hand hygiene could be the spread of infection and contaminants. He stated staff had been trained to disinfect the BP cuff between resident use. He stated the potential negative outcome of not disinfecting the BP cuff could be the spread of contaminants and infection. <BR/>Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment last revised October 2018 revealed: <BR/>Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. <BR/> .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. <BR/>(1.) <BR/>Non-critical resident care items include bedpans, blood pressure cuffs .<BR/>(2.) <BR/>Most non-critical reusable items can be decontaminated where they are used.<BR/>Record review of facility policy titled Handwashing/Hand Hygiene last revised August 2019 revealed:<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations:<BR/> .h. Before moving from a contaminated body site to a clean body site during resident care; .<BR/> .m. after removing gloves;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 1 of 1 residents (Resident #3 reviewed for privacy issues in that: <BR/>1. CNA A failed to provide full privacy for Resident #3 during peri care by not completely closing privacy curtains or providing a towel or sheet during peri care. <BR/>2. ADON failed to provide privacy by not providing a sheet or towel to cover the resident and not fully drawing Resident #3's curtain during peri care and wound care. <BR/>This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by.<BR/>Findings include:<BR/>Resident #3:<BR/>Record Review of Resident #3 face sheet dated 07/07/2024 originally admitted on [DATE] with a readmission date of 06/27/2024 reveals a [AGE] year-old female with a diagnosis of: metabolic encephalopathy (chemical imbalance in the blood that causes a problem with the brain), urinary tract infection, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), depression, high blood pressure, anemia, type 2 diabetes, fibromyalgia (a long-term condition that causes widespread pain and tiredness), Sjogren syndrome (an immune system illness that causes dry eyes and dry mouth), type 2 diabetes, acid reflux disease.<BR/>Record review of resident #3 MDS with a date of 06/09/2024, reveals a BIMS score of 12 which indicates resident is moderately impaired. <BR/>During an observation of peri care with CNA A for Resident #3 on 07/08/2024 at 1:07 PM. CNA A failed to provide complete privacy for Resident #3 during peri care. CNA A did not provide a sheet for maximum privacy during peri care. CNA A did not pull the curtains all the way during peri care causing Resident #3's body to be exposed during peri care . CNA A gathered peri care supplies and went into Resident #3's room to provide peri care. CNA A shut Resident #3's room door but did not close the curtain dividing the door from the resident all of the way. CNA A did not pull the privacy curtain to the full extent to cover the bed. CNA A removed Resident #3 removed clothing from the waist down to provide peri care and completed peri care while not providing a sheet for maximum privacy. Observed a camera at the end of Resident #3's bed for family to be able to view Resident #3. CNA A completed peri care with Resident #3. <BR/>During an observation of wound care with ADON for Resident #3 on 07/08/2024 at 1:54 PM. ADON entered Resident #3's room to provide wound care and did shut the door but did not close privacy curtain all the way around the resident to provide optimum privacy. The curtain was only halfway drawn on the right side of the resident that divides the resident from the door. ADON removed Resident #3's clothing from the waist down. There was a camera where the family could view the entire procedure. While Resident #3's pants were pulled down and the brief was open, a CNA walked into the room. There was no sheet that had been provided to cover the resident. ADON and CNA completed peri care and ADON completed wound care and exposed Resident #3 the entire time. <BR/>During an Interview with ADON on 07/08/2024 at 3:03 PM, she stated that she should have provided more privacy for the resident's by shutting the door, making sure blinds are closed, and closing the curtains. ADON stated that the policy stated that staff should provide privacy during care. ADON stated that the negative potential outcome for not providing privacy during care is that the resident is being exposed and it may make them feel bad or upset. ADON stated that she had been trained in privacy by in-services when needed or quarterly. <BR/>During an Interview with DON on 07/08/2024 at 3:24 PM, she stated that she expects that when staff walks in a resident's room to provide resident care they should close the door, close the blinds, close all curtains and cover the resident to provide privacy. The DON stated that the negative potential outcome would be that resident's may not want other people to see their business and may also cause them to become embarrassed. DON stated that the facility provides training quarterly, monthly, and as needed by in-services. <BR/>During an Interview with CNA A on 07/08/2024 at 3:46 PM, she stated that she did know to provide complete privacy for residents. She stated that she wasn't thinking about pulling the curtain closed, just providing peri care. CNA A stated that the negative potential outcome of not providing privacy is that someone could walk in and see the resident. CNA A stated that she had been trained in providing privacy for residents by in-services, monthly. <BR/>Record review of facility policy, labeled, Resident Rights date Revised December 2016, revealed:<BR/>Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. <BR/>Policy Interpretation and Implementation:<BR/>a). a dignified existence<BR/>b). be treated with respect, kindness, and dignity. <BR/>t). privacy and confidentiality.<BR/>Record review of facility provided in-services, labeled, Peri Care, dated June 20, 2024, revealed:<BR/>1. Enters room and identifies self and patient/resident. <BR/>2. Explains the procedure addresses questions and other PPE as indicated. <BR/>3. Provide privacy<BR/>4. Washes hands, applies disposable gloves and other PPE as indicated. <BR/>5. Assembles supplies at bedside. <BR/>6. Raise bed to comfortable working height; assists the resident to a supine position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans.<BR/>This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails.<BR/>This failure could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Findings include:<BR/>Resident #9<BR/>Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). <BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #9 was understood and had a BIMS score of 00 indicating that the resident's cognition was severely impaired. <BR/>Record review of the current care plan for Resident #9, undated, revealed there was no specific care plan regarding bedrails. <BR/>Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have &frac14; side rails on right and left side of bed. <BR/>Resident #11<BR/>Record review of the admission record for Resident #11, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (problem in the brain), acute and chronic respiratory failure (lung disease), and pneumonia (lung infection).<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #11 was understood and had a BIMS score of 12 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #11, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #11, dated 02/27/24, revealed the following order: May use siderails for positioning and ease of mobility as an enabler every shift for siderails with an order start date of 09/29/22.<BR/>Resident #160<BR/>Record review of the admission record for Resident #160, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (motor disability), seizures (neurological disorder), and muscle weakness.<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #160 was usually understood and had a BIMS score of 15 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #160, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #160, dated 02/27/24, revealed the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20.<BR/>During an interview on 02/29/24 at 12:07 PM, the DON and the ADON stated they were both responsible for ensuring the care plans for the residents were completed. The DON and the ADON stated they were unsure why Residents #9, #11 and #160 were missing care plans for bed rails. The DON and ADON stated the care plans were audited last week but they did not look for bedrails in the care plan at that time. The DON stated the potential negative outcome to the residents was the bed rails would not be followed up on and assessed to see if they were still appropriate for the residents. <BR/>During an interview on 02/29/24 at 12:16 PM, the ADM stated the DON and ADON were responsible for ensuring the care plans were completed. The ADM stated the facility had a change in nursing management last year and ensuring bed rails were care planned fell through the cracks. The ADM stated the potential negative outcome to the residents was staff could not be aware and it could cause a possible injury of some sort. <BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following:<BR/>Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure Resident 1's Physician Ordered dressings for the left thigh, coccyx, and left hip, based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for (Residents #1) resident reviewed for pressure ulcer care, in that:<BR/>1. Resident #1's pressure ulcer on his left thigh was observed being uncovered with no dressings. Resident #1's pressure ulcer on coccyx (a small bone at the base of the spinal column) was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcers being exposed. Resident #1's pressure ulcer to the coccyx was observed with the dressing soaked with drainage from the pressure ulcer. <BR/>These failures could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers, and infection.<BR/>Findings included:<BR/>Findings include:<BR/>Record review of Resident #1 face sheet revealed a [AGE] year-old male, admitted on [DATE] with a primary diagnoses of lung cancer, anemia, low potassium, high blood pressure, hyperlipidemia, atherosclerotic heart disease, nicotine dependence, cancer in bone, tachycardia, congestive heart failure, acid reflux.<BR/>Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had a BIMS of 9 which indicated Resident #1 is moderately impaired cognition. Under Bladder and Bowel Resident #1 is listed as always being incontinent with urinary and bowel. Under skin conditions Resident #1 is listed as being a risk of developing pressure ulcers but is not listed as having any pressure ulcers upon admission. <BR/>Record review of Resident #1's Care Plan date revealed: on 06/03/2024, Resident #1 was care planned for pressure ulcers care with interventions of: monitor ulcers for signs of infection, notify provider if no signs of improvement on current wound regimen, provide wound care per treatment orders. There is no care plan for Resident #1 removing his own dressings. <BR/>Record review of Resident #1's Order Summary, date received 06/04/2024, revealed: <BR/>On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the coccyx. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left hip. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure as needed for wound care. <BR/>On 05/27/2024 verbal orders were given for wound care to the left thigh. Cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care. <BR/>Record review of Resident #1's Treatment Administration Record for June 2024, date received of 06/04/2024, revealed:<BR/>Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. Treatment record indicated that June 1st and 2nd wound care was provided. There was nothing indicated for the 3rd. <BR/>Wound Care: coccyx, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Wound Care: left hip, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Wound Care: left thigh, cleanse with wound cleanser, pat dry with gauze, apply foam dressing, tape and secure every night shift for wound care, start date: 05/27/2024 at 6:00 PM. There was nothing indicated for PRN. <BR/>Observation had been made of Resident #1 on 06/03/2024 at 8:37 PM, revealed the ADON went with the Surveyor to show Resident #1's pressure ulcers. The ADON gathered a few supplies to cover Resident #1's pressure ulcers when completed with observation. Resident #1 was lying on his back in his room, sleeping. Resident #1 awakened to interview and allowed observations of his pressure ulcers. It was observed that Resident #1's pressure ulcer on his left thigh was uncovered, and with no dressings. Resident #1's pressure ulcer on his coccyx was observed with having a dressing hanging off the backside above the pressure ulcer with the pressure ulcer being exposed, with the dressing being dated 06/02/2024 with initials. Resident #1's pressure ulcer to his coccyx was observed with a dressing soaked with drainage from the pressure ulcer. The dressing had a watery brown drainage from the pressure ulcer on the dressing that was hanging off the top of the pressure ulcer. Resident #1 had blood on the backside and side of his gown and bedding. Observed the ADON following physician's orders per cleaning all wounds and covered with foam dressings with date and initials. <BR/>Interview on 06/03/2024 at 8:32 PM with CNA A revealed she said that she checks the residents every 2 hours. The CNA C stated that she was not aware that Resident #1's pressure ulcers were uncovered but she had just come onto shift and had not had a chance to make her rounds. The CNA C stated that she had seen Resident #1's pressure ulcers uncovered before. The CNA C stated that she is not sure if Resident #1 had removed the dressing or if someone didn't cover the pressure ulcers. The CNA C stated that she had not witnessed staff not covering the pressure ulcers. The CNA C stated that if she had seen the pressure ulcers uncovered, she would report it to the LVN, the ADON, or DON. CNA C stated that she would check to make sure that the pressure ulcers were covered. <BR/>Interview on 06/03/2024 at 8:50 PM with ADON revealed she said that Resident #1's orders did call for the pressure ulcers to be cleaned and covered. The ADON stated that she did not know why the pressure ulcers were uncovered. The ADON stated that the pressure ulcers are scheduled to be cleaned and covered for night shift. The ADON stated that night shift begins at 6 pm to 6 am. The ADON stated that she would assume that the staff had not had time to cleanse and cover the pressure ulcers yet but as long as it had gotten completed before the end of the night shift, it would be fine. ADON stated that usually the staff will make rounds every 2 hours, so they would report to the nursing staff if pressure ulcers were uncovered. <BR/>Interview on 06/03/2024 at 9:18 PM with Resident #1 revealed that he said that he is pain because of the open pressure ulcers and them not being covered. Resident #1 stated that he had not taken off any bandages. Resident #1 stated that the nursing staff do treat his wounds and usually covers them but stated he could not tell that they were uncovered until he moves around a little. <BR/>Interview on 06/03/2024 at 9:10 PM with LVN B revealed he said that he was unaware of Resident #1's wounds because he is only PRN and had not worked in the facility for a while. The LVN B stated that he would get to the pressure ulcers when he finished medication pass. <BR/>Interview on 06/04/2024 at 5:32 PM with ADON revealed she said that she is not sure why there is not a dressing on the left leg wound. The ADON stated that the orders do state to put a dressing on all pressure ulcers for Resident #1. The ADON stated that all nursing staff are responsible for making sure that the dressings is on the pressure ulcers. The ADON stated, Resident #1 does take off the dressings sometimes. There was no dressing observed by Surveyor in the room on the bed or on the floor to show that the resident might have removed it from the pressure ulcer. The ADON stated that the negative potential outcome of the pressure ulcers being uncovered is that it could cause infection, bigger pressure ulcers, and potential to be hospitalized . <BR/>Interview on 06/04/2024 at 5:45 PM with DON revealed she said that she does agree with the physician's orders for pressure ulcers for Resident #1. The DON stated that she expects the staff to follow physician's orders. The DON stated that she did expect staff to let someone know when a pressure ulcer is uncovered so that staff could cover the pressure ulcer as soon as possible and not wait the whole shift. The DON stated that she and the ADON are responsible for training staff. The DON stated that she had provided training for pressure ulcers monthly by in-services. The DON stated that the negative potential outcome for not following physician's orders for Resident #1's uncovered pressure ulcers would be they could get worse and possibly get infected. <BR/>Interview on 06/04/2024 at 6:01 pm with the Administrator revealed she said that she expects the staff to follow physician orders and cover pressure ulcers. The Administrator stated that the DON is responsible for the training for the staff and the staff have been trained. The Administrator stated that the pressure ulcers could worsen or get infected if they are not treated according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Residents #41, #32, #98, #38, #195, #40) reviewed for infection control.<BR/>1. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #41 and Resident #32.<BR/>2. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #32 and Resident #98. <BR/>3. <BR/>MA A failed to sanitize the blood pressure cuff between resident use for Resident #98 and Resident #38. <BR/>4. <BR/>CNA C failed to utilize hand hygiene between glove changes during incontinence care with Resident #195. <BR/>5. <BR/>CNA B failed to change gloves and perform hand hygiene during incontinence care with Resident #40. <BR/>These failures could place residents at risk for cross contamination and infection. <BR/>The findings include: <BR/>During a medication administration observation on 4/09/2025 at 8:34AM MA A used the blood pressure cuff to take Resident #41's blood pressure. At 8:38 AM, MA A used the same blood pressure cuff to take Resident #32's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #41 or Resident #32. <BR/>During a medication administration observation on 4/09/2025 at 8:38AM MA A used the blood pressure cuff to take Resident #32's blood pressure. At 8:42 AM, MA A used the same blood pressure cuff to take Resident #98's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #32 or Resident #98. <BR/>During a medication administration observation on 4/09/2025 at 8:42AM MA A used the blood pressure cuff to take Resident #98's blood pressure. At 9:08 AM, MA A used the same blood pressure cuff to take Resident #38's blood pressure. No sanitation of equipment was conducted before or after using the blood pressure cuff on Resident #98 or Resident #38. <BR/>Record review of Resident #195's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident #195 had a past medical history of cerebral infarction (a type of stroke caused by a blockage of blood flow to the brain, leading to tissue damage and potential cell death), type two diabetes, and urinary tract infection. <BR/>Record review of Resident #195's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 10:28 AM, CNA C cleaned Resident #195's buttocks, removed contaminated gloves, and donned clean gloves. CNA C failed to utilize hand hygiene between glove change. <BR/>Record review of Resident #40's undated face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident 340 had a medical history of major depressive disorder, cerebrovascular disease (conditions that affect the blood vessels and blood supply to the brain), and retention of urine. <BR/>Record review of Resident #40's MDS dated [DATE] Section H- Bladder Bowel revealed she was always incontinent of bowel and bladder.<BR/>During an observation of incontinence care on 4/09/2025 at 11:02 AM, CNA B cleaned Resident #40's buttocks, removed dirty brief and placed clean brief on Resident #40. CNA B failed to change gloves and utilize hand hygiene prior to placing clean brief on Resident #40. <BR/>During an interview on 4/10/2025 at 10:00AM with MA A, she stated the DON was the infection preventionist. She stated she had been rained on infection prevention earlier this year. She stated she had been trained to disinfect the blood pressure cuffs before and after use. She stated the potential negative outcome of not disinfection the BP cuff could be spreading infection between residents. She stated she knew she had to disinfect the BP cuff with the disinfecting wipes but forgot to do so. <BR/>During an interview on 4/10/2025 at 10:30AM with CNA C, she stated the ADM was the infection preventionist. She stated she had been trained on infection control and the last training occurred March 2025. She stated she had been trained to use hand hygiene between glove changes. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection. She stated the DON and ADON do competencies all the time and will check them off on hand hygiene. She stated she did notice she failed to wash her hands between glove changes but had forgotten to do so. <BR/>During an interview on 4/10/2025 at 10:36AM with CNA B, she stated the DON and ADON were the infection preventionist. She stated she had been trained on infection prevention and her last training was approximately a month and a half ago. She stated she had been trained to change gloves when going from dirty to clean. She stated the potential negative outcome of not changing gloves when going from an area of dirty to clean could be spreading bacteria. She stated she had changed her gloves once and forgot to change them again after she cleaned the resident's bottom. <BR/>During an interview on 4/10/2025 at 10:49 AM with the DON, she stated she was the infection preventionist. She stated staff were trained on infection control upon hire, quarterly and as needed. She stated she was unsure of the last training date due to having just started at this facility in January 2025. She stated there was an infection control training scheduled for this month. She stated she expected her staff to wash their hands immediately upon removing their gloves. She stated the potential negative outcome of not changing their gloves and performing hand hygiene could be the spread of infection and an outbreak. She stated staff had been trained to disinfect the blood pressure cuffs and she expects staff to disinfect the blood pressure cuffs before and after resident use. She stated the potential negative outcome of not disinfecting the blood pressure cuff between residents could be the spread of infection. <BR/>During an interview on 4/10/2025 at 11:27AM with the ADM, he stated the ADM, and DON were the infection preventionist. He stated staff were trained on infection control upon hire, annually and as needed. He stated there was an infection control in-service approximately six weeks ago. He stated staff had been trained on washing their hands when changing gloves. He stated the potential negative outcome of not performing hand hygiene between glove changes could be spreading infection. He stated staff had been trained to change gloves when going from a dirty area to a clean area. He stated the potential negative outcome of not changing gloves and performing hand hygiene could be the spread of infection and contaminants. He stated staff had been trained to disinfect the BP cuff between resident use. He stated the potential negative outcome of not disinfecting the BP cuff could be the spread of contaminants and infection. <BR/>Record review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment last revised October 2018 revealed: <BR/>Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard. <BR/> .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. <BR/>(1.) <BR/>Non-critical resident care items include bedpans, blood pressure cuffs .<BR/>(2.) <BR/>Most non-critical reusable items can be decontaminated where they are used.<BR/>Record review of facility policy titled Handwashing/Hand Hygiene last revised August 2019 revealed:<BR/> .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations:<BR/> .h. Before moving from a contaminated body site to a clean body site during resident care; .<BR/> .m. after removing gloves;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 2 of 5 (Resident #1 and Resident #2) reviewed for neglect. <BR/>The ADM and DON failed to report Resident #1 fall that resulted in the resident sustaining 2 head laceration and being transported to a local emergency room. <BR/>The ADM and DON failed to report Resident #2 fall that resulted in a Compression fracture of lumbar vertebra .<BR/>These failures could place residents at risk of allegations not being reported and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators.<BR/>Findings Included: <BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling).<BR/>Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/> Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #1's care plane revealed the following:<BR/>[DATE] <BR/>Problem:<BR/>Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand.<BR/>Intervention:<BR/>Anticipate and meet Resident #1 needs<BR/>Review past falls and attempt to determine cause of the falls.<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #1 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] 9:55 AM<BR/>Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C<BR/>Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. <BR/>Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. <BR/>Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. <BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck.<BR/>Physical Exam<BR/>Constitutional: She is in acute distress<BR/>Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound.<BR/>Neck: Patient is in a c-collar<BR/>Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed.<BR/>Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness <BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. <BR/>Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #2's care plan revealed the following:<BR/>[DATE]<BR/>Problem:<BR/>Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Resident #2encouraged to utilize call light and wait for assistance.<BR/>Intervention:<BR/>o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE]<BR/>Problem:<BR/>The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 states she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE]<BR/>Intervention:<BR/>[DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. <BR/>Date Initiated: [DATE]<BR/>Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not<BR/>want to go to the ER states, I barely hit my head. Date Initiated: [DATE]<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #2 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] <BR/>Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D<BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>Chief Complaint: Fall<BR/>Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]).<BR/>Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back.<BR/>During a confidential interview, it was stated that the CNA was suspended on [DATE]. They stated that the incident was not reported regarding Resident #1 until [DATE] because the ADM said she wanted people to shut up about it. They stated the incident/fall with Resident #1 and with Resident #2 was not reported. They stated that the person responsible for reporting was the ADM. She said the ADM was the abuse coordinator. After Resident #1 fell out of her wheelchair, the Regional Clinical Director completed an in-service about wheelchair safety. They stated they had been trained to report unwitnessed falls, misappropriation of property, injuries, and anything dealing with abuse to the state entity. They said not reporting makes the facility appear to be hiding something. They said not reporting and not investigating incidents could result in a decrease in the level of care. They said the injury could progress into something worse if they do not thoroughly look into it. They said it could make the residents involved and other residents feel unsafe if they were cognitive enough to know the facility did not address it. They stated they did not know much about Resident #2's fall but that it had happened at night, and it was also not reported. <BR/>During a confidential interview, it was stated It was their understanding that the only reason Resident #2 incident/fall was reported was because there had been an uproar made. The uproar was staff talking about it and questioning the death of the resident and why the incident with Resident #1 was not reported. They stated they had expressed to the DON that something was not right. They indicated that the DON had reassured them that everything was ok, that Resident #1 was checked at the hospital, and that the facility had done everything they were supposed to do. They said because of the response they were getting, it made them not want to talk about it anymore. They stated that due to the staff talking about Resident #1, the ADM would speak with them separately and tell them the gossiping needed to stop. They said that during their turn with the ADM, they expressed that they felt something was not right with the incident with Resident #1. They stated the Regional Clinical Director told them that because of the staff talking and not letting it go, the facility had to self-report the incident with Resident #1's fall. They stated that once it was reported, they were relieved. They stated regarding Resident #2 fall, she was told that she went to the hospital, and during updates, we were told that she had broken her back. They said they did not know if Resident #2 fall/injury had been reported. They stated that failure to report and investigate could make the residents scared and unsure of their care. They stated the abuse coordinator was the ADM. They stated they understood that the ADM had to be the one to call the incidents in. They said they do not know why Resident #1's incident was not called in, nor Resident #2. <BR/>During a confidential interview, they stated they asked the DON if Resident #1's fall/incident had been reported. The DON told them it had not been reported. They said they were confused, especially since CNA A had been suspended, confirmed, and terminated. They stated they knew they had a 2-hour window to report it to the state. They said they knew that if there was no injury, they had 24 hours. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They stated they asked the DON if Resident #2's fall had been reported, and again, they were told it had not been reported. They said they were told by the ADM that the incident with Resident #1 and Resident #2 was not reported because they knew what happened in both instances. They stated that they were concerned that both falls should have been reported. They said they reported their concerns about the ADM not reporting the falls and other concerns with how the staff were treated and were told that her supervisor would address it. They said many staff had concerns with fear of retaliation from the ADM, which was why they do not want to report or say anything. <BR/>During a Confidential Interview, it was stated that they heard CNA B yell stop. Before that, they heard Resident #1 yelling. They said Resident #1 yells, but this particular day ([DATE]), the yell was elongated. Resident #1's yell was abnormal. After that, we heard the fall. They said they went to assist. They stated there were two lacerations, and they were not able to get the bleeding to stop. They stated when the local ambulance arrived, one of the lacerations was still bleeding. They said the major laceration had 7 or 8 stitches. They stated that they were asked questions by the ADM and were told that CNA A would be suspended so that an investigation could be conducted. They said everything that was told in this interview was told to the ADM. They stated that they did not have any information about Resident #2's fall but that he heard it was bad. <BR/>During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They stated that it was her understanding that the fall was not reported because it was witnessed. They said they did not have any information on Resident #2 fall. <BR/>During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they did not know anything about Resident #2's fall. <BR/>During a confidential interview, they stated they were working with Resident #1 on the day that she fell. She said she was present on the day of the fall and saw everything. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. She stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him (CNA A) to stop, and CNA A kept pushing Resident #1. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. <BR/>During a confidential interview, they stated they were pulled to the floor to help the staff because another staff member was sick. They said it was near mealtime. They stated they observed Resident #1 yelling. She stated she observed Resident #1 feet under the chair. They stated they told CNA A that Resident #1's feet were under the chair and that he was dragging Resident #1's feet. They said they told CNA A that was why Resident #1 was yelling. They stated that the Activity Director called them, and when CNA A passed the door, they again told CNA that they were still dragging Resident #1 feet. They stated shortly after that moment, they heard the fall. They said when they told CNA A, he never readjusted her, checked her (Resident #1) feet, or even responded to them. They stated he kept pushing her. They stated they did not have any information about Resident #2 fall. <BR/>During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They said they did not know anything about Resident #2's fall. <BR/>During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days. She stated she did not call it in because it was not intentional on CNA A behalf. She stated she went ahead and called Resident #1 in because she had passed away, and staff were making a big deal about it. She said Resident #1 fell on [DATE], and she died on [DATE]. The ADM stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17.<BR/>During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at her son's home, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December.<BR/>During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing.<BR/>During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems.<BR/>During an interview on [DATE] at 2:38 PM, the Regional Clinical Director stated that she did not consider a laceration to be a serious injury. She stated a laceration was minor. She said serious was when surgical repair was needed. She stated urgent care was more. She stated she was unaware of Resident #2 injuries until the investigator was in the facility. She said that she did not feel that Resident #1 fall was reportable. She stated when she called the other regional nurse, she was instructed that if they were unsure, then the incident needed to be reported. She stated the ADM had initiated an investigation, and CNA A had already been terminated. She said they allow the DON and ADM to oversee the facility and have yet to read the self-report submitted regarding Resident #1. She said they did not report Resident #1 because it was perceived as a minor injury. She stated Resident #2 was unaware of it.<BR/>During an interview on [DATE] at 2:38 PM at 2:52 PM, CNA A stated he did not mean for Resident #1 to fall. He stated he did not know her feet were under the wheelchair. He stated he did not feel a difference in pushing her. He said he did not hear anyone tell him to stop. He stated that he was the only CNA on the side where Resident #1 resided. He stated that he believed this was why he did not pay attention. He said he was worried about getting everyone out of the dining room by himself. He stated there was no other staff in the dining room with him. He stated there were other residents in the dining room. He stated the kitchen staff was in the kitchen. He said he was unaware that Resident #1 would put her feet down. He stated that she had large legs and had previously inquired about leg rest for another resident. He said he had not asked for leg rest for Resident #1. He stated he was told by housekeeping staff that maintenance would get them. He said he brought this to maintenance attention and was told it would be taken care of. He stated he felt that he did not receive adequate training. He stated he was on the floor one day with another staff and that training did not include getting to know the other residents but instead included asking him to help with the larger residents and telling him to change people on his own. He was never informed that Resident #1 would drop her feet. He stated if he had been trained about Resident #1, he would have checked her feet. He said he pushed her, and she fell out of the chair. He stated he only stopped because he saw her fall forward. He stated he never stopped until she started falling forward.<BR/>Record review of the ADM witness statement dated [DATE] revealed the following:<BR/>On [DATE], she was in the hallway on station 1 when she heard someone yell, Stop !She stated she looked down the hallway and saw CNA A look back. She stated he turned his head. He stopped pushing the wheelchair, and at this time, Resident #1 fell forward. She was assessed and sent to the hospital for evaluation.<BR/>Record review of a confidential witness statement revealed the following:<BR/>They assisted in the assessment of Resident #1. During the course of providing care to Resident #1, they overheard the Activity director tell CNA A, We told you to stop pushing her; her legs were under her wheelchair. They stated they addressed the ADM about reporting the resident death to the state and were told by the ADM that they knew how and why she died. They said the ADM told them that when a resident was on hospice, they were filled with morphine, and then they die. <BR/>Record review of a confidential witness statement revealed the following:<BR/> They were not present the day Resident #1 fell but were notified that Resident #1 was being pushed by CNA A and, after being told to stop, failed to stop. She stated that while others rendered aid, 911 was called. Resident #1 was sent to the hospital and received 7-8 stitches. They said that during a meeting, Resident #1 death was brought up. They stated the ADM stated she would report it since there was a lot of discussion about it. They stated that the ADM said she would report it because if the Activity Director quits, she would ultimately report it. <BR/>Record review of a confidential witness statement revealed the following:<BR/>They heard Resident #1 screaming for at least 5 seconds. They stated they recognized her scream because when Resident #1 did not want to be moved, she would scream. They looked at another staff and then took a step where they could see out the door. They saw Resident #1 mid-fall. They stated Resident #1 hit her head first. They stated they heard CNA A say they

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 5 allegations reviewed for reporting alleged resident abuse (Resident #1 and Resident #2). <BR/>The facility failed to ensure an allegation of neglect for Resident #1 was thoroughly investigated. <BR/>The facility failed to ensure an allegation of neglect for Resident #2 was thoroughly investigated. these failures could place residents at risk of unidentified abuse due to allegations not being investigated as required.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling).<BR/>Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/> Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #1's care plane revealed the following:<BR/>[DATE] <BR/>Problem:<BR/>Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand.<BR/>Intervention:<BR/>Anticipate and meet Resident #1 needs<BR/>Review past falls and attempt to determine cause of the falls.<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #1 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] 9:55 AM<BR/>Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C<BR/>Record review of Form 3613 dated and signed [DATE] revealed that on [DATE] CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. <BR/>Record review of CNA A's witness statement, dated [DATE], stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. <BR/>Review of CNA B's witness statement, dated [DATE], stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. <BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck.<BR/>Physical Exam<BR/>Constitutional: She is in cute distress<BR/>Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound.<BR/>Neck: Patient is in a c-collar<BR/>Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed.<BR/>Record review of Resident #2's face sheet, undated, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with altered mental status, anxiety disorder (increased feeling of worry, fear and uneasiness), cellulitis (skin infection that causes redness and swelling) and muscle weakness <BR/>Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. <BR/>Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #2's care plane revealed the following:<BR/>[DATE]<BR/>Problem:<BR/>Resident #2 is resistive to care such as refusing to lay in bed to avoid falls out of wheelchair. Resident is redirected multiple times to avoid injuries and future falls. Resident #1 prefers to stay in chair while she sleeps and leans over in wheelchair despite redirection and education. [DATE] Resident #1 continues to get up without assist. She leans forward in the chair also causing herself to fall forward out the chair. Resident #1 took herself to the toilet and upon return to the bed she slid down onto her knees. Resident #1 does have Skin tears, first aid given, back to bed in lowest position, call light visible and within reach. Ms. [NAME] encouraged to utilize call light and wait for assistance.<BR/>Intervention:<BR/>o If possible, negotiate a time for ADLs so that the resident participates in the decision making process. Return at the agreed upon time. Date Initiated: [DATE]<BR/>Problem:<BR/>The resident #2 has had an actual fall with no injury's r/t Poor Balance, Psychoactive drug use, Unsteady gait [DATE]: Resident #2 forgot to lock her w/c, Resident #2 leaned forward and fell out to the floor. Resident #2 Left knee, treated by CN. Frequently Remind Resident #2 to lock her wheel chair, Frequent rounding on residents. Keep call light visible and within reach, anticipate residents needs, respond timely. [DATE] Resident #2 was reported to be on the floor in her room by her roommate. Resident #2 States she went to the bathroom and did not scoot far enough back into the wheelchair landed on floor causing multiple skin tears and a [NAME]. Reminded Resident #2 to utilize the call light and wait for assist. Continue POC. [DATE] Resident #2 on the floor. Assessed for injury and does have skin tears. [DATE]: Resident #2 leaned forward in her wheelchair causing her to fall Date Initiated: [DATE] Revision on: [DATE]<BR/>Intervention:<BR/>[DATE]: Resident #2 asleep in her w/c, dreamed she was dancing and fell out of wheelchair. <BR/>Date Initiated: [DATE]<BR/>Resident #2 fell out of her wheelchair outside leaning forward and hit her head. She did not<BR/>want to go to the ER states, I barely hit my head. Date Initiated: [DATE]<BR/>Record review of the facility incident report from [DATE] to [DATE] revealed the following:<BR/>Resident #2 had a witnessed fall on [DATE]<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>[DATE] <BR/>Resident was found on the floor in her room. Wheelchair was upright and locked. Resident states that she slipped out of her wheelchair while leaning over to pick something up. Resident is short of breath, and has non-verbal signs and symptoms of pain to left lower leg and back. Noted new hematoma to proximal left lower leg, resident unable to toe touch pressure to lower extremity. This nurse called ambulance for transportation. Author: LVN D<BR/>Record review of hospital records dated [DATE] revealed the following:<BR/>Chief Complaint: Fall<BR/>Clinical Impression: Compression fracture of lumbar vertebra (one or more of the vertebrae in the spine crumple) (New vertebral body height loss of L4 and L5 compared to t [DATE]).<BR/>Discharge instruction: Please wear your brace whenever you are up and out of bed. Avoid bending, twisting, pulling, tugging or twisting your back.<BR/>During a confidential interview, it was stated that they were standing in the doorway with another staff member. They observed CNA A go retrieve Resident #1. When CNA A and Resident #1 passed by, Resident #1 screamed, and CNA B yelled to CNA A, CNA A, her feet!. They stated they heard a noise, and they looked out, and Resident #1 was on her face. They said they heard the ADM tell CNA A to turn her over, and this was before any nurse had come. They stated the ladies from therapy may have witnessed it as well. There was a therapy staff on the floor keeping her calm, and nursing staff assessed her. They stated that what concerned them was that they were never interviewed or asked for a statement. They stated that it was customary that if something of this magnitude happened all staff were interviewed that were there that day. They stated this could not have happened since they were not interviewed. They said because of the response they were getting, it made them not want to talk about it anymore. They said they could not understand why they did not have to give a statement, and at this time, no one still had asked them what they knew or saw. They stated that failure to report and investigate could make the residents scared and unsure of their care. She said regarding Resident #1 fall, CNA A was the only CNA working on the floor on his side, and not investigating it, the facility may not see that this may have also been a factor. They stated the quality of care may decrease if not enough people are working. They said there were times when there was just one CNA, and there were unwitnessed falls. They stated the abuse coordinator was the ADM. They stated they did not feel that Resident #1's incident/fall was investigated because they were present that day, and no one asked them about the incident or took a statement. They stated they don't know much about Resident #2's fall. <BR/>During a confidential interview, they stated they interacted with Resident #1 before her fall. The resident was not acting abnormally. They said they were not present the day Resident #1 fell but were present the day after she had fallen. They stated that they observed the wound, and Resident #1 still had matted-up blood in her hair. They said Resident #1 was vocally crying and moaning but did not have tears. They stated they were present when Resident #2 fell. When Resident #2 fell, the resident would not let the nurse touch her leg. There was a large lump on Resident #2 leg. They stated they placed Resident #2 in the wheelchair with the help of another staff. They said Resident #2 was in a lot of pain because we would not allow staff to touch her without wincing. They said they were never interviewed about Resident #2 fall. They stated they were not interviewed after both falls. <BR/>During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. They said they observed a lot of blood, and it was running down into Resident #1 eyes. They stated they were with Resident #1 until the local ambulance arrived. They said the ADM never interviewed them. <BR/>During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling and getting closer. They said as they looked towards the entry of the dining room that was when they could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. They said they never interviewed her to see what they saw or heard. <BR/>During a confidential interview, they stated they were not working with Resident #1 on the day that she fell. They said she was present on the day of the fall and saw everything. They stated they were not interviewed. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. They stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him to stop, and CNA A kept pushing her. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They said that Resident #1 continued to bleed until the local ambulance arrived. They stated they were unsure if the bleeding stopped when Resident #1 left. They stated that the CNA was suspended and fired. They stated they observed CNA A keep pushing even after CNA B said to stop. <BR/>During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. They stated that no one came and interviewed her about what she had seen. <BR/>During a confidential interview, it was stated that she was not present when Resident #2 fell when she broke her back. They said Resident #2 falls a lot. They stated they had never been questioned at all when Resident #2 fell. They stated that all they knew was Resident #2 was in the hospital. They said she was present often during the overnight shift. <BR/>During a confidential interview, it was stated that they were present the night Resident #2 fell and broke her back. They stated that they were not interviewed by anyone regarding the incident. They said Resident #2 hit the call light, and the resident was on the floor when they went in. They stated they asked Resident #2 what happened, and Resident #2 said she was trying to sit in her chair, and it moved. They stated Resident #2 hit her bottom. They stated they retrieved another staff to help and assess. They said Resident #2 was in pain. They stated they sent her out to the hospital, and she was gone for about a week. They stated that they had not been interviewed about Resident #2's fall when she broke her back, nor had she ever been interviewed about any of her falls. They stated Resident #2 falls a lot. <BR/>During an interview on [DATE] at 1:25 PM, the ADM stated that she was walking near the nurse's station. She said she heard someone yell stop. She stated that CNA A turned his head, and Resident #1 fell and hit her head. She stated she could not tell if Resident #1 feet were tangled based on where she was. She stated Resident #1's feet are large, as well as her legs. She said that after the resident fell, several staff members went to assist her. She stated Resident #1 went to the hospital and came back the same day with 7 or 8 stitches. She stated she suspended CNA A immediately. She said he was later terminated due to having a bad attitude, being late, and the incident with Resident #1. She said it was not working out for him. She stated that she watched the video, and according to the video, you could not see the position of her feet and could not tell if CNA A was going too fast. She stated she had no surveillance for the investigator to review because it was erased after three days She said Resident #1 fell on [DATE], and she died on [DATE]. The AD stated she was on off on [DATE] and called it in on [DATE]. She stated she spoke with the Regional Clinical Director, and she also did not see the need to call in the falls for Resident #1 and Resident #2. She stated that they did not consider stitches a major injury. She stated Resident #1 fracture to her back was not reported because she could tell her exactly what happened. She stated Resident #1 was alert. She stated that once the resident came back to the facility, she knew it was fractured but did not see a reason to report it. She said she uses the guidelines listed in the provider letter 19-17.<BR/>During an interview on [DATE] at 2:27 PM, Resident #1 stated that she broke her back on Thanksgiving day. She said she had fallen while at a family members home during the hoiday, and that was when she started having back spasms. She stated he reported this to staff when she returned. She stated that last fall, she was in her room alone at the end of December. She said she fell while going to the restroom. She said she was in a lot of pain when she fell. She stated no one asked her about her fall besides the staff who assisted her in getting Resident #2 up that night at the end of December.<BR/>During an interview on [DATE] at 1:34 PM, the DON stated the potential negative outcome for not reporting or not investigating an incident of abuse or neglect was that it could place residents in danger. She said it could affect the quality of care. She stated she was aware of the fall, with Resident #2 not being reported. She stated the Regional Clinical Director told her that Resident #2 was coherent and could say to them what happened; therefore, it was not reportable. She stated she was told that the guidelines have changed and that certain things that were once reportable are no longer reportable. She said she had concerns and spoke with the Regional Clinical Director and spoke with the ADM. She stated the rationale that she was given was that the resident was coherent. She said she was aware that Resident #1 fall was not reported. She stated the ADM told her that since the fall was witnessed and since CNA A was terminated, they did not have to report it. She said that she did not think there was a system in place at the facility that assisted in monitoring that things that should be reported were reported. She stated she had been trained on what to report to the state. She said anything out of the norm should be reported to the state. She stated unwitnessed falls, injuries, complaints of theft, any sexual activity, and anything that was not a part of day-to-day activity that can cause harm to the residents. She stated that Resident #1's and #2's falls were out of the norm and should have been reported. She stated both falls resulted in serious bodily injury. She stated although they fall frequently, their treatments as a result of the fall require higher levels of care. She stated the ADM was the abuse coordinator. The DON stated that CNA A should have stopped and readjusted the resident before pushing Resident #1. She stated this was neglectful on CNA A's part. She stated she did not report either fall but did investigate Resident #1 fall. When asked if she investigated why the provider investigation report was unfounded, she stated she was unaware that Resident #1's fall had not been thoroughly investigated. She stated the ADM instructed her on who to speak to. She stated she was asked to talk to LVN E, the Activity Director, LVN F, LVN C, and CNA A. She stated that during her interviews, she found that CNA A should have stopped, and this would have prevented the fall. She stated she never saw any of the investigation paperwork and was told it was unfounded because CNA A did not mean to do it. She stated CNA A never told her that he did not mean to do it, but it was told to her that he told other staff this. She stated that before the interview with the investigator, she was under the impression that the ADM was responsible for the entire investigation process. She stated that she was never asked for any documentation from what she found out through her interviews. She stated she was only aware of her role in the investigation process on the day of the interview on [DATE]. She stated she learned that she and the ADM are both responsible. She stated that she thought investigations were on the ADM as she was the abuse coordinator. She stated she was instructed to terminate CNA A because of the fall. She stated she, as the DON, did not report Resident #1 or Resident #2 falling within 2 or 24 hours. She stated she did not report the falls because she had asked about them and was given a rationale for why they did not need to be reported. She stated that regarding Resident #2, she did not investigate or talk with any of the staff on duty. She stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #2 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing.<BR/>During an interview on [DATE] at 2:05 PM, the ADM stated that regarding reporting the incident, the potential negative outcome was that all residents could be affected. She did not expound how. She said she did report Resident #1 incident/fall, but she reported it late. She stated she did not report Resident #2's incident/ fall because she was following the provider's letter and did not believe it met the requirement. She said regarding systems to help monitor what to report versus what not to report was the provider letter that was issued by the state. She stated that she expected all things that met the state requirements per the provider letter to be reported. She said she did not report those based on the requirements listed in the provider letter. She stated that she and the DON were responsible for reporting appropriate items to the state. She said she felt that Resident #2 did not meet the requirements of the provider letter because Resident #2 could tell staff what happened. She stated she did not report Resident #1 because it also did not meet the requirements based on the requirements of the provider letter. She said she did not suspect abuse or neglect and believed in regard to Resident #1 and CNA A it was an accident. She stated she suspended CNA A as a part of the initial investigation. She stated she always suspended the staff as a part of the investigation process. She stated she was investigating the fall, not abuse or neglect. She stated that he was terminated for other things, not the fall. She stated that she was unaware that the DON had terminated CNA A. She stated that the things he was terminated for were addressed at once at the time of the fall and not as they happened during his employment. She stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated that regarding Resident #1, she could not determine if receiving sutures was serious because she was not clinical. She said she did not report either of the incidents to the police or the local ombudsman. Regarding investigating the incident, she stated she unfounded the incident because she did not believe he (CNA A) intended to hurt Resident #1. She stated she did not know who yelled. She stated she did not think or suspect abuse or neglect. She stated things such as punching as an example of abuse. She stated that she only obtained witness statements from CNA A and CNA B because CNA A was involved, and CNA B told me she saw what happened. She stated she believed she had talked to everyone who was there that day. She stated she did not speak with any kitchen staff. She stated she only chose people who saw Resident #1 fall. She stated regarding Resident #2, she only took the word of the DON and did not go any further. She stated that she spoke with Resident #2, and she was able to tell her what happened, and she did not suspect abuse. She stated that failure to investigate could compromise the residents. She stated she had been trained to investigate. She stated she and the DON were responsible for conducting investigations. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she did not interview any residents because no residents were in the dining room. She stated she was unaware if CNA A had any hearing problems.<BR/>Record review of an untitled, undated document provided by the DON on [DATE] revealed the following:<BR/>The DON was not involved in the self-report process. It stated that she was notified by LVN C about the incident with Resident #1. It said that on the date she terminated CNA A, it was at the ADM's request. It stated that she spoke with LVN P, LVN Q, the Activity Director, and CNA A on the same date. (The outcome of the interviews was not included in this document).<BR/>Record review of the facility policy titled abuse investigation and Reporting, revised [DATE], revealed the following: <BR/>Policy Statement<BR/>All reports of resident abuse, neglect, exploitation, misappropriation of rcsident property, mistreatment and/or<BR/>injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.<BR/>Role of the Investigator: <BR/>The individual conducting the investigation will, as a minimum:<BR/>a. Review the completed documentation forms;<BR/>b. Review the resident's medical record to determine events leading up to the incident;<BR/>c. Interview the person(s) reporting the incident;<BR/>d. Interview any witnesses to the incident;<BR/>e. Interview the resident (as medically appropriate);<BR/>f. Interview the resident's Attending Physician as needed to determine the resident's current level of<BR/>cognitive function and medical condition;<BR/>g. Interview staff members (on all shifts) who have had contact with the resident during the period of the<BR/>alleged incident;<BR/>h. Interview the resident's roommate, family members, and visitors;<BR/>i. Interview other residents to whom the accused employee provides care or services; and<BR/>j. Review all events leading up to the alleged incident.<BR/>The following guidelines will be used when conducting interviews:<BR/>a. Each interview will be conducted separately and in a private location.<BR/>b. The purpose and confidentiality of the interview will be explained thoroughly to each person involved<BR/>in the interview process.<BR/>c. Should a person disclose information that may be self-incriminating, that individual will be informed<BR/>of his/her rights to terminate the interview until such time as his/her rights are protected (e.g.,<BR/>representation by legal counsel).<BR/>d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and<BR/>date it, or the investigator may obtain a statement, read it back to the member and have him/her sign<BR/>and date it.<BR/>3. The investigator will notify' the ombudsman that an abuse investigation is being conducted. The<BR/>ombudsman will be invited to participate in the review process. <BR/>a. If the ombudsman declines the invitation to participate in the investigation, that information will be<BR/>noted in the investigation record. The ombudsman will be notified of the results of the investigation as<BR/>well as any corrective measures taken.<BR/>4. The investigator will consult daily with the Administrator concerning the progress/findings of the<BR/>investigation.<BR/>5. Upon conclusion of the investigation, the investigator will record the results of the investigation on<BR/>approved documentation forms and provide the completed documentation to the Administrator.<BR/>Record review of the facility policy titled Accidents and Incidents-Investigating and reporting, revised [DATE], revealed the following: <BR/>Policy Statement<BR/>All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.<BR/>1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and<BR/>document investigation of the accident or incident.<BR/>2. The following data, as applicable, shall be included on the Report of Incident/Accident form:<BR/>a. The date and time the accident or incident took place;<BR/>b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);<BR/>c. The circumstances surrounding the accident or incident;<BR/>d. Where the accident or incident took place;<BR/>e. The name(s) of witnesses and their accounts of the accident or incident;<BR/>f. The injured person's account of the accident or incident;<BR/>g. The time the injured person's attending physician was notified, as well as the time the physician<BR/>responded and his or her instructions;<BR/>h. The date/time the injured person's family was notified and by whom;<BR/>1. The condition of the injured person, including his/her vital signs;<BR/>j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work,<BR/>etc.);<BR/>k. Any corrective action taken;<BR/>1. Follow-up information;<BR/>m. Other pertinent data as necessary or required; and<BR/>a. The signature and title of the person completing the report.<BR/>3. This facility is in compliance with current rules and regulations governing accidents and/or incidents<BR/>involving a medical device.<BR/>5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of<BR/>Incident/Accident form and submit the original to the director of nursing services within 24 hours of the<BR/>incident or accident.<BR/>6. The director of nursing services shall ensure that the administrator receives a copy of the Report of<BR/>Incident/Accident of form for each occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 5 residents (Residents #1) reviewed for accident hazards, in that:.<BR/>CNA A failed to adhere verbal redirection from staff, verbal yelling from Resident #1 and failed to check resident position in her wheelchair causing her to fall out of her wheelchair sustaining 2 lacerations, one to the head and one to the neck and being transported to the local emergency department. <BR/>These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 01/17/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include dementia (memory loss), muscle weakness, cellulitis (skin infection that causes redness and swelling).<BR/>Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: <BR/>Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. <BR/> Section GG 120. Mobility Devices <BR/>C. Wheelchair<BR/>Record review of Resident #1's care plane revealed the following:<BR/>08/21/2020 <BR/>Problem:<BR/>Resident #1 is high risk for falls related to impaired cognition, weakness and unable to stand.<BR/>Intervention:<BR/>Anticipate and meet Resident #1 needs<BR/>Review past falls and attempt to determine cause of the falls.<BR/>Record review of the facility incident report from 11/1/23 to 1/16/24 revealed the following:<BR/>Resident #1 had a witnessed fall on 12/26/23<BR/>Record review of Resident #1 progress notes revealed the following:<BR/>12/26/23 9:55 AM<BR/>Resident was being pushed out of dining room after breakfast, while being pushed her feet got caught up under wheelchair and resident fell out of chair hitting her head on the floor. Resident has a laceration to forehead with bleeding noted, resident did yell in pain when CNA tried to put sock back on her foot. Resident is being sent to ER via ambulance for a more in-depth evaluation of head. Author: LVN C<BR/>Record review of Form 3613 dated and signed 01/04/24 reveled that on 12/26/24 CNA A was transporting Resident #1 from the dining room. CNA B noticed Resident #1 feet dragging and CNA B yelled for CNA A to stop. When CNA A stopped Resident #1 fell forward. Investigation findings was unfounded. <BR/>Record review of CNA A's witness statement, dated 12/26/23, stated that he was pushing Resident #1 down the hall at 10:00 AM when she put her foot down and her forward momentum threw her out of the wheelchair. <BR/>Review of CNA B's witness statement, dated 12/26/23, stated that she saw CNA A pushing Resident #1 in her wheelchair. CNA B said she told him to stop dragging Resident #1 feet and this was the reason Resident #1 was yelling. She stated she went to the Activity Director's office. At this time she had to tell CNA A again to stop because he was dragging Resident #1 feet under the chair and that was when she heard a loud bang and looked out and Resident #1 was on the floor. <BR/>Record review of hospital records dated 12/26/23 revealed the following:<BR/>admission Diagnoses: Laceration without foreign body of unspecified part of head and Laceration without foreign body of unspecified part of neck.<BR/>Physical Exam<BR/>Constitutional: She is in acute distress<BR/>Hent: Patient has a 2.5 centimeter vertical laceration mid forehead with oozing bleeding and gaping. A Second laceration is noted above the left eyebrow triangular in nature and not gaping. It had been steri-stripped by the nursing home. Dermabound would be appropriate for this wound.<BR/>Neck: Patient is in a c-collar(Neck Brace)<BR/>Discharge instructions: Wound should be kept clean and dry. Glue will flake off in 7-10 days. Sutures should be removed in 7 days. Those can be done by urgent care or some primary care or she can return to the emergency room if needed.<BR/>During a confidential interview, it was stated that they were standing in the doorway with another staff member. They observed CNA A go retrieve Resident #1. When CNA A and Resident #1 passed by, Resident #1 screamed, and CNA B yelled to CNA A, CNA A, her feet!. They stated they heard a noise, and they looked out, and Resident #1 was on her face. <BR/>During a Confidential Interview, it was stated that they heard CNA B yell stop. Before that, they heard Resident #1 yelling. They said Resident #1 yells, but this particular day (12/26/23), The yell was elongated. It was abnormal. After that, we heard the fall. <BR/>During a confidential interview, it was stated that she was present on the day of Resident #1's fall. She said that she heard Resident #1 screaming, and it was elongated and abnormal. Shortly after that, they heard a thud. By the time they got to Resident #1, CNA A was trying to turn her over. <BR/>During a confidential interview, they stated they were present the day Resident #1 fell. They said they heard Resident # 1 screaming, and it lasted longer than usual. They stated they heard the sound of Resident #1 yelling and getting closer. They said as they looked towards the entry of the dining room that was when she could see Resident #1 coming out of the chair and hitting the floor. They stated Resident #1 hit the ground with such an impact that her ponytail holder came out of her head. <BR/>During a confidential interview, they stated they were working with Resident #1 on the day that she fell. She said she was present on the day of the fall and saw everything. They stated Resident #1 had a habit of dragging her feet, especially if she does not want to go somewhere. They stated all staff knew about Resident #1 putting her feet down during transport. They said they heard another staff member repeatedly tell him (CNA A) to stop, and CNA A kept pushing her. They stated CNA A was not going fast, but he continued to push her. They said they did not see CNA A stop or readjust her until it was too late, and she had fallen. They stated CNA B tried to stop him by verbally telling him, but he did not listen. They stated they observed CNA A keep pushing even after CNA B said to stop. <BR/>During a confidential interview, they stated they were pulled to the floor to help the staff because another staff member was sick. They said it was near mealtime. They stated they observed Resident #1 yelling. She stated she observed Resident #1 feet under the chair. They stated they told CNA A that Resident #1's feet were under the chair and that he was dragging Resident #1's feet. They said they told CNA A that was why Resident #1 was yelling. They stated that the Activity Director called them, and when CNA A passed the door, they again told CNA that they were still dragging Resident #1 feet. They stated shortly after that moment, they heard the fall. They said when they told CNA A, he never readjusted her, checked her (Resident #1) feet, or even responded to them. They stated he kept pushing her. <BR/>During a confidential interview, it was stated that they were in the kitchen area when Resident #1 fell. They said they heard Resident #1 hollering first as if she was in pain. They stated they heard CNA B yell that CNA A was dragging her feet. They said that Resident #1 had swollen feet. They stated that CNA A did not readjust Resident #1 in her wheelchair but kept pushing her from the dining table to the dining room exit. <BR/>During an interview on 01/17/24 at 1:34 PM, the DON stated not preventing incidents or accidents could result in a decline in residents' health. She stated that future incidents may occur. She stated she was not present the day Resident #1 fell. She stated she expected staff to adhere to verbal commands, especially if it kept residents safe. She said she expected the CNA to stop and readjust to prevent accidents. She stated they are all responsible for preventing accidents. She stated that although she does not believe he intentionally hurt Resident #1, he did not take any actions to avoid it either. She stated she was unaware of any history of CNA having difficulty hearing.<BR/>During an interview on 01/17/24 at 2:05 PM, the ADM stated that she heard CNA B yell stop once, and that was when the fall occurred. She said on the video, she observed CNA A stop once CNA B yelled, and that was when the resident fell. She stated that during the observation of the video surveillance, she did not see CNA A stop to readjust Resident #1 in her wheelchair. She stated she did not know who yelled. Regarding preventing accidents and hazards, she stated the potential negative outcome was the safety of the residents. She stated that the video did not reveal that the resident feet were under the wheelchair. She stated she did not see him readjust her or check for positioning in the video. She stated she was unaware if CNA A had any hearing problems.<BR/>During an interview on 01/18/24 at 2:38 PM at 2:52 PM, CNA A stated he did not mean for Resident #1 to fall. He stated he did not know her feet were under the wheelchair. He stated he did not feel a difference in pushing her. He said he did not hear anyone tell him to stop. He stated that he was the only CNA on the side where Resident #1 resided. He stated that he believed this was why he did not pay attention. He said he was worried about getting everyone out of the dining room by himself. He stated there was no other staff in the dining room with him. He stated there were other residents in the dining room. He stated the kitchen staff was in the kitchen. He said he was unaware that Resident #1 would put her feet down. He stated that she had large legs and had previously inquired about leg rest for another resident. He said he had not asked for leg rest for Resident #1. He stated he was told by housekeeping staff that maintenance would get them. He said he brought this to maintenance attention and was told it would be taken care of. He stated he felt that he did not receive adequate training. He stated he was on the floor one day with another staff and that training did not include getting to know the other residents but instead included asking him to help with the larger residents and telling him to change people on his own. He was never informed that Resident #1 would drop her feet. He stated if he had been trained about Resident #1, he would have checked her feet. He said he pushed her, and she fell out of the chair. He stated he only stopped because he saw her fall forward. He stated he never stopped until she started falling forward.<BR/>Record review of a confidential witness statement revealed the following:<BR/>They assisted in the assessment of Resident #1. During the course of providing care to Resident #1, they overheard the Activity director tell CNA A, We told you to stop pushing her; her legs were under her wheelchair. <BR/>Record review of a confidential witness statement revealed the following:<BR/>They heard Resident #1 screaming for at least 5 seconds. They stated they recognized her scream because when Resident #1 did not want to be moved, she would scream. They looked at another staff and then took a step where they could see out the door. They saw Resident #1 mid-fall. They stated Resident #1 hit her head first. They stated they heard CNA A say they were sorry several times. <BR/>Record review of a confidential witness statement revealed the following:<BR/>They stated the Tuesday after Christmas the heard Resident #1 shouting. It was for at least 5 seconds before they got up to check. They said it was normal for Resident #1 to shout, but not for long. They stated that as they were walking towards the door, that was when they heard the thud. <BR/>Record review of a confidential witness statement revealed the following:<BR/>They stated the day Resident #1 fell, CNA A pushed her even though she was yelling. They said they observed the ADM in the hallway. They stated if the ADM had asked what was going on, the fall may have been prevented. They stated they observed the ADM continue to walk until CNA A yelled, ' Ol Lord. <BR/>Record review of the facility policy, Safety and Supervision of Residents (Revised 2017), revealed:<BR/> Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. <BR/>The care team shall target interventions to reduce individual risk related to hazard in the environment, including adequate supervision and assistive devices.<BR/>Implementing interventions to reduce accident risk and hazard shall include the following:<BR/>Communicating specific interventions to all relevant staff assigning responsibility for carrying out interventions providing training is necessary.<BR/>ensuring that interventions are implemented and documenting interventions<BR/>Systems Approach to Safety<BR/>Resident supervision is a core component of systems approach to safety. The type and frequency of the resident supervision is determined by the individual's residents assess needs and identified hazards in the environment.<BR/>Resident Risks and Environmental Hazards <BR/>Due to their complexity and scope, certain residents risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include:<BR/>Falls<BR/>Other topics related to resident risk and environmental hazards may be addressed within related policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for 1 of 3 residents (Resident #23) reviewed for admission Physician Orders.<BR/>The facility failed to have Physician orders for dialysis treatments, graft dressing, changes and resident care before and after dialysis for Resident #23.<BR/>This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. <BR/>Findings include:<BR/>Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments).<BR/>Record review of the facility's document titled, Resident Matrix, dated 02/27/24 revealed Resident #23 received hemodialysis treatments. <BR/>Record review of Resident #23's comprehensive MDS, dated [DATE], revealed Resident #23 was understood and had a BIMS score of 15 which indicated her cognition was intact.<BR/>Record review of Resident #23's Care Plan initiated on 01/22/24 revealed; Problem: Resident #23 needs hemodialysis related to renal failure; Goal: [Resident #23] will have immediate intervention should any of signs or symptoms of complications from dialysis occur through the review date. [Resident #23] will have no signs or symptoms of complications from dialysis through the review date; Interventions: Encourage [Resident #23] to go for the scheduled dialysis appointments. [Resident #23] receives dialysis three times weekly. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage.<BR/>Record review of Resident #23's order summary report dated 02/27/24 revealed there were no orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis treatments.<BR/>Interview on 02/29/24 at 9:17 AM, LVN A stated Resident #23 does go to dialysis treatments offsite and she has seen transportation taking Resident #23 to dialysis every Tuesday, Thursday, and Saturday. LVN A stated there were no physician orders for dialysis treatments or dialysis graft care at the facility. LVN A stated the nurses were responsible for ensuring residents who went to dialysis had orders for dialysis treatments, graft dressing changes and care. LVN A stated she was unsure why the orders were not in Resident #23's physician orders. LVN A stated the potential negative outcome to the resident was they could get an infection at the graft site. <BR/>Interview on 02/29/24 at 9:24 AM, the DON stated she did not know why Resident #23 was missing physician orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis. The DON stated all of the nurses were responsible for ensuring physician orders for dialysis care were in place. The DON stated her and the ADON were responsible for ensuring dialysis care orders were in place after admission. The DON stated the potential negative outcome to the resident was there may be issues with the graft that the facility was unaware of and made the resident at risk to not get a dialysis treatment. <BR/>Interview on 02/29/24 at 9:31 AM, the ADM stated the admitting nurse was responsible for ensuring dialysis orders were in place and the DON and ADON were responsible to follow-up and review the admission orders. The ADM stated she was unsure why the dialysis orders were missing for Resident #23. The ADM stated the potential negative outcome was the resident could miss a dialysis treatment.<BR/>Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, with a revised date of September 2010, reflected the following:<BR/>Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23) reviewed for dialysis.<BR/>The facility failed to ensure Resident #23 had physician's orders for dialysis treatments, graft dressing changes related to dialysis or resident care before and after dialysis. <BR/>This failure could place residents at risk of not receiving proper medical care related to dialysis services which could result in a decline in health. <BR/>The findings were: <BR/>Record review of Resident #23's face sheet dated 02/27/24 revealed an admission date of 01/03/24 with diagnoses which included: chronic systolic congestive heart failure (heart disease), end stage renal disease (kidney disease), and dependence on renal dialysis (kidney treatments).<BR/>Record review of the facility's document titled, Resident Matrix, dated 02/27/24 revealed Resident #23 received hemodialysis treatments. <BR/>Record review of Resident #23's comprehensive MDS, dated [DATE], revealed Resident #23 was understood and had a BIMS score of 15 which indicated her cognition was intact.<BR/>Record review of Resident #23's Care Plan initiated on 01/22/24 revealed; Problem: Resident #23 needs hemodialysis related to renal failure; Goal: [Resident #23] will have immediate intervention should any of signs or symptoms of complications from dialysis occur through the review date. [Resident #23] will have no signs or symptoms of complications from dialysis through the review date; Interventions: Encourage [Resident #23] to go for the scheduled dialysis appointments. [Resident #23] receives dialysis three times weekly. Monitor/document/report PRN any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage.<BR/>Record review of Resident #23's order summary report dated 02/27/24 revealed there were no orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis treatments.<BR/>Interview on 02/29/24 at 9:17 AM, LVN A stated Resident #23 does go to dialysis treatments offsite and she has seen transportation taking Resident #23 to dialysis every Tuesday, Thursday, and Saturday. LVN A stated there were no physician orders for dialysis treatments or dialysis graft care at the facility. LVN A stated the nurses were responsible for ensuring residents who went to dialysis had orders for dialysis treatments, graft dressing changes and care. LVN A stated she was unsure why the orders were not in Resident #23's physician orders. LVN A stated the potential negative outcome to the resident was they could get an infection at the graft site. <BR/>Interview on 02/29/24 at 9:24 AM, the DON stated she did not know why Resident #23 was missing physician orders for dialysis treatments, graft dressing changes or care of the resident before and after dialysis. The DON stated all of the nurses were responsible for ensuring physician orders for dialysis care were in place. The DON stated her and the ADON were responsible for ensuring dialysis care orders were in place after admission. The DON stated the potential negative outcome to the resident was there may be issues with the graft that the facility was unaware of and made the resident at risk to not get a dialysis treatment. <BR/>Interview on 02/29/24 at 9:31 AM, the ADM stated the admitting nurse was responsible for ensuring dialysis orders were in place and the DON and ADON were responsible to follow-up and review the admission orders. The ADM stated she was unsure why the dialysis orders were missing for Resident #23. The ADM stated the potential negative outcome was the resident could miss a dialysis treatment.<BR/>Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with, with a revised date of September 2010, reflected the following:<BR/>Policy Statement: Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 3 of 19 residents (Resident #9, # 11 and #160) reviewed for bed rails. <BR/>The facility failed to obtain consent prior to installing and utilizing bedrails for Residents #9, #11 and #160.<BR/>This failure could place residents at risk for potential injuries.<BR/>Findings include:<BR/>1. Record review of the admission record for Resident #9, dated 02/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses which included: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). <BR/>Record review of the comprehensive MDS assessment, dated 01/11/24, reflected Resident #9 was understood and had a BIMS score of 00, which indicated the resident's cognition was severely impaired. <BR/>Record review of Resident #9's, undated, care plan reflected there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #9, dated 02/27/24, reflected there were no orders for bed rails. <BR/>Record review of Resident #9's electronic medical records reflected no signed consent for bed rails .<BR/>Record review of Resident #9's electronic medical record reflected no signed consent for bedrails . <BR/>Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have &frac14; side rails up on right and left side of bed . <BR/>2. Record review of Resident #11's face sheet, dated 02/07/24, reflected a [AGE] year-old female with an initial admission date of 01/10/23 and readmission on [DATE]. Resident #11 had primary admitting diagnoses which included metabolic encephalopathy (alteration in consciousness caused due to brain dysfunction), depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental illness), post-traumatic stress disorder (flashbacks, nightmares, serve anxiety and uncontrollable thoughts about an event) and bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs and lows).<BR/>Record review of Resident #11's Quarterly MDS assessment, dated 02/18/24, reflected Resident #11 had a BIMS score of 12, which indicated the resident's cognition was moderately impaired. She required partial/moderate assistance with toileting, bathing, and personal hygiene. She required partial/moderate assistance with lying to sitting on side of bed, sit to stand, transfers and walking. Section P reflected she used bed rails daily.<BR/>Record review of Resident #11's Care Plan dated 12/8/23 reflected no care plan for bed rails. <BR/>Record review of Resident #11's physician orders, dated 02/27/24, reflected may use siderails for positioning and ease of mobility as an enabler, dated 09/29/22. <BR/>Record review of Resident #11's treatment administration record, dated 02/28/24, reflected an order may use siderails for positioning and ease of mobility as an enabler every shift for siderail start date 09/29/22.<BR/>Record review of Resident #11's Bed Rail Safety Review, dated 02/20/24 , reflected alternatives to bedrails were attempted and bedrails enable Resident #11 to turn and position. The resident used half rails on both sides. <BR/>Record review of Resident #11's electronic medical records reflected no signed consent for bed rails.<BR/>Observation on 02/27/24 at 11:00 AM revealed Resident #11 sitting in her wheelchair beside the bed. Resident #11's bed had half rails in an up position on both sides of bed. <BR/>During an interview on 02/28/24 at 04:00 PM with the DON, she stated they did not have a consent signed for bedrails. She stated she was not aware a consent was needed . <BR/>During an interview on 02/28/24 at 04:00 PM with the ADON, she stated when a resident needed bedrails, the nurse would complete a bedrail assessment, obtain order and care plan. She stated she was not aware a consent was needed. <BR/>3. Record review of the admission record for Resident #160, dated 02/27/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #160 had diagnoses which included: cerebral palsy (motor disability), seizures (neurological disorder) and muscle weakness.<BR/>Record review of the comprehensive MDS assessment, dated 03/08/23, reflected Resident #160 was usually understood and had a BIMS score of 15, which indicated the resident's cognition was intact. <BR/>Record review of Resident #160's, undated, care plan reflected there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #160, dated 02/27/24, reflected the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20.<BR/>Record review of Resident #160's electronic medical record reflected no signed consent for bedrails . <BR/>Observation on 02/27/24 at 10:43 AM revealed Resident #160 was noted to have &frac14; side rails up on right and left side of bed . <BR/>During an interview on 02/29/24 at 11:48 AM with the DON, she stated bed rails require a consent per her facility policy. She stated she was not aware consent was needed for bed rails. She stated bed rails were used for repositioning but can be a restraint. She stated the bed rails were put in place before she was hired as DON and was not sure shy no consent was obtained. She stated consent should be obtained before bed rails were put in place. She stated nurses were responsible for obtaining consent. She stated the potential negative outcome was adverse effect from bed rails and could be a liability issue if resident was injured. She stated she started training all nursing staff on Wednesday (2/28/24). <BR/>During an interview on 02/29/24 at 11:57 AM with the ADM, she stated all residents who use bed rail require a consent. She stated there was no system in place to monitor for bed rail consents. She stated she was not sure why consents were not obtained prior to bed rail being put on bed. She stated the potential negative of using bed [NAME] could be resident injury. She stated he expectations were for all residents with bed rails to have consent signed before bed rails is placed on bed. <BR/>Record review of the facility's policy titled Bed Safety and Bed Rails, dated August 2022, reflected:<BR/>Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met .<BR/>8. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 4 of 4 staff (Dietary Staff A, B, C and D) in 1 of 1 kitchen, in that:<BR/>1) Dietary staff A, B, and C failed to serve or process foods in a manner to prevent contamination. <BR/>2) The facility failed to ensure Time/Temperature Controlled for Safety (TCS)/Potentially Hazardous (PHF) pureed foods were rapidly reheated to 165 degrees F.<BR/>3) Dietary staff A failed to handle food contact equipment in a manner to prevent contamination <BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>- The following observations were made during a kitchen tour that began on 1/10/23 at 11:35 AM and concluded at 1:01 PM: <BR/>Dietary staff A was observed preparing puree foods. Prior to her placing noodles in the processor pot, the underside of the processor blade was wet. She placed the noodles in the pot, pureed the noodles and then placed the noodles a pan. Next, she was about to place the Swedish meatballs in a processor pot, but the surveyor intervened before she put the Swedish meatballs into the processor. The surveyor showed Dietary staff A there was a piece of food debris on the inside of the processor pot. She took the processor to the dishwasher to be rewashed. <BR/>Dietary staff D washed the processor parts and then shook the parts in order to remove excess water. The blade was still wet from the dishwasher. Dietary staff A then placed the meatballs in the processor which had a wet blade and pur&eacute;ed the food. She then placed the puree in a pan and put it on the steam table. She took the processor pot to the dishwasher. After washing the processor, she showed the surveyor the blade which was still wet. When she showed the surveyor the wet blade, she picked up the blade with her bare hands. Dietary staff A had fingernails that were at least 2 inches long and she handled the blade top with her bare fingers. She then placed the blade back in the processor and placed carrots in the processor and pur&eacute;ed the carrots. After pur&eacute;eing the carrots, she placed them in a pan and then placed the pan on the steam table.<BR/>Record review of the label on the sanitizer container for the dishwasher, Ecolab Ultra San, revealed the following, . Directions for use . Sanitization. Tableware Sanitizer and Destainer for Mechanical Spray Warewashing Machines. Air dry or follow with a potable water rinse .<BR/>On 1/10/23 at 12:01 PM temperatures were observed taken on the steam table by Dietary staff A:<BR/>Pasta and meatballs, no temperature taken<BR/>Pur&eacute;ed Swedish meatballs 122&deg;F. On 1/10/23 at 12:01 PM Dietary staff A stated she had just pur&eacute;ed the meatballs after noting that the temperature of the pur&eacute;e Swedish meatballs was 122&deg;F. Dietary staff A did not reheat the food and continued to take temperatures on the steamtable.<BR/>The pur&eacute;ed bread was not on any heat source and no was temperature taken.<BR/>The sausage was in a pot of water on the stove and there was no heat on.<BR/>Dietary staff B took containers of thickened liquids, cranberry (2 cartons), and lemon flavored water (1 carton), from the refrigerator and held it against her chest and carried it to a cart where she poured the liquids into glasses.<BR/>- The following observations were made during a kitchen tour that began on 1/10/23 at 5:03 PM and concluded at 5:35 PM: <BR/>Temperatures were observed taken on the steam table at 5:07 PM by Dietary staff C of the following foods:<BR/>Hamburger patty, Pur&eacute;ed sweet potatoes, Pur&eacute;ed cabbage, Pur&eacute;e pulled pork sandwich, Chicken noodle soup, Regular pulled pork, Ground pulled pork, and Cabbage, <BR/>As Dietary staff C was observed taking temperatures she allowed the upper plastic casing of the thermometer, and casing areas past the probe, to fall into the foods. Between foods she cleaned the probe, but not the casing areas that fell in the foods. This was done after taking temperatures of each food.<BR/>On 1/12/23 at 6:04 PM an interview was conducted with Dietary staff A. She stated really had not been told about rapidly reheating food to 165 degrees F and had learned about it today. She stated the last in-services that were conducted were related to getting ready for the state survey. She stated the in-service covered the basics. She stated dietary staff had training on not handling equipment with their bare hands. She stated the dietary issues occurred due to her being in a hurry. She stated the subject of allowing equipment to air dry was not brought up in the in-service training. She stated residents could get sick as a result of her observed dietary actions.<BR/>On 1/12/23 at 6:30 PM an interview was conducted with Dietary staff B about holding the cartons of drinks against her clothing and chest. She stated she thought the reason that happened was because she had been running behind. She stated everything on her clothes would get on the food if she carried foods against her body.<BR/>On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager. Regarding staff not rapidly reheating foods to 165 degrees F, processing food in wet processors, and handling of equipment, she stated Dietary staff A was nervous and late. Regarding foods being held against the body of staff, she stated Dietary staff B moved from nursing, and this was her first week of training. She stated training for new employees usually lasted three days and she reassessed training with them and conducted additional training if needed. The Dietary Manager stated she had conducted in-services for the staff. She stated cross-contamination could occur from the problems observed in the dietary department. She stated she was the person responsible to ensure correct dietary sanitation procedures were implemented. <BR/>Record review of the In-Service Training Reports from October 2022 through December 2022 revealed the following topics: <BR/>10/12/22 - Cleaning procedures - Attended by Dietary staff A, C and D<BR/>11/29/22 - State Regulations, Summary of in-service: handwashing, glove use, labeling and heating food, temperature logs, teamwork, and food handlers - Attended by Dietary staff A, C and D<BR/>12/7/22 - Serving time. Attended by Dietary staff A and C<BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding dietary sanitation. She stated she expected staff to implement correct dietary procedures. She stated the observed dietary sanitation problems could result in possible contamination.<BR/>Record review of a posted sign near the service line revealed the following documentation:<BR/>Food temperatures.<BR/>Are you doing everything to keep food hot<BR/>Hot food 135 (degrees F) and higher<BR/>If not at least 135 (degrees F) must reheat to 165 (degrees F) and hold for 15 seconds.<BR/> Reheat your pur&eacute;e and mechanical food to ensure temperature .<BR/>Thermometer stem cleaned/sanitized between testing of each food.<BR/>Record review of the facility policy, titled Nutrition, Policies, and Procedures, Complete Revision: 10/2/2017 revealed the following documentation, SUBJECT: Safe Food Handling. Policy: food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. <BR/>Procedures: <BR/>General statements . <BR/>6. Follow all local, state, and federal regulations when handling food . <BR/>Food/Beverages Prepared and Served By Facility Staff For Patients/Residents: <BR/>1.All facility staff, (culinary, nursing, therapy, activities, etc.) involved in the preparation and service of food adheres to safe food handling techniques . <BR/>4.All foods are stored, prepared and served at temperatures that prevent bacterial growth. Hot foods are maintained at 140&deg;F or higher in cold foods are maintained at 40&deg;F or below at point of service . At point of delivery, hot foods should be 120-1 40&deg;F, cold food 41-40 5&deg;F or per state regulations . <BR/>6. Food is served with clean, sanitized utensils. There is no bare hand contact <BR/>Record review of the facility policy, titled Nutrition, Policies, and Procedures., Complete Revision: 10/2/2017, SUBJECT: Safe Food Preparation. POLICY: During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent foodborne illness. Procedures: <BR/>1. Prepare foods in a sanitary manner with minimal handling. When feasible, foods are prepared the same day as service and as close to the time of service as possible . <BR/>9. Hands do not touch areas of utensils, dishware, or silverware, where the food or mouth is placed <BR/>Record review of the facility policy titled, Subject: Safe, Food Temperatures, Complete Revision: 10/2/2017. revealed the following documentation, POLICY: Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. The steam table may not be used to reheat food . <BR/>Procedures <BR/>7. Check and record tray line food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165&deg;F for 15 seconds (for hot foods) or discarded . <BR/>GUIDELINES FOR CHECKING FOOD TEMPERATURES . <BR/>Note: the thermometer must be cleaned and sanitized between each product that is tested . <BR/>4. If temperatures do not meet requirements, notify the Nutrition Services Director (NSD) for direction . <BR/>USING THE THERMOMETER CORRECTLY: <BR/>1.Do not submerge the entire thermometer into the liquid portion of the food; this could damage the thermometer

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 5 residents (Resident #1) reviewed for misappropriation of property and exploitation. <BR/>The facility failed to prevent the misappropriation of Resident #1's money and debit card, when CNA A allowed Resident #1 to purchase a meal for her in the amount of $27.03 using Resident #1's debit card number. Shortly after the purchase of the meal approximately 23 transactions were attempted to transfer money from Resident #1's account to Cash App. Seven of the attempted transactions were to CNA A's name. <BR/>This failure could place residents at an increased risk for misappropriation of their property.<BR/>Findings include:<BR/>Record review of Resident #1's undated faces sheet indicated the resident was admitted to the facility on [DATE]: Her diagnosis include depression, acute kidney failure, diabetes mellitus, and heart failure. <BR/>Record review of Resident #1's MDS dated [DATE] indicated a BIMS of 14 indicating cognitively intact. <BR/>During an interview on 08/15/2023 at 9:00 AM, the Administrator stated it was reported to her that Resident #1 had purchased a meal for CNA A on the night of 07/29/2023 in the amount of $27.03. That Resident #1 had her debit card number written down in a book in her room and CNA A used her personal cell phone to call and place the order for the food, using the debit card number for Resident #1. The Administrator stated Resident #1 had received a call from the fraud department with her local bank alerting to possible fraud regarding multiple attempts of withdrawal from Resident #1's account to CNA A via Cash App, along with two other unknown names for Cash App. The Administrator stated Resident #1 reported the fraud department had stopped the transactions. The Administrator stated she suspended CNA A pending the investigation. The Administrator stated Resident #1 had the local bank take her a printout of the attempted transactions. The Administrator stated there were multiple attempts to withdrawal money from Resident #1 and several of the attempts did have CNA A's name listed. The administrator stated there were two other names listed and they were not employees of the facility. The Administrator stated she did interview CNA A and CNA A admitted to allowing the resident to purchase food for her on 07/29/2023, and that she did use her personal cell phone to order the food and Resident #1's debit card number was used to purchase the food. The Administrator stated CNA A denied attempting to withdrawal money from Resident #1 account/debit card via Cash App and was not sure why her name was used to attempt to make the withdrawals. The Administrator stated CNA A told her she did not have Cash App on her phone and did show her the cell phone. The Administrator stated that the facility policy is that staff will not take money, gifts anything from residents, and CNA A did admit to accepting the meal that valued $27.03 from Resident #1. The Administrator stated if CNA A had not accepted the meal from Resident #1 then the whole situation would not have happened. The Administrator stated the facility did report the incident to Health and Human Services and to the Local Police and provided the police report number 23-22643. The administrator stated the facility did in-service staff over exploitation of the elderly and financial abuse. <BR/>During an interview on 08/15/2023 at 12:00 PM, Resident #1 stated that she enjoys doing things for others and she knows the staff worked their butts off. She stated that she was not feeling well on 07/29/2023 and CNA A had been going in her room taking care of her. Resident #1 stated she wanted to but CNA A, a meal and offered to order pizza for her. Resident #1 stated CNA A accepted the offer. Resident #1 stated she did not have her debit card with her however had the number written down in her green book that she kept in a basket near her bed. Resident #1 stated that CNA A told her that she didn't need to use her phone that CNA A would use her own cell phone. Resident #1 stated she thought that was unusual but let CNA A use her own phone. Resident #1 stated CNA A called the restaurant on speaker phone and placed the order and then Resident #1 read her card number off. Resident #1 stated CNA A did help her repeat some of the numbers from her debit card to restaurant. Resident #1 stated that since she had not been feeling well that evening after ordering the food she went back to bed. Resident #1 stated that the next day she did receive three calls form a 1-800 number and that she doesn't do 1-800 number, so she didn't answer. Resident #1 stated that the 1-800- number was from the fraud department at her local bank and they were trying to alert her of possible fraud charges to her account and asked her if she had authorized the charges. Resident #1 stated that the fraud department told her there had been something like 26 attempts to withdrawal money. Resident #1 stated the bank offered to bring her a copy of the statement showing the attempted transactions to her at the facility. Resident #1 stated when she received the statement, she was able to see CNA A's name on the statement with something about a cash thing you can put on your phone but didn't know what that was. Resident #1 stated that she was trying to be nice and buy a meal for CNA a, that she knew CNA A had six children with six different baby daddies and she was trying to help and be nice. Resident #1 stated some of the transaction attempts were to other people she didn't know and thought it was probably one of CNA A baby daddies or her boyfriend. Resident #1 stated it upset her that she was trying to be nice and buy CNA A the meal and that CNA A would have taken her debit card information and try to get money from her account. Resident #1 stated she didn't think what CNA A had done was right and that she would hope that CNA A would not be able to work with people in a nursing home again. <BR/>Record review of a copy of the bank statement for Resident #1 dated 07/31/2023 revealed on 07/29/2023, a pre-authorized debit Cash App CNA A's name, ($250.00), 07/29/2023 a pre-authorized debit Cash App CNA A's name ($50.00) two times and on 07/29/2023, a pre-authorization debit ($5.00), one additional transaction dated 07/29/2023 a pre-authorization debit Cash App Name Unknown C ($5.00). On 07/30/2023 there were 16 pre-authorization debit Cash App Name Unknown C for ($5.00) each, one pre-authorization debit Cash App CNA A's name ($50.00) and one pre-authorization debit Cash App Name Unknown D ($5.00). <BR/>During an interview on 08/15/2023 at 10:42 AM, CNA A stated that she did work at the facility on 07/29/2023 and did provide care for Resident #1 on that date. She stated that Resident #1 had offered to buy her food in the past and she had always said no, but that day she agreed and let Resident #1 but her the pizza. CNA A stated that Resident #1's phone was not working like no service or something so she told Resident #1 that she would just call form her cell phone. CNA A stated that she called the restaurant from her cell phone and placed the call on speaker phone. She stated that she ordered a medium pizza and a soda, and the total was about $27.00 dollars and then Resident #1 had a green book in her room and opened it up and read her debit card number out loud. CNA A stated she had to repeat some numbers for Resident #1 because the person taking the call could not understand what Resident #1 had said. CNA A stated Resident #1 was not feeling well so after placing the order she left the room. CNA A stated she received a call from the Administrator to come to the facility and give a statement about the incident and what had happened. CNA A stated she went to the facility and told them that she did not use Resident #1 card to try and withdrawal money to Cash App. CNA A stated she told the Administrator she doesn't have Cash App on her phone and doesn't know why her name would have shown on the records that she was trying to get money. CNA A stated she didn't know the other two names listed as trying to get the money. CNA A stated she showed the Administrator her phone so she could see there wasn't Cash App on her phone. CNA A stated she doesn't have a bank account only an App that allows her to like deposit her checks and she received paper checks from the facility. CNA A stated she had used Cash App in the past but not recently and did not have that App on her phone. CNA A stated she had received training from the facility on abuse, neglect, misappropriation, and exploitation when she started in June 2023, but was not aware that she could not allow a resident to buy her food. <BR/>Record review of CNA A's Individual Timecard for date range 07/16/2023 - 07/31/2023 revealed CNA A was working on 07/29/2023, CNA A clocked in at 5:33 PM and clocked out at 6:01 AM. <BR/>Record Review of CNA A's receipt and acknowledgement of facility Code of Conduct dated revised 01/2013 revealed CNA A signed the documents acknowledging she had read the document and understood she was responsible for knowing and adhering to the principles and standards of the code. Gift and Gratuities on page 7 revealed, employees may not accept monetary gifts or gifts of any value from residents, their responsible party or legal representative. CNA A signed the document on 06/23/2023. <BR/>Record Review of CNA A acknowledgment of receipt of employee handbook undated, revealed CNA A signed the document on 06/23/2023 that she had received a copy of the employee handbook, and was to comply with all the terms of the handbook, and continued employment depended on full compliance with all company rules and policies; and federal, state, and local laws governing long-term care facilities. Page 2 of the handbook revealed employees, shall not solicit, or accept any personal gift or favor from any facility resident or residents' family member without the express approval of facility administrator. <BR/>During an interview on 08/15/2023 at 1:02 PM, LVN B stated he had worked as the charge nurse on 08/15/2023 with CNA A. He stated that CNA A came to the nurse's station and said, Resident #1 had bought pizza if he wanted any. He stated he told CNA A no and that she did not need to let any resident buy her anything. LVN B stated he has told the staff that they should not let residents buy them anything, or run errands for residents, to just do their work. LVN B stated the facility had provided training often on abuse, neglect, misappropriation, and exploitation. <BR/>During an interview on 08/15/2023 at 2:30 PM, CNA E stated she had worked on 07/29/2023 with CNA A. CNA E stated that she had split the hall with CNA A and CNA A had provided care for Resident #1 that shift. CNA E stated that CNA A told her that Resident #1 had bought CNA A, a pizza. CNA E stated she had been trained on abuse, neglect, misappropriation, and exploitation by the facility usually monthly and that she knew not to accept any gifts or money from a resident. <BR/>Record review of facility in-service dated 07/31/2023 Exploitation of Elderly and Financial Abuse signed by 24 staff members. <BR/>Record review of facility policy Gifts, Gratuities, and Payments dated (Revised February 2008), revealed: Policy statement: Our facility prohibits employees from receiving or giving any gift, gratuity, or payment for services rendered; the making of any promise(s) on behalf of the facility; or engaging in any activity, practice, or act which conflicts with the interest of the facility or its residents.<BR/>Policy Interpretation and Implementation<BR/>2. The giving or accepting of anything of value by our employees to or from any of our suppliers, residents, family members, visitors, or other employees in any form whatsoever is prohibited. Such conduct may be criminal under certain laws. <BR/>5. Any employee(s) who receives a gift which is prohibited by this policy must report it to the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident with a mental disorder was accurately screened prior to admission for 2 of 3 of (#18 and #23) residents reviewed for PASRR: <BR/>The facility did not correctly identify Resident #18 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. <BR/>The facility did not correctly identify Resident #23 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. <BR/>This failure could affect residents with mental illness that were not considered to be a positive PASRR level one and could result in a failure to receive a PASRR level two evaluation and individually specialized services to meet their needs.<BR/>The Findings were:<BR/>Resident #18:<BR/>Record review of Resident #18's electronic facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included recurrent major depressive disorder (onset date of 04/10/2019), anxiety disorder due to know physiological condition (onset date of 04/10/2019), and psychosis not due to a substance or know physiological condition (onset date of 04/10/2019). Dementia was not listed in the diagnosis information.<BR/>Record review of Resident #18's Quarterly MDS, dated [DATE], revealed under section I Active Diagnoses, psychiatric/mood disorder revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 <BR/>Record review of Resident #18's most recent care plan dated 01/04/2023 revealed a focus area which reflected in part that Resident #18 is at risk for adverse consequences r/t receiving antidepressant medication for treatment of depression. He takes Cymbalta BID (twice daily) and Wellbutrin XL BID with interventions in place that included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and or EPS (extrapyramidal symptoms - side effects from antipsychotics). Monitor Resident #18's mood and response to medication. Pharmacy consultant review. Additionally, the care plan contained a focus area which reflected The resident uses antidepressant medication Cymbalta r/t Depression with interventions in place that included Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. <BR/>Record review of Resident #18's Preadmission Screening and Resident Review Level (PL1) One form dated 04/10/2019 and completed prior to admission revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. <BR/>During an interview with Resident #18 conducted on 01/13/2023 at 1:20 PM, he said he had his diagnosis of major depressive disorder (MDD) going on ten years or so, prior to being admitted to the facility. He said he lost both parents and two brothers as well and those events made his depression worse. He said he did not get any specialized services pertaining to his diagnosis of MDD at the facility. He said other than taking medication for his MDD, the facility was not doing anything else. He said some days he feels like the medication is helping and some days he feels like he could use some extra help.<BR/>During an interview with the MDS Coordinator conducted on 01/12/23 at 11:09 AM, she said she has been at the facility since October of 2022. She said some residents come in with the PL1 screening already done and said she was responsible for reviewing them to double check that they were accurate. She said if they were not accurate, she should have contacted the local mental health authority to verify diagnoses of the resident that are considered mental illnesses. She said that MDD is a mental illness that should be indicated as a yes for section C0100 on the PL1 screening form. She said she does not know why Resident #18's PL1 shows an answer of no for section C0100. She said she should have conducted a new PL1 and had a PL2 evaluation done for the resident. She said the risk of an inaccurate PL1 screening would be the resident missing out on extra services needed for them to receive optimal care. She said it could hinder the overall well-being of the resident.<BR/>During an interview with the MDS Coordinator conducted on 01/13/23 at 09:35 AM, she said she is in the process of updating the PL1 for Resident #18 to accurately reflect his diagnosis and will be contacting the local mental health care authority to have a level 2 evaluation done. She said she would provide a copy of the updated PL1 as well as a facility policy pertaining to PASRR Level 1 Screenings.<BR/>During an interview with the MDS Coordinator and the PASRR Coordinator from the local mental health authority conducted at 01/13/23 at 2:27 PM, they stated that Resident #18 was being evaluated this evening.<BR/>Resident #23:<BR/>Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Paranoid Schizophrenia, Generalized Anxiety Disorder, Anxiety Disorder, Unspecified, and Wandering In Diseases Classified Elsewhere. Further record review of the face sheet for Resident #23 revealed that one of her admitting diagnoses was paranoid schizophrenia on 1/08/20.<BR/>Record review of the admission MDS for resident #23 dated 1/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 13.<BR/>Record review of the quarterly MDS for resident #23 dated 11/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 15.<BR/>Record review of the current undated care plan for Resident #23 revealed a problem that reflected, [Resident #23] is/has potential to be verbally aggressive, yelling at staff and suspicious behavior toward staff. She has the dx of Dementia and Paranoid Schizophrenia. She has auditory and visual hallucinations. She refuses counseling and psych. services . Date Initiated: 07/16/2020. Revision on: 08/06/2020. A documented Intervention reflected, Administer medications as ordered. Monitor/document for side effects and effectiveness <BR/>Record review of the PASRR Level 1 screening for Resident #23 dated 1/3/2020 revealed the resident was documented as negative for mental illness, intellectual disability, or developmental disability. This PASRR screening was conducted by the resident's discharging hospital.<BR/>A record review was conducted of the facility provided PASRR list dated 1/10/23. The list consisted of residents in the facility that were positive on a PASRR Level 1 screening for mental illness, intellectual disability, or developmental disability and had a PASRR Evaluation. There were 3 residents listed and Resident #23 was not on the list.<BR/>On 1/10/23 at 5:54 PM an observation and interview were conducted with Resident #23. During this conversation, the resident expressed delusional thoughts and her conversation was agitated and confused.<BR/>On 1/13/23 at 11:57 AM an interview was conducted with Resident #23's Appointed Guardian who stated he had been her guardian for a few years and that the resident had a history of mental illness.<BR/>On 1/11/23 at 5:20 PM an interview was conducted with the MDS Coordinator regarding Resident #23's PASRR Level 1 screening. She stated she thought Resident #23 had a diagnosis of schizophrenia after admission and was diagnosed with dementia at some time during her stay. She stated in 2020 the facility had a managing company change and she was not able to find a PASRR Evaluation developed from the PASRR Level 1 screening. She stated she had been the MDS Coordinator since 2022. She stated residents could miss out on mental health services if incorrect PASRR Level 1 screenings were conducted.<BR/>Further record review of the face sheet for Resident #23 dated 1/10/23 revealed that one of Resident 23's admitting diagnoses was paranoid schizophrenia on 1/08/20.<BR/>During an interview with the Administrator conducted on 01/13/23 at 9:48 AM, she said it was the MDS Coordinator's responsibility to review PL1 screenings for accuracy when residents come another facility. She said if a resident came from home, the MDS Coordinator or social worker should complete the PL1. When asked what the risks for a resident could be if they did not receive an accurate PL1 or subsequent PL2 evaluation, she said she couldn't really think of any risks because she thinks they offer the same services. <BR/>During an interview with the Administrator conducted on 01/13/23 on 1:27 PM, she said they currently do not have a full-time social worker at the facility. She said they have a part time social worker who comes to the facility in the evenings and is currently not at the facility. <BR/>Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 01/17/2023) reflected in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, the comprehensive person-centered care plan, and the residents' choices for 2 of 20 residents (Resident #15 and 23) with orders for psychotropic and/or antibiotic medications, in that:<BR/>1) The facility failed to have physician's orders, assessments, care plan, communication, and coordination of care with physician/pharmacist/staff/pain management physician in place for Resident #15 related to pain management. <BR/>2)The facility failed to ensure Resident #23 received physician ordered medications prescribed for anxiety and a UTI.<BR/>An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>These failures affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. Additionally, these failures could place residents at risk for an increase in behaviors and infection symptoms. <BR/>The findings include:<BR/>Resident #15:<BR/>Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle).<BR/>Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23.<BR/>Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023.<BR/>Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8:<BR/>7/7/22 at 7:34 AM - 7<BR/>7/23/22 at 19:22 (7:22 PM) - 8<BR/>8/7/22 at 14:32 (2:23 PM) -6<BR/>8/23/22 at 8:59 AM - 6<BR/>8/30/22 at 22:49 (10:49 PM) - 8<BR/>9/2/22 at 6:58 AM - 7<BR/>1/13/23 at 3:58 AM - 6<BR/>Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following:<BR/>Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . <BR/>Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 .<BR/>Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give &frac12; hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 .<BR/>Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: <BR/>Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus.<BR/>Tylenol extra strength 500mg every 8 hours as needed for MS.<BR/>Requip 0.25mg every day for Restless Leg Syndrome.<BR/>Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms.<BR/>Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. <BR/>An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10.<BR/>Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention.<BR/>Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump.<BR/>Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities.<BR/>Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed.<BR/>Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication.<BR/>Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following:<BR/>Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day.<BR/>Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. <BR/>Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. <BR/>Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. <BR/>Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). <BR/>Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations.<BR/>Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN.<BR/>Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. <BR/>Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. <BR/>Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations.<BR/>Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18.<BR/>Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following:<BR/>Steps in the procedure: <BR/>8. Skin: <BR/>A. Intactness.<BR/>B. Moisture.<BR/>C. Color.<BR/>D. Texture.<BR/>E. Presence of bruises, pressure, sores, redness, edema, rashes.<BR/>14. Pain:<BR/>Pain: a. F. Current medication and treatments for pain.<BR/>Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following:<BR/>The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain.<BR/>General guidelines:<BR/>1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management.<BR/>2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals.<BR/>3. Pain management is a multidisciplinary care process that includes the following:<BR/>F. Identifying and using specific strategies for different levels and sources of pain.<BR/>G. Monitoring for the effectiveness of interventions.<BR/>Steps in the procedure:<BR/>Assessing pain:<BR/>1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative):<BR/>A. History of pain and its treatment including pharmacological and non-pharmacological interventions.<BR/>Implementing Pain Management Strategies:<BR/>3. The physician and staff will establish a treatment regimen based on consideration of the following: <BR/>B. Current medication regimen.<BR/>4. Strategies that may be employed when establishing the medication regimen include:<BR/>C. Combining long-acting medication with PRN's for breakthrough pain.<BR/>5. Implement the medication regimen as ordered, carefully documenting the results of the interventions.<BR/>Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following:<BR/>Policy statement:<BR/>Orders for medication and treatments will be consistent with principles of safe and effective order riding<BR/>Policy, interpretation, and implementation:<BR/>3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.<BR/>Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following:<BR/>Policy statement:<BR/>All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care.<BR/>Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following:<BR/>Policy statement:<BR/>The attending physician will be responsible for the following:<BR/>1. Excepting responsibility for initial and subsequent resident care.<BR/>2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards.<BR/>Providing appropriate care:<BR/>9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions.<BR/>On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested.<BR/>The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following:<BR/>Request to remove immediate jeopardy dated 1/12/2023<BR/>How corrective action will be accomplished for those residents affected by the violation:<BR/>Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. <BR/>Completion date 1/12/2023.<BR/>LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. <BR/>Completion 1/12/2023<BR/>In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care.<BR/>Completion 1/12/ 2023<BR/>How the facility will identify other residents with the potential to be affected by the same violation:<BR/>Only one resident in the facility has an internal pain pump currently.<BR/>Completion 1/12/2023<BR/>What measures will be put into place or systematic changes made to ensure the violation will not reoccur.<BR/>admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information.<BR/>Completion 1/12/2023.<BR/>How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur.<BR/>Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved.<BR/>Completion 1/13/2023<BR/>Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023.<BR/>Addendum to request to remove immediate Jeopardy dated 1/12/2023<BR/>Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff.<BR/> Nursing staff was in-serviced included regarding the remote bolus PRN doses.<BR/>In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. <BR/>The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows:<BR/>Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's.<BR/>Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs.<BR/>During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. <BR/>During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. <BR/>During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. <BR/>Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. <BR/>The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan.<BR/>Resident #23:<BR/>Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for one (Resident #15) of 24 residents reviewed for pain management. <BR/>The facility did not ensure Resident #15's implanted pain pump for pain was being used as prescribed by a physician. The facility was unaware Resident #15 had pain medication prescribed for the pain pump as needed up to three times a day. <BR/>An immediate jeopardy (IJ) was identified on 01/12/2023 at 5:55 p.m. While the IJ was removed on 1/13/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy and a scope of isolated, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.<BR/>The failure affected one resident who had an implanted pain pump for chronic pain and placed her at risk for unrelieved pain and discomfort. <BR/>Findings included:<BR/>Record review of Resident #15's face sheet dated 1/12/23 indicated she was admitted to the facility on [DATE], was [AGE] years old, and had diagnoses of: Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Multiple Sclerosis MS (a potentially disabling disease of the brain and spinal cord (central nervous system), Idiopathic Peripheral Autonomic Neuropathy (occurs when there is damage to the nerves that control automatic body functions. It can affect blood pressure, temperature control, digestion, and bladder function), Systemic Lupus Erythematosus (An autoimmune disease where the immune system of the body mistakenly attacks healthy tissue. It can affect the skin, joints, kidneys, brain, and other organs), Seizures (A sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements, or feelings, and in levels of consciousness), Post Traumatic Disorder, PTSD (A mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event), Restless Leg Syndrome (A condition that causes an uncontrollable urge to move the legs, usually because of an uncomfortable sensation), Schizoaffective Disorder/Bipolar Type (Type of mental illness. It's characterized by symptoms of both schizophrenia and symptoms of a mood disorder. Bipolar type, which includes episodes of mania and sometimes major depression), and Muscle Spasms (Involuntary and forceful contraction of a muscle).<BR/>Record review of Resident #15's Annual MDS dated [DATE] revealed under Section J Pain, it was documented that the resident had experienced pain in the last five days. The pain frequency level was frequently. It further documented that the resident pain made it hard for her to sleep and affected her day-to-day activities. It was further documented that on a scale of zero to 10, with 10 being the worst her current pain level was a four. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the quarterly MDS for Resident #15 dated 11/19/22 revealed the resident had a BIMS of 12. The resident was assessed as usually makes herself understood and unusually understands others. Further record review of the quarterly MDS revealed in Section J Health Conditions that the resident received scheduled and PRN pain medications. It further documented under pain assessment interview that the resident had not experienced any pain in the last five days. This MDS also documented under Medications, that the resident did not receive any opioids in the last 7 days.<BR/>Record review of the Pain Assessment for Resident #15 dated 1/12/2023 at 6:39 PM revealed that the resident had experienced pain or hurting in the last five days. It further documented that over the past five days she had experienced pain or hurting Almost constantly. Further record review revealed the resident experienced a pain intensity of 8 on a scale of 0 to 10, with 10 being the worst. It also documented that a verbal descriptor of the scale was Severe. Further documentation stated that the frequency with which the resident complains or shows evidence of pain or possible pain was one to two days. The assessment also documented that the resident received PRN medications in which the resident states that muscle relaxers help her with her pain which is the tizanidine 4 mg QID scheduled. Comments documented revealed the following, Tylenol, ES for pain scheduled twice a day she states, but actually every eight hours scheduled. Gabapentin 600 mg one PO QID scheduled. The document was signed by LVN D on 1/12/23.<BR/>Record review of the Summary of Pain Assessments for a Resident #15 revealed that the resident had 6 Pain Assessments documented since 8/24/2020. It further documented that the resident had no full pain assessments, such as conducted on 1/12/23, documented between 8/18/2021 and 1/12/2023.<BR/>Record review of the Vitals Pain Level documentation for Resident #15 between 7/5/22 and 1/13/23 revealed the resident experienced a pain level of 4 or greater on 19 occasions on 16 days. Seven of the 16 days, the resident experienced pain levels that were between 6 and 8:<BR/>7/7/22 at 7:34 AM - 7<BR/>7/23/22 at 19:22 (7:22 PM) - 8<BR/>8/7/22 at 14:32 (2:23 PM) -6<BR/>8/23/22 at 8:59 AM - 6<BR/>8/30/22 at 22:49 (10:49 PM) - 8<BR/>9/2/22 at 6:58 AM - 7<BR/>1/13/23 at 3:58 AM - 6<BR/>Record review of Resident #15's current undated care plan prior to 1/12/23 IJ, revealed pain was addressed. The care plans addressed baclofen and morphine pumps. Further record review of the care plan revealed care plans for the following:<BR/>Problem; Resident #15 is on pain medication therapy r/t MS and neuropathy. Date Initiated: 8/28/2020. Revision on: 08/28/2020 Interventions included, .Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 08/28/2020. Review every shift and PRN for pain medication efficacy. assess whether pain intensity acceptable to resident . <BR/>Problem: Resident #15 has Multiple Sclerosis. Resident #15 has an implanted baclofen pump. Date Initiated: 08/28/2020. Revision on: 09/03/2020. Interventions included, Dr. [NAME] to manage and fill baclofen pump. Date Initiated: 09/03/2020, Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to cerebellar or brainstem regions: intention tremor, nystagmus, other tremors, poor coordination, ataxia, facial weakness, dysphagia, dysarthria, slurred or scanning speech. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor and sensory control centers: urinary frequency, urgency or retention, urinary or fecal incontinence, constipation. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to motor nerve tracts: weakness, paralysis, spasticity, fatigue, diplopia. Date Initiated: 08/28/2020. Monitor/document/report to MD PRN: S/sx of damage to sensory nerve tracts: decreased perception of pain, touch, temperature, paresthesias, decrease or loss of proprioception, optic neuritis. Date Initiated: 08/28/2020. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 08/28/2020. Pain management as needed. See MD orders. Provide alternative comfort measures PRN. Date Initiated: 08/28/2020 .<BR/>Problem: The resident has chronic pain r/t Disease process MS Pt has a Morphine Pump that is monitored by pain management. Date Initiated: 11/28/2022 Revision on: 11/28/2022 . Interventions included, Administer analgesia Tizanidine, Tylenol Extra Strength as per orders. Give &frac12; hour before treatments or care. Date Initiated: 11/28/2022 Revision on: 11/28/2022. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Date Initiated: 11/28/2022. Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. Date Initiated: 11/28/2022. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Date Initiated: 11/28/2022 .<BR/>Record review of Resident #15's active physician's order dated 01/11/2023 reflected she had the following orders for pain/conditions that may cause pain: <BR/>Meloxicam 7.5mg every day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Neurontin 600mg four times a day for Idiopathic Peripheral Autonomic Neuropathy<BR/>Tizanidine HCL 4mg four times a day for MS and Systemic Lupus Erythematosus.<BR/>Tylenol extra strength 500mg every 8 hours as needed for MS.<BR/>Requip 0.25mg every day for Restless Leg Syndrome.<BR/>Cymbalta delayed release 60mg every day for severe major depression with psychotic symptoms.<BR/>Interview and observation on 1/12/23 at 11:03 AM was conducted with Resident #15. Observation of the resident revealed she was in bed and had a speech pattern that contained pauses and intermittent stutters. During the interview the resident was asked about pain. At that time, the resident told the surveyor that she had an implanted pain pump and pointed at the location of the pump which was a visible slightly raised flat hard area at the abdomen. When asked if the facility staff monitored the pain pump, she said no one checked on it. Resident #15 stated the only time the pain pump was checked was every three months when she went to the pain clinic to have it refilled. She stated the pain clinic also gave her what she called the bugs (because she thought it looked like a cockroach) to help control her pain as needed (the resident activated Medtronic remote device for as needed pain medication administration). She said the facility had not been giving the pain pump remote to her when she has been in pain. She further stated that there had been times when her pain level was high and she asked staff for the bug, and they would not give it to her. She said her next appointment to the pain clinic for a pain pump refill was 3/21/23. <BR/>An interview was conducted with Resident #15 on 1/13/23 at 11:18 AM. She stated that her pain level was currently a 4 on a scale of 0 to 10.<BR/>Record review of Resident #15's nursing progress notes revealed 1 entry regarding her implanted pain pump which was on 6/2/2021. A nursing progress note was added on 1/13/2023 regarding the pain pump, after surveyor intervention.<BR/>Record review of the facility Nurse Data (Assessment Tool) Tool dated 11/17/22 for Resident #15 reflected no documentation of a pain pump.<BR/>Record review of this Skin Observation Tool (Licensed Nurse) dated 8/4/20 and 8/24/22 revealed no documentation of any skin abnormalities.<BR/>Interview on 1/12/23 at 11:49 AM with Physician A about Resident #15's implanted pain pump revealed when asked if he was the physician that oversaw the pain pump, he said no. He said the resident would have a pain specialist physician monitoring the pain pump. He stated the resident may not even have a pain pump that it might be the Resident #15's psychosis. When asked what was in the pump, he stated he was not sure. He stated he thought the pump may be more of a baclofen pump for muscle spasms due to her multiple sclerosis. He said an implanted pump did not require any special monitoring because it was not required and would have no way to access the settings, only the pain specialist doctor would have access to changing the settings on the pump. He stated it was not very likely the pain pump would give the resident too much medication unless it malfunctioned. He said the drug interactions would be checked while the pump was being filled or refilled by the physician who installed it, they would know if the medication in the pump was compatible with the other medicines the resident was prescribed.<BR/>Interview on 1/12/23 at 1:56 PM with Physician B, the pain specialist who's office refilled Resident #15's implanted pain pump. Regarding what prescription Resident #15 was on for her pain pump, he stated it was automatically scheduled Dilaudid .1045 mg a day and that she could have it PRN, a dose of .0104 mg each time, up to 3 times a day. He stated his office would send a Session Report copy with the resident back to the facility. He said the facility usually sent a current list of her medications at the time of her visit with any changes she may have had during the last 3 months. He said there was also a prescription monitoring database for controlled substances that he reviews. He further stated that the resident had the pain pump approximately 3 or 4 years. Regarding what the potential negative outcome could be related to the pain pump, he said a lot could happen. He said if the resident fell the pump could flip, it could become damaged or programmed incorrectly and if the resident received any of the medication subcutaneously, there could be complications. He stated he had never had a pump malfunction by giving the resident too much medication, but only malfunction by giving the resident too small of a dose of medication.<BR/>Record review of Resident #15's medical record reflected 2 pain clinic visit summaries dated 6/8/22 and 9/14/22 revealed the following:<BR/>Record review of the Session Long Report from the pain clinic visit dated 6/8/22 revealed that the pump should be refilled before 11/27/22. It was also documented that there was a refill date of 9/7/22 written on the sheet. It was further documented that the medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day.<BR/>Record review of the Session Long Report from the pain clinic visit dated 9/14/22 revealed that the pump should be refilled before 3/5/23. Further documentation revealed a refill date November 12/14/22 at 2 PM written on the sheet. The documented medication in the pump was Dilaudid 1.0 mg/ml and that it administered a scheduled 24 hour dose: 01045 mg/day. <BR/>Record review of Resident #15's medical record revealed there were no orders for Dilaudid as needed for pain up to 3 times a day via Medtronic implanted pain pump. <BR/>Record review of the EMR (electronic medication records MAR/TAR) revealed no documented evidence Resident #15 ever received any PRN Dilaudid medication. <BR/>Record review of Resident #15's current undated care plan prior to the 1/12/23 IJ, revealed pain was addressed, but there was no specific care plan for a pain pump that included Dilaudid or use of the medication PRN. The care plans addressed baclofen and morphine pumps but not Dilaudid which was 2-8 times more potent than morphine (dea.gov). <BR/>Record review of the Consultant Pharmacist medication regimen review for dates between 1/1/23 and 1/8/23 reflected that Resident #15 did not require any recommendations.<BR/>Interview with the Pharmacy Consultant on 1/12/23 at 12:44 PM revealed she was not aware of Resident #15 having a prescription for a pain pump with Dilaudid that was scheduled daily and PRN.<BR/>Interview with the Director of Nurses on 1/12/23 at 2:45 PM revealed when asked if she was aware Resident #15 had an implanted pain pump, she said no. When asked why she didn't know about the pain pump she said she was trying to resolve a lot of different things. She said in the last four years the facility has been troubled, it needs leadership, that it has been hard, and that she was still struggling. She said the facility was trying to find out who the doctor was that put the implanted pain pump in the resident. She said the facility spoke with Physician A's nurse and trying to find out who the doctor was that prescribed the pump. When asked if the facility staff had been trained on the pain pump and the side effects to monitor for Dilaudid, she shook her head no. Regarding who was responsible for the knowledge, upkeep, and monitoring of the pain pump she said she thought it would be the Director of Nurses. The Director of Nurses did not know what the frequency of the pain pump to get a refill was, did not know how long the resident had had the pain pump and did not know what medication was in the pump but it was maybe something for pain. <BR/>Interview with the Director of Nurses on 1/13/23 at 1:10 PM revealed when asked what the potential negative outcome could be for Resident #15 if the facility was not aware she had the pain pump, she said the facility needs to know the signs and symptoms of what to look for and what the orders are for the pump. She said the staff needed to monitor and know the side effects if the resident was over sedated. The DON said they were going to train, educate, follow up with staff, and recheck the resident's pain level after the pain medication is given. She said they were going to come up with a process to document each time Resident #15 requested the PRN Dilaudid with the remote for the Medtronic device, and to recheck the pain level. When asked if she should have known about the pain pump, she said yes probably. She further stated that how do would an individual know something that is not there. Regarding if the pharmacy consultant had notified her that the resident had a pain pump, she said no. Regarding if she knew what to look for if the pain pump malfunctioned, she said no. She said if she had known about the pain pump, she would have found some information to look up on the pump malfunctioning. Regarding her expectations of her staff, she said she needed to know about the issue first and then she would expect them to carry out instructions, to follow up, and if they weren't sure on how to do something to let her know. When the Director of Nurses was informed of which medication was inside the pain pump, she said she was processing that information. When asked if she would expect an order to be there, she said yes, but she was having a difficult time getting the staff to document. Regarding what the staff should be monitoring for, she said she thought they should be doing an assessment and follow the guidelines in telling what to monitor, know what it's for, and signs and symptoms of a change in condition. <BR/>Interview with the Administrator on 1/13/23 at 2:42 PM revealed regarding her expectation was of her staff regarding Resident #15's pain pump she said it was to report findings, such as implanted devices, during a skin assessment and not to assume that everyone knows about something. Regarding what the potential negative outcome for this resident was if staff were not aware or educated about Dilaudid and the facility not having physician's orders for the Dilaudid, she said she could not say because she was not a clinical person to give a clinical answer. She said she knew that things could happen such as lowered respirations.<BR/>Interview and observation on 1/12/23 at 1:21 PM with LVN C revealed LVN C had found a Medtronic box in the medication room that was for Resident #15's pain pump at this time. She said she had never seen it before today. She said she was reading the information inside the box and she was going to send the box back to the prescribing physician because she did not know what it was for (which had the remote to administer the pain medicine). Regarding what medication was in the pump she said baclofen (muscle relaxer). Observation revealed the date of service that was printed on the pain pump box was 12/17/18.<BR/>Record review of the facility policy and procedure dated February 2014 titled Resident Examination and Assessment documented the following:<BR/>Steps in the procedure: <BR/>8. Skin: <BR/>A. Intactness.<BR/>B. Moisture.<BR/>C. Color.<BR/>D. Texture.<BR/>E. Presence of bruises, pressure, sores, redness, edema, rashes.<BR/>14. Pain:<BR/>Pain: a. F. Current medication and treatments for pain.<BR/>Record review of the facility policy and procedure dated March 2020 titled Pain Assessment and Management documented of the following:<BR/>The purpose of this procedure is to help staff identify pain in the resident and to develop interventions that are consistent with the resident goals and needs that address the underlying causes of pain.<BR/>General guidelines:<BR/>1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain based on professional standards of practice, the comprehensive care plan, and the resident's choice related to pain management.<BR/>2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establish treatment goals.<BR/>3. Pain management is a multidisciplinary care process that includes the following:<BR/>F. Identifying and using specific strategies for different levels and sources of pain.<BR/>G. Monitoring for the effectiveness of interventions.<BR/>Steps in the procedure:<BR/>Assessing pain:<BR/>1. During the comprehensive pain assessment gather the following information as indicated from the resident (or legal representative):<BR/>A. History of pain and its treatment including pharmacological and non-pharmacological interventions.<BR/>Implementing Pain Management Strategies:<BR/>3. The physician and staff will establish a treatment regimen based on consideration of the following: <BR/>B. Current medication regimen.<BR/>4. Strategies that may be employed when establishing the medication regimen include:<BR/>C. Combining long-acting medication with PRN's for breakthrough pain.<BR/>5. Implement the medication regimen as ordered, carefully documenting the results of the interventions.<BR/>Record review of the facility policy and procedure dated July 2016 titled Medication and Treatment Orders documented the following:<BR/>Policy statement:<BR/>Orders for medication and treatments will be consistent with principles of safe and effective order riding<BR/>Policy, interpretation, and implementation:<BR/>3. Drug and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis.<BR/>Record review of the facility policy and procedure dated July 2017, titled Charting and Documentation documented the following:<BR/>Policy statement:<BR/>All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition in response to care.<BR/>Record review of the facility policy and procedure dated August 2014 titled Attending Physician Responsibilities documented the following:<BR/>Policy statement:<BR/>The attending physician will be responsible for the following:<BR/>1. Excepting responsibility for initial and subsequent resident care.<BR/>2. The attending physician will seek, provide, and analyze information regarding a resident's current status, recent history, and medication and treatments to enable safe, effective, continuing care and support facility compliance with regulations and care standards.<BR/>Providing appropriate care:<BR/>9. The physician will periodically review all medication prescribed for his/her patients and will monitor both for continuing indications and for possible adverse drug reactions.<BR/>On 1/12/23 at 5:55 PM, the Administrator was informed of the Immediate Jeopardy. At this time the Immediate Jeopardy Template was presented to her, and a Plan of Removal was requested.<BR/>The Plan of Removal was accepted on 1/13/23 at 1:13 PM AM detailing the following:<BR/>Request to remove immediate jeopardy dated 1/12/2023<BR/>How corrective action will be accomplished for those residents affected by the violation:<BR/>Facility contacted the pain specialist (Physician B) for current orders and physician notes regarding the internally implanted pain pump. Facility contacted the primary care physician (Physician A) regarding the internally implanted pain pump. Pharmacy consultant notified. Facility received orders from Dr. [NAME] for the need for breakthrough pain to be used by the controlled by the electronic device. <BR/>Completion date 1/12/2023.<BR/>LVN (LVN D) completed pain assessment with no adverse reactions. LVN (LVN E) completed skin assessment with no adverse reactions. Plan of care completed regarding intra-thechal catheter spinal infusion. Facility contacted pain management doctor for communication of resident's visits. In-service initiated to nursing staff 1/12/23. Education to staff on side effects, signs and symptoms of overdose, and general knowledge of medication (Dilaudid). Resident chart is now red flag for x-rays and MRIs of the internal pain pump. <BR/>Completion 1/12/2023<BR/>In-service initiated to nursing staff on placement of pain pump of signs to respond to a malfunctioning, displacement, overdose, skin reaction and lowered respirations of overall resident health status. In-service to staff on orders, plan of care.<BR/>Completion 1/12/ 2023<BR/>How the facility will identify other residents with the potential to be affected by the same violation:<BR/>Only one resident in the facility has an internal pain pump currently.<BR/>Completion 1/12/2023<BR/>What measures will be put into place or systematic changes made to ensure the violation will not reoccur.<BR/>admission checklist to check residents for any implanted devices. Electronic health records and physical chart will be flagged with implant device information.<BR/>Completion 1/12/2023.<BR/>How the facility will monitor its corrected actions to ensure that the violation is being corrected and will not reoccur.<BR/>Director of Nurses or nurse management will track residents with implanted devices. Residents with internal monitoring devices will be reviewed at QAPI meeting monthly X 3 or until substantial compliance is achieved.<BR/>Completion 1/13/2023<BR/>Supporting evidence of correction will be hand-delivered to the survey team upon arrival 1/13/2023.<BR/>Addendum to request to remove immediate Jeopardy dated 1/12/2023<BR/>Failure of pain management physician, communication to nursing staff and as well as the PCP when resident returned from pain MD appointments. Facility did not receive any orders related to her internal pain pump. Pain management physician's office staff reports communication slips were given to resident and resident did not deliver to staff.<BR/> Nursing staff was in-serviced included regarding the remote bolus PRN doses.<BR/>In-service initiated to nursing staff on placement of pain pump, signs and symptoms to respond to malfunctioning, displacement, overdose, skin reaction, and lowered respiration of overall health status. In-service to nursing staff on pain pump order, plan of care, to cover all aspects of the IJ. Signed by Administrator. <BR/>The implementation of the facility's Plan of Removal (POR) was verified by surveyors through record review, interviews and observation as follows:<BR/>Record review of the In-service Training Report dated 1/12/23 revealed that and then service was given with the Subject: implanted pump device monitored by physician office for use of Dilaudid signs and symptoms to monitor for. No exams such as X-rays or MRI's. Further documentation revealed that the Administrator, DON, ADON, LVN on both shifts, 6A to 6P and 6P to 6A had attended. Summary of In-service: resident has an implanted pump device, monitored by physician's office. Please view attached information - related to implanted pump and Dilaudid. Monitor for signs and symptoms of unusual dizziness, Lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Resident is not to have exams such as X-rays or MRI's.<BR/>Record review of the Inservice Training Report dated 1/12/23 revealed and in-service with the Subject: Pain Assessment and Management. Further documentation reveal that the Don, ADON, N LVN's on both shifts attended vein service. Separate documentation was provided to attendees related to pain assessment and management.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed and in-service was held with the Subject: Medication and Treatment Orders. This in-service was attended by LVN's, treatment nurse and RN Regional DON. Separate documentation was provided to attendees related to medication and treatment orders.<BR/>Record review of the In-Service Training Report dated 1/13/23 revealed a Subject: Skin Assessment. It was conducted by the treatment nurse. Summary of In-service: when doing a skin assessment - start from head to toes, looking through every area of concerns behind ears, in ears, nose, mouth, Bony prominences, shoulders, elbows, spine, hips, ankles, heels. Look between buttocks, vaginal, penis. Look for skin tears, abrasions, bruises. Report any and all skin issues to wound care treatment nurse and Don. Skin assessments to be done on initial and weekly and PRN such as falls etcetera. This in service was attended by CNA's, LVN, DON, medication aids and LVNs.<BR/>During an interview conducted on 1/13/2023 at 11:17 AM with LVN A, she said she would assess for decreased level of consciousness, altered mental status, and decreased respirations when assessing the resident. She said that when conducting her skin assessments, she would look at the area where the implanted device is located and check for redness at the area, localized pain, and obvious signs of displacement such as shifting in location from previous assessments. She said she would verify orders from the physician for information pertaining to the drug type and frequency of PRN doses of pain medication. <BR/>During an interview conducted on 1/13/2023 at 11:40 AM with Medication Aid D, she said she would assess for decreased level of alertness when interacting with the resident as well as confusion and changes in heart rate and blood pressure. She said that as a medication aid she does not conduct skin assessments but has been made aware of which resident has the implanted pain medication infusion device. <BR/>During an interview conducted on 1/13/2023 at 11:51 AM with LVN C, she said that she has been in-serviced on the implanted pain pump and said she would assess for drowsiness, lethargy, sweating, pupil changes, hypotension, decreased heart rate, and mentioned that respiratory distress was the main one that she would look for. She said she would assess the resident's skin at the site of device implantation, which she said was the right lower quadrant of the abdomen and look for signs of displacement. She said there is an audible beeping sound that is present when the battery is low on the device and when the remote for PRN doses is held close to the implant. She said there should be an order for the device and would check there for information pertaining to PRN doses and assessment instructions. <BR/>Staff from all areas of the facility were interviewed regarding skin assessments, physician orders and implanted pain pumps including signs and symptoms of adverse reactions. Verification interviews were conducted on 1/13/23 beginning at 11:17 AM through 11:51 AM with the following staff -LVN A, LVN C and Medication Aide D. Their responses were appropriate. <BR/>The IJ was removed on 1/13/23 at 1:13 PM, the facility remained out of compliance at a severity level of no actual harm with a potential of more than minimal harm that is not Immediate Jeopardy and a scope of isolated as the facility continued to monitor their plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a medication error rate of less than or equal to 5%. The medication error rate was 17% with 6 errors in 34 opportunities involving 2 staff (Medication Aide's A and C) and 2 Residents (Residents #34 and #58) reviewed for medication pass. <BR/>Medication Aide A failed to administer the correct medications as ordered for Resident #58, and <BR/>Medication Aide C failed to ensure all medications administered to Resident #34 had an active physician's order.<BR/>This facility failure can cause residents to not receive their medications as prescribed according to physician's orders and facility policy and procedures.<BR/>Findings Include: <BR/>Record review of the Annual MDS for male Resident #34 dated 5/01/21 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnosis of coronary artery disease, benign prostatic hyperplasia, peripheral vascular disease, hyperlipidemia, hypertension, wound infection and diabetes mellitus.<BR/>Record review of the physician Order Summary dated 1/10/23 revealed female Resident #58 was admitted to the facility on [DATE] and was [AGE] years old. Further record review revealed that the resident had diagnosis of Further record review revealed that the resident had diagnosis of Essential (Primary) Hypertension, Diabetes Mellitus Due To Underlying Condition With Diabetic Polyneuropathy, Chronic Obstructive Pulmonary Disease, Unspecified, Presence Of Coronary Angioplasty Implant And Graft, Unspecified Atrial Fibrillation, Gastro-Esophageal Reflux Disease Without Esophagitis, Acquired Absence Of Right Leg Below Knee, Hyperlipidemia, Unspecified, Depression, Unspecified, Elevated [NAME] Blood Cell Count, Unspecified, Local Infection Of The Skin And Subcutaneous Tissue, Unspecified, Other Specified Soft Tissue Disorders. <BR/>Record review of the admission MDS dated [DATE] revealed the resident had a BIMS score of 15.<BR/>Observation of medication pass for resident #58 with Medication Aide A on 01/11/23 at 7:08 AM revealed resident #58 was administered the following medications:<BR/>Esomeprazole DR 40MG by mouth<BR/>Diltiazem 24H ER CD 120MG by mouth<BR/>Record review of resident #58's order summary report with active orders as of 01/11/23 reflected she had orders for the following medications:<BR/>Esomeprazole Magnesium packet 40MG by mouth every day<BR/>Diltiazem HCL 120MG by mouth every day <BR/>Observation of medication pass for resident #34 with Medication Aide C on 01/11/23 at 7:28 AM revealed resident #34 was administered the following medications:<BR/>Acidophilus with Pectin by mouth<BR/>Multivitamin with Zinc by mouth <BR/>Zinc 50MG by mouth <BR/>Record review of resident #34's order summary report with active orders as of 01/11/23 reflected he had orders for the following medications:<BR/>Multiple Vitamin tablet by mouth every day<BR/>Stress Formula/Zinc tab (multivitamin with minerals) DAW dispense as written<BR/>Record review of the order summary report with active orders as of 01/11/23 revealed Resident #34 did not have an order for Zinc 50MG by mouth every day. Resident #34 did not have an order for Multivitamin with Zinc.<BR/>Interview on 01/11/23 at 11:33 AM Medication Aide A said she had been trained on the different variants that medication comes in such as delayed release and controlled dose. When asked if she had been checking for the different variances of medications before administering them to a resident she said no and she had just gone through her cart to check for things that might be wrong on the med cart. She said she was aware of it now. When asked the last time she was trained over the different medication variants, she said it had been a while. She said the potential negative outcome for a resident could include the resident getting, have an allergic reaction, and overall a decline in health. She said she would start paying close attention to make sure the numbers and letters variations matched appropriately on the medications. <BR/>Interview on 01/13/23 at 12:20 PM with Medication Aide C about the medication errors observed during medication pass revealed when asked about the medication is given versus what was on the physicians' orders Medication Aide C said she follows exactly what the doctor orders. She said she asked the facility about the stress formula vitamin not being available and she was told the combination of vitamin B6 and zinc would be the same or equal to the stress formula vitamin. She said the stress formula was a B complex combination. She stated instead of following what they told her she should've put the medication as unavailable. When asked what the potential negative outcome could be for a resident if the orders were not followed, exactly as written, she said it could be a life-or-death situation and could cause a whole lot of bad things such as nerve or brain damage. <BR/>Interview with the Regional DON on 01/11/23 at 1:10 PM, she said the multivitamin with zinc was the stress formula. She said putting the multivitamin with zinc and the vitamin B complex tab together was an exchange for the ordered stress formula/zinc tab (multivitamin with minerals) medication. She stated the pharmacy was not able to get the physician's ordered stress formula/zinc tab (multivitamin with minerals) and sent the multivitamin with zinc and complex B instead. She said it was an exchange for what was supposed to be sent. She said the staff should have called the doctor and got it changed if the pharmacy did not have the exact medication; the nurse should have received clarification from the doctor.<BR/>In an interview on 01/13/23 at 12:48 PM with the DON, after being notified the medication error rate was 17%, the DON stated all the medication's that were in question were taken off the medication cart. She said the facility audited the medication carts and got order clarifications for the medications that were given in the medication pass. When asked if she trained her staff over medications, she said yes. When asked how often her staff were trained she said they were in-serviced anytime something came up related to medications. The DON said she expected her staff to report to her if they did not understand the orders, if something looked abnormal like the pill looks different than it normally does, or if the physician's orders don't match what is on the electronic medication administration error. When asked what that potential negative outcome could be for residents she said that not giving the medication properly was dangerous and anything could happen to the resident. She said the facility would do a medication error report, notify the family and the doctor as well. <BR/>Record review of the facility's policy and procedure dated April 2014, titled Adverse Consequences and Medication Errors documented the following:<BR/>Policy Interpretation and Implementation:<BR/>5. A medication error is defined as the preparation or administration of drugs, or biological, which is not in accordance with physician's orders, manufacturer specifications, or excepted professional standards, and principles of the professional providing services.<BR/>6. Examples of medication errors include:<BR/>A. Omission - a drug is ordered, but not administered.<BR/>B. Unauthorized drug - a drug is administered without a physician's order.<BR/>F. Wrong drug (e.g., Vibramycin ordered, vancomycin given).<BR/>H. Failure to follow, manufacture instructions, and/or excepted professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the menu was followed for 6 of 6 residents (Residents #1, 31, 38, 51, 53, and 312), who consumed 2 of 3 food forms (mechanical soft and pureed), in that:<BR/>The facility failed to ensure 6 residents received the correct portions that were called for on the menu at 1 of 3 meals observed. These resident meal trays had foods omitted and had lesser amounts of food served than called for on the menu.<BR/>These failures could place residents at risk for unwanted weight loss and hunger. <BR/>The findings include:<BR/>-Record review of the physician order Summary dated 1/12/23 revealed male Resident #1 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Pain In Unspecified Joint, Hypothyroidism, Unspecified, Essential (Primary) Hypertension, Angina Pectoris, Unspecified, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Unspecified Intellectual Disabilities, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Atrophy Of Thyroid (Acquired), Fracture Of Unspecified Part of Neck Of Right Femur, Sequela, and Unspecified Osteoarthritis, Unspecified Site.<BR/>Record review of the Order Summary Report dated 1/12/23 revealed Resident #1 had an order start date of 7/14/22 that reflected, Regular diet Pureed texture, Thin consistency, divider plate- Double Portions for diet order.<BR/>Record review of the current undated tray card for Resident #1 revealed a listing of Likes that included double portions all but not printed as part of the physician diet order section of the card.<BR/>-Record review of the and Order Summary Report dated 1/12/23 revealed male Resident #38 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Cirrhosis Of Liver, Hepatic Failure, Unspecified Without Coma, End Stage Renal Disease, Anemia In Chronic Kidney Disease, Hypertensive Chronic Kidney Disease With Stage 1 Through Stage 4 Chronic Kidney Disease, Or Unspecified Chronic Kidney Disease, Hemiplegia, Unspecified Affecting Left Dominant Side, Unilateral Inguinal Hernia, With Obstruction, Without Gangrene, Not Specified As Recurrent, Gastro-Esophageal Reflux Disease Without Esophagitis, Anxiety Disorder, Unspecified, Insomnia, Unspecified, and Psychotic Disorder With Delusions Due to Known Physiological Condition.<BR/>Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #38 had an order start date of 12/01/22 that stated, Regular diet Pureed texture, Honey consistency, for diet.<BR/>-Record review of the Order Summary Report dated 1/12/23 revealed Resident female #31 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Parkinson's Disease, Edema, Unspecified, Constipation, Unspecified, Anemia In Other Chronic Diseases<BR/>Classified Elsewhere, Hypothyroidism, Unspecified, Type 2 Diabetes Mellitus Without Complications,<BR/>Unspecified Protein-Calorie Malnutrition(E46), Disease Of Thymus, Unspecified, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, Other Chorea, Sleep Apnea, Unspecified, Essential (Primary) Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Dyskinesia Of Esophagus, Gastroparesis, Pain In Unspecified Joint, Overactive Bladder, Dysphagia, Unspecified, and Gastrostomy Status.<BR/>Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #31 had an order start date of 6/15/22 that stated, Regular diet Pureed texture, Nectar consistency, as tolerated.<BR/>-Record review of the Order Summary Report dated 1/12/23 revealed female Resident #51 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Syncope and Collapse, Unspecified Atrial Fibrillation, Essential (Primary) Hypertension, Hyperlipidemia, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Unspecified Dementia, Unspecified<BR/>Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.<BR/>Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #51 had an order start date of 9/01/22 that stated, Regular diet Mechanical Soft texture, Regular/Thin consistency.<BR/>-Record review of the Order Summary Report dated 1/12/23 revealed Resident male #53 was admitted to the facility on 823/22 and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Essential (Primary) Hypertension, Mixed Hyperlipidemia, Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Muscle Weakness(Generalized), Need For Assistance With Personal Care, Dementia In Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Edema, Unspecified.<BR/>Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #53 had an order start date of 8/25/22 that stated, Regular diet Mechanical Soft texture, thin consistency.<BR/>-Record review of the Order Summary Report dated 1/12/23 revealed female Resident #312 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Disorder Of Muscle, Unspecified, Congenital Hypertonia, Rash And Other Nonspecific Skin Eruption, Age related Osteoporosis Without Current Pathological Fracture, Hypothyroidism, Unspecified, Other Specified Depressive Episodes, Muscle Weakness (Generalized), Dysphagia, Oral Phase, Other Seizures, Other Lack Of Coordination, Nail Dystrophy, Covid-19, Cerebral Palsy, Unspecified, Anxiety<BR/>Disorder, Unspecified, Insomnia, Unspecified, Constipation, Unspecified, and Vitamin Deficiency, Unspecified.<BR/>Record review of the current undated tray card and Order Summary Report dated 1/12/23 revealed Resident #312 had an order start date of 8/20/22 that stated, Regular diet Pureed texture, Regular/Thin consistency, Please add extra gravy for her food related to DYSPHAGIA, ORAL PHASE (swallowing disorder).<BR/>- The following observations were made during a kitchen tour that began on 1/10/23 at 11:35 AM and concluded at 1:01 PM: <BR/>On 1/10/23 at 12:01 PM the following foods were observed on the steamtable:<BR/>Pasta and meatballs <BR/>Pur&eacute;ed Swedish meatballs served with a #8 scoop (1/2 cup/4ounces)<BR/>Pur&eacute;ed noodles served with the #10 scoop (3 ounces)<BR/>Mechanically altered Swedish meatballs serve with the #6 scoop (2/3 cup)<BR/>Gravy served with a 2 ounce ladle<BR/>Chicken noodle soup<BR/>Beef patty <BR/>Swedish meatballs served with a 4 ounce ladle<BR/>Carrots served with a 4 ounce ladle<BR/>Pur&eacute;ed carrots served with a #16 scoop (1/4 cup/2 ounces)<BR/>Noodles served with a 4 ounce ladle<BR/>Pur&eacute;ed bread served with a #30 scoop (1 - 1.5 ounces)<BR/>Sausage<BR/>Record review of the fall/winter 2022 Diet Spreadsheet Week 4 Day 23 Lunch revealed residents on a pur&eacute;ed diet were to receive two #8 scoops (1cup total) of Swedish meatballs pur&eacute;ed, one #10 scoop (3 ounces) of parsley noodles pur&eacute;ed, one #16 scoop (1/4 cup) of seasoned carrots pur&eacute;ed and one #30 scoops (1-1.5 ounces) of pur&eacute;ed bread. Further record review of the menu revealed residents on mechanical altered/soft diet were receive a #6 scoop (2/3 cup) of Swedish meatballs, #8 (4 ounce) scoop of parsley noodles, 1/2 cup (4 ounce) of soft mashed carrots, and pur&eacute;ed bread.<BR/>Further record review of this menu also revealed residents on mechanical altered/soft diets received a #6 scoop (2/3 cup) of Swedish meatballs, #8 (4 ounce) scoop of parsley noodles, 1/2 cup (4 ounce) of soft mashed carrots, and pur&eacute;ed bread.<BR/>On 1/10/23 at 12:34 PM revealed Resident #1 was plated one #16 scoop of pur&eacute;e carrots, one #8 scoop of pur&eacute;ed Swedish meatball, one #10 scoop of pur&eacute;e noodles, and one #30 scoop of pur&eacute;ed bread. The resident should have received four #8 scoops of Swedish meatballs pur&eacute;ed, two #10 scoop of parsley noodles pur&eacute;ed, two #16 scoop of seasoned carrots pur&eacute;ed and two #30 scoops of pur&eacute;ed bread due to his double portions order.<BR/>On 1/10/23 at 12:35 PM Resident #312 was plated one #10 scoop of pureed noodles and one #8 scoop of pur&eacute;ed Swedish meatballs. The resident should have received two #8 scoops of Swedish meatballs pur&eacute;ed. The resident disliked carrots and bread. <BR/>On 1/10/23 at 12:38 PM Resident #38 was plated one #8 scoop of pur&eacute;ed Swedish meatballs, one #10 scoop of pur&eacute;e noodles, one #30 scoop of pur&eacute;ed bread, and two #16 scoops of pur&eacute;ed carrots. The resident should have received two #8 scoops of Swedish meatballs pur&eacute;ed.<BR/>On 1/10/23 at 12:40 PM Resident #51 was plated a mechanical soft diet with &frac12; cup carrots, &frac12; cup noodles, and #6 scoop of mechanically altered Swedish meatballs with gravy. She did not receive bread.<BR/>On 1/10/23 at 12:41 PM Resident #53 was plated a mechanical soft diet with #6 scoop of mechanically altered Swedish meatballs with gravy, &frac12; cup noodles and &frac12; cup carrots, but did not receive bread.<BR/>On 1/10/23 at 12:56 PM Resident #31 was plated one #16 scoop of pur&eacute;ed carrots, one #30 scoop pur&eacute;ed bread, one #8 scoop of pur&eacute;ed Swedish meatballs and one #10 scoop pur&eacute;ed noodles. The resident should have received two #8 scoops of Swedish meatballs pur&eacute;ed.<BR/>On 1/10/23 at 1:07 PM an interview was conducted with Dietary staff A and she stated Resident #51 and Resident #53 did not receive bread because they needed speech evaluations. She stated dietary staff have said that bread was not served because they were on mechanical soft diets. <BR/>On 1/12/23 at 6:04 PM an interview was conducted with Dietary staff A. She stated she was told about the residents only receiving one scoop of pur&eacute;e Swedish Meatball instead of two as called for on the menu. She stated Dietary staff D previously went over scoop sizes with her regarding the meat and serving two scoops. She stated she forgot about it during the meal service. Regarding the missing bread for Residents #53 and #51, she stated she missed the bread on them. She stated residents could lose weight if foods were omitted or not served the correct amounts.<BR/>On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager. She stated she had conducted in-services in the last 3 months for the staff. Regarding following the menu, she stated she went over portion sizes before this meal. She stated staff think they knew the residents and that they could change the servings on their own. She stated she tells staff to serve correctly. She further stated that residents on mechanical soft diets receive pur&eacute;ed bread. She stated residents' nutritional status was at risk and weight loss could result if residents did not receive the correct serving sizes of food. She also stated she was responsible for ensuring the menu was followed. She stated training for new employees usually lasted three days and she assesses training with them and conducts additional training if needed. <BR/>Record review of the In-Service Training Reports from October 2022 through December 2022 revealed there was no specific documentation related to the subject of following the menu. <BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator. She stated she expected staff to follow the menu. She further stated residents' weight could be affected if the menu was not followed.<BR/>Record review of the facility policy, titled Nutrition, Policies, and Procedures, Complete Revision: 10/2/2017, revealed the following documentation, SUBJECT: Menus. Policy: menus will be planned to meet the nutritional needs and preferences of the patient's/residents and are in accordance with recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. Menu requirements may vary, per state regulation. A computerized nutrient analysis is available for the base menu. Procedures: <BR/>2. Use the menus without modification the first time through the menu cycle. <BR/>8. Substitutions offer similar nutritive value to the food being replaced.<BR/>Record review of the facility policy, titled, Nutrition, Policy, and Procedures, Complete Revision: 10/2/2017, revealed the following documentation, SUBJECT: Therapeutic Diets. Policy . Therapeutic and mechanically altered diets are ordered by the physician and planned by a dietitian. <BR/>The Definition . a mechanically alter diet is a diet specifically prepared to alter the consistency of food in order to facilitate oral intake. Examples include mechanical soft - ground meat, pur&eacute;ed foods and chopped meat. <BR/>Procedures. <BR/>6. Portion sizes are evident for each item on the menu extensions. <BR/>8. Prepared serve all therapeutic and mechanically altered diets as planned. <BR/>9. Check all trays for accuracy before they are served to the patient/resident.

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 breakfast meals from 1 of 1 kitchen.<BR/>1) The facility failed to provide food that was palatable for 1 of 1 breakfast meal observed (1/12/23). <BR/>These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. <BR/>The findings include:<BR/>Two of 7 residents confidentially interviewed, and ate in their rooms on Station 1, voiced concerns related to food palatability. One resident stated, Our food is cold, and my roommate gets cold eggs. Another resident stated her eggs were cold and that breakfast was cold often. <BR/>Record review of the Resident Council Minutes dated 12/7/22 revealed, under New Business, residents stated an issue of cold food at dinner time.<BR/>Record review of the Resident Council Minutes dated 1/4/23 revealed, under Old Business, Dietary - Cold food at dinner time.<BR/>During an interview on 1/12/22 at 7:07 AM, the Dietary Manager was informed of a test tray request.<BR/>During a kitchen observation on 1/12/23 at 7:30 AM, temperatures were taken of the foods on the steam table by the Dietary Manager. The temperatures were as follows:<BR/>Over Easy Eggs no temperature taken<BR/>Toast no temperature taken<BR/>Eggs scramble 174.2&deg;F <BR/>Oatmeal 198 3&deg;F<BR/>Sausage patty 192&deg;F.<BR/>Bacon no temperature taken<BR/>Pur&eacute;ed sausage 154&deg;F<BR/>Gravy 167&deg;F <BR/>Cream of wheat 181&deg;F <BR/>Pur&eacute;ed eggs, 160.1&deg;F<BR/>Pur&eacute;e bread 149&deg;F<BR/>On 1/12/23 at 7:44 AM an observation revealed the Dietary Manager started serving/preparing the Station 2 hall cart trays. The cart left the dining room at 7:58 AM. It was observed that the plates had insulated covers, but the cart was not heated. It was also observed that the over easy eggs were plated on the stove and covered with plates. At 7:58 AM preparation started for the Station 1 cart. The last tray was prepared for the Station 1 cart at 8:07 AM and preparation began for the test trays. The test tray preparation ended at 8:10 AM. The hall cart for Station 1 left the dining room at 8:11 AM and arrived on the Station 1 at 8:11 AM. At 8:12 AM two staff (CNAs B and D) started serving trays on Station 1. The last tray on the Station 1 cart was served to Resident #167 at 8:34 AM. The resident began eating at 8:35 AM. <BR/>Observation on 1/12/23 at 8:39 AM, the test trays were sampled by surveyors with the following results:<BR/>Pur&eacute;ed, eggs - lukewarm cold, 100.4&deg;F.<BR/>Pur&eacute;ed sausage with gravy - cold, salty, 97.5&deg;F.<BR/>Pur&eacute;ed bread - cold, 97.5&deg;F<BR/>Bacon- cold<BR/>Scrambled Eggs - lukewarm/cold, 106&deg;F<BR/>Sausage- cold, 92.1&deg;F<BR/>Toast - cold<BR/>Over easy eggs - cold, 99.4&deg;F <BR/> Oatmeal - warm, 135.8&deg;F <BR/>Cream of wheat - lukewarm, 119.6&deg;F <BR/>The test ended at 8:50 AM.<BR/>On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager regarding the cold and lukewarm foods on the test tray. She stated it took longer to serve; staff were late, and nurses delayed. She stated breakfast would get cold fast, and the facility had no heated carts. She stated staff encouraged dining room dining to ensure residents received meals that were at palatable temperatures. She stated they usually finished serving everyone by 8:00 AM and they have a new person working in the kitchen. She stated the dietary staff have met with the residents about menus and alternates. She stated she was responsible for ensuring foods were palatable. She stated residents would not eat the food if the foods were not palatable. A policy related to food palatability was requested at this time. <BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding food palatability. She stated staff were expected to serve food that was palatable. She stated residents could be unhappy if their food was not palatable.<BR/>A policy specific for food palatability was not provided at the time of the exit on 1/13/23 at 6:45 PM.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 4 of 4 staff (Dietary Staff A, B, C and D) in 1 of 1 kitchen, in that:<BR/>1) Dietary staff A, B, and C failed to serve or process foods in a manner to prevent contamination. <BR/>2) The facility failed to ensure Time/Temperature Controlled for Safety (TCS)/Potentially Hazardous (PHF) pureed foods were rapidly reheated to 165 degrees F.<BR/>3) Dietary staff A failed to handle food contact equipment in a manner to prevent contamination <BR/> These failures could place residents at risk for food contamination and foodborne illness. <BR/>The findings include:<BR/>- The following observations were made during a kitchen tour that began on 1/10/23 at 11:35 AM and concluded at 1:01 PM: <BR/>Dietary staff A was observed preparing puree foods. Prior to her placing noodles in the processor pot, the underside of the processor blade was wet. She placed the noodles in the pot, pureed the noodles and then placed the noodles a pan. Next, she was about to place the Swedish meatballs in a processor pot, but the surveyor intervened before she put the Swedish meatballs into the processor. The surveyor showed Dietary staff A there was a piece of food debris on the inside of the processor pot. She took the processor to the dishwasher to be rewashed. <BR/>Dietary staff D washed the processor parts and then shook the parts in order to remove excess water. The blade was still wet from the dishwasher. Dietary staff A then placed the meatballs in the processor which had a wet blade and pur&eacute;ed the food. She then placed the puree in a pan and put it on the steam table. She took the processor pot to the dishwasher. After washing the processor, she showed the surveyor the blade which was still wet. When she showed the surveyor the wet blade, she picked up the blade with her bare hands. Dietary staff A had fingernails that were at least 2 inches long and she handled the blade top with her bare fingers. She then placed the blade back in the processor and placed carrots in the processor and pur&eacute;ed the carrots. After pur&eacute;eing the carrots, she placed them in a pan and then placed the pan on the steam table.<BR/>Record review of the label on the sanitizer container for the dishwasher, Ecolab Ultra San, revealed the following, . Directions for use . Sanitization. Tableware Sanitizer and Destainer for Mechanical Spray Warewashing Machines. Air dry or follow with a potable water rinse .<BR/>On 1/10/23 at 12:01 PM temperatures were observed taken on the steam table by Dietary staff A:<BR/>Pasta and meatballs, no temperature taken<BR/>Pur&eacute;ed Swedish meatballs 122&deg;F. On 1/10/23 at 12:01 PM Dietary staff A stated she had just pur&eacute;ed the meatballs after noting that the temperature of the pur&eacute;e Swedish meatballs was 122&deg;F. Dietary staff A did not reheat the food and continued to take temperatures on the steamtable.<BR/>The pur&eacute;ed bread was not on any heat source and no was temperature taken.<BR/>The sausage was in a pot of water on the stove and there was no heat on.<BR/>Dietary staff B took containers of thickened liquids, cranberry (2 cartons), and lemon flavored water (1 carton), from the refrigerator and held it against her chest and carried it to a cart where she poured the liquids into glasses.<BR/>- The following observations were made during a kitchen tour that began on 1/10/23 at 5:03 PM and concluded at 5:35 PM: <BR/>Temperatures were observed taken on the steam table at 5:07 PM by Dietary staff C of the following foods:<BR/>Hamburger patty, Pur&eacute;ed sweet potatoes, Pur&eacute;ed cabbage, Pur&eacute;e pulled pork sandwich, Chicken noodle soup, Regular pulled pork, Ground pulled pork, and Cabbage, <BR/>As Dietary staff C was observed taking temperatures she allowed the upper plastic casing of the thermometer, and casing areas past the probe, to fall into the foods. Between foods she cleaned the probe, but not the casing areas that fell in the foods. This was done after taking temperatures of each food.<BR/>On 1/12/23 at 6:04 PM an interview was conducted with Dietary staff A. She stated really had not been told about rapidly reheating food to 165 degrees F and had learned about it today. She stated the last in-services that were conducted were related to getting ready for the state survey. She stated the in-service covered the basics. She stated dietary staff had training on not handling equipment with their bare hands. She stated the dietary issues occurred due to her being in a hurry. She stated the subject of allowing equipment to air dry was not brought up in the in-service training. She stated residents could get sick as a result of her observed dietary actions.<BR/>On 1/12/23 at 6:30 PM an interview was conducted with Dietary staff B about holding the cartons of drinks against her clothing and chest. She stated she thought the reason that happened was because she had been running behind. She stated everything on her clothes would get on the food if she carried foods against her body.<BR/>On 1/13/23 at 9:29 AM an interview was conducted with the Dietary Manager. Regarding staff not rapidly reheating foods to 165 degrees F, processing food in wet processors, and handling of equipment, she stated Dietary staff A was nervous and late. Regarding foods being held against the body of staff, she stated Dietary staff B moved from nursing, and this was her first week of training. She stated training for new employees usually lasted three days and she reassessed training with them and conducted additional training if needed. The Dietary Manager stated she had conducted in-services for the staff. She stated cross-contamination could occur from the problems observed in the dietary department. She stated she was the person responsible to ensure correct dietary sanitation procedures were implemented. <BR/>Record review of the In-Service Training Reports from October 2022 through December 2022 revealed the following topics: <BR/>10/12/22 - Cleaning procedures - Attended by Dietary staff A, C and D<BR/>11/29/22 - State Regulations, Summary of in-service: handwashing, glove use, labeling and heating food, temperature logs, teamwork, and food handlers - Attended by Dietary staff A, C and D<BR/>12/7/22 - Serving time. Attended by Dietary staff A and C<BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding dietary sanitation. She stated she expected staff to implement correct dietary procedures. She stated the observed dietary sanitation problems could result in possible contamination.<BR/>Record review of a posted sign near the service line revealed the following documentation:<BR/>Food temperatures.<BR/>Are you doing everything to keep food hot<BR/>Hot food 135 (degrees F) and higher<BR/>If not at least 135 (degrees F) must reheat to 165 (degrees F) and hold for 15 seconds.<BR/> Reheat your pur&eacute;e and mechanical food to ensure temperature .<BR/>Thermometer stem cleaned/sanitized between testing of each food.<BR/>Record review of the facility policy, titled Nutrition, Policies, and Procedures, Complete Revision: 10/2/2017 revealed the following documentation, SUBJECT: Safe Food Handling. Policy: food acquisition, storage, and distribution will comply with accepted food handling practices. Proper food handling is essential in preventing foodborne illness. <BR/>Procedures: <BR/>General statements . <BR/>6. Follow all local, state, and federal regulations when handling food . <BR/>Food/Beverages Prepared and Served By Facility Staff For Patients/Residents: <BR/>1.All facility staff, (culinary, nursing, therapy, activities, etc.) involved in the preparation and service of food adheres to safe food handling techniques . <BR/>4.All foods are stored, prepared and served at temperatures that prevent bacterial growth. Hot foods are maintained at 140&deg;F or higher in cold foods are maintained at 40&deg;F or below at point of service . At point of delivery, hot foods should be 120-1 40&deg;F, cold food 41-40 5&deg;F or per state regulations . <BR/>6. Food is served with clean, sanitized utensils. There is no bare hand contact <BR/>Record review of the facility policy, titled Nutrition, Policies, and Procedures., Complete Revision: 10/2/2017, SUBJECT: Safe Food Preparation. POLICY: During the food production process, food will be handled by methods to minimize contamination and bacterial growth to prevent foodborne illness. Procedures: <BR/>1. Prepare foods in a sanitary manner with minimal handling. When feasible, foods are prepared the same day as service and as close to the time of service as possible . <BR/>9. Hands do not touch areas of utensils, dishware, or silverware, where the food or mouth is placed <BR/>Record review of the facility policy titled, Subject: Safe, Food Temperatures, Complete Revision: 10/2/2017. revealed the following documentation, POLICY: Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, serving, delivery, cooling and reheating. The steam table may not be used to reheat food . <BR/>Procedures <BR/>7. Check and record tray line food temperatures on the food temperature record before each meal. If the food temperatures are not within acceptable parameters, reheat the food to at least 165&deg;F for 15 seconds (for hot foods) or discarded . <BR/>GUIDELINES FOR CHECKING FOOD TEMPERATURES . <BR/>Note: the thermometer must be cleaned and sanitized between each product that is tested . <BR/>4. If temperatures do not meet requirements, notify the Nutrition Services Director (NSD) for direction . <BR/>USING THE THERMOMETER CORRECTLY: <BR/>1.Do not submerge the entire thermometer into the liquid portion of the food; this could damage the thermometer

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 2 of 2 common resident baths (Station 1 and 2) and 4 of 12 resident rooms on Station1 (Rooms 2, 3, 9 and 16), in that:<BR/>1)The facility failed to ensure the shower bed/gurney padded overlay was not damaged with splits and torn areas that exposed the foam interior, <BR/>2) The facility failed to ensure oxygen tanks were stored in a secure manner (rooms [ROOM NUMBERS]),<BR/>3) The facility failed to ensure resident use hot water was at comfortable temperatures (room [ROOM NUMBER]),<BR/>4) The facility failed to ensure chemicals were stored in a safe manner and inaccessible to residents ((Station 2 bath),<BR/>5) The facility failed to ensure the resident environments were in good repair (2 of 2 common baths, and room [ROOM NUMBER]).<BR/>These failures could lead to resident injuries, spread of infections and cause the facility to have an unsightly appearance. <BR/>The findings include:<BR/>On 1/10/23 at 1:59 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank that had a gauge indicating there was oxygen still in the tank. It was nearest the A bed area. Residents #22 and #58 resided in this room. <BR/>On 1/10/23 at 2:20 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank near the commode chair. The level on the oxygen tank gauge indicated that there was still oxygen in the tank. Resident #165 resided in this room. <BR/>On 1/10/23 at 6:05 PM, observation of room [ROOM NUMBER] revealed an approximately 8-foot section of window trim missing under the window ledge next to Resident #17's bed. It exposed nail heads that extended out from the wall. <BR/>On 1/10/23 at 6:26 PM, observation of room [ROOM NUMBER] revealed a freestanding oxygen tank in the room. During an interview with Resident #58 at this time the resident revealed the oxygen tank had been in the room since Resident #22 had moved into the room. The resident was unsure of the date.<BR/>On 1/10/23 at 6:49 PM, observation of room [ROOM NUMBER] revealed an oxygen tank was freestanding and not secured.<BR/>On 1/10/23 at 6:50 PM an interview was conducted with the Administrator. Regarding the unsecured oxygen tanks, she stated the facility had to watch hospice staff related to oxygen storage to ensure the tanks were stored appropriately.<BR/>On 1/10/23 at 6:51 PM an interview was conducted with Resident #22. Regarding the freestanding oxygen tank in her room (room [ROOM NUMBER]), she stated the oxygen tank was from hospice. She stated the tank had been in her room for a week.<BR/>On 1/11/23 at 8:42 AM, observation of room [ROOM NUMBER] revealed the temperature of the hand sink hot water peaked at 117.5&deg;F then declined to 114 degrees F which the 114 degrees F temperature was witnessed by RN A. It was checked with the surveyor's digital thermometer. Resident #23 resided in this room, used a wheelchair and had confusion.<BR/>Record review of the current undated American Burn Association SCALD INJURY PREVENTION <BR/>Educator's Guide revealed that 100 degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third degree burn (full thickness burn) in 5 minutes <BR/>On 1/11/23 at 8:57 AM an interview was conducted with the Maintenance Supervisor. He stated the facility water circulating system began at room [ROOM NUMBER]. He stated he had not experienced any plumbing problems related to hot water. He stated he tested the hot water every week in random resident rooms. He stated four rooms were tested each week, two on each hall. He also stated he tested hot water at random times and random days of the week, using a digital thermometer.<BR/>Record review of the Hot Water Temperature Logs between October 2022 and 1/9/23 revealed that temperatures were taken in resident rooms 40 times. 38 of the 40 test times were between 9:30 AM and 11:30 AM. The temperatures ranged from 101.2&deg;F to 105.4&deg;F. Further record review of the instructions documented on the Hot Water Temperature Logs sheet revealed the following, . Hot water in wash sink must be 110&deg;F or above . Water for handwashing must be between 100&deg;F and 110&deg;F <BR/>On 1/11/23 at 8:58 AM an interview was conducted with the Housekeeping Supervisor regarding freestanding oxygen in the rooms. She stated some oxygen tanks from hospice were moved, but did not specify when. She stated on 1/10/23 she asked LVN A to retrieve the oxygen tank from room [ROOM NUMBER]. She further stated she failed to follow up to see if the oxygen tank had been removed from the room. <BR/>On 1/11/23 at 11:30 AM an observation was made of the Station 2 bath. The door was fully open, and the room was unattended. There were spray bottles of chemicals on a lower shelf in an unlocked cabinet, which included Comet with Bleach cleaner/disinfectant which was labeled, If swallowed drink a glass of water. Call physician immediately , Micro Kill Q 10 disinfectant labeled .Causes moderate eye irritation. Avoid contact with eyes and clothes. and a spray bottle of a purple liquid that had an unclear label. The heat and exhaust fans were not operational. There was an unshielded fluorescent light in the room. Two of two shower area circular ceiling lights were not operational.<BR/>On 1/11/23 at 11:35 AM an observation was made of Station 1 bath and the door was open. There was a spray bottle of Comet with Bleach on the top shelf above resident toiletries. The face plate was missing from an electrical outlet at the sink/toilet area which exposed the interior of the wall. A privacy curtain was missing between the 2 shower stall areas. <BR/>On 1/11/23 at 11:37 AM CNA A was asked about the shower stalls in the Station 1 bath. She stated both shower units worked, but one (sprayer) had a lower water pressure than the other. She further stated there used to be privacy curtains between the stalls. She stated when they had a leak in the ceiling the privacy curtain was gone after that.<BR/>On 1/11/23 11:38 AM an interview was conducted with CNA B regarding the privacy curtain that was missing in the Station 1 bath. She stated she noticed the privacy curtain missing a month ago. She further stated she did not report this to anyone. <BR/>On 1/11/23, 11:45 AM an interview was conducted with the Maintenance Supervisor. Regarding the process he used to know about needed maintenance services, he stated the facility had a logbook and a calendar for scheduled maintenance services. He stated staff placed their maintenance requests in the logbook that was located at Station 2 in a purple binder. He stated he tried to check the book daily, but usually residents or nurses told him the issue. He stated he had been the Maintenance Supervisor for two years.<BR/>On 1/11/23 at 1:03 PM an observation was made of room [ROOM NUMBER]. There was an approximately 8-foot section of missing window trim that had three areas where nail heads extended beyond the wall at the B bed. <BR/>On 1/11/23 at 1:31 PM an observation was made of the shower bed at Station 2 with CNA A. During an interview with her at this time, she stated the only residents that used the shower bed were those needing it, such as Resident #4. Observation of the foam overlay of the shower bed revealed an approximately 3-inch split on the underside that exposed the foam interior. There was also a corner piece that had a sharp edge on the PVC frame. The CNA stated the corner piece had been that way a couple of days and maintenance was going to repair it today.<BR/>On 1/12/23 at 9:40 AM an observation was made of the Station 2 bath. The door was fully open and unattended. The cabinet was unlocked and had spray bottles of a poorly labeled bottle of a purple liquid, Comet with Bleach and Micro Kill Q 10 disinfectant.<BR/>On 1/12/23 at 9:45 AM an interview was conducted at Station 2 with CNA C. She stated she did not know what chemical was in the spray bottle of purple liquid, but the other two bottles were disinfectants used on shower chairs. She stated staff should store those chemicals in the housekeeping room. Regarding the accessible, improperly stored and labeled chemicals, she stated it would not be good if residents got into the chemicals. Regarding the ceiling heat unit and exhaust fans not being operational, she stated she noticed the ceiling heater unit and exhaust fan not working on 1/11/23. She stated she had not mentioned this to anyone.<BR/>On 1/12/23 at 9:58 PM an interview was conducted with the Maintenance Supervisor regarding repairs and how he knew when they were completed. He stated he writes done by the request in the logbook but sometimes he forgets to do so. He also stated he was not aware of the Station 2 circular shower lights, ceiling heater and the exhaust fan not working. Regarding the missing Station 1 privacy curtains, he stated he was not sure how long the curtain had been gone. He stated his repair schedule was driven mostly by what was in the logbook. He stated residents also stop and tell him about repairs. He stated he was not aware of the missing window trim in room [ROOM NUMBER]. He stated residents could get hurt if items were left unrepaired. Regarding oxygen storage, he stated an in-service was conducted on oxygen a few months ago. He added, oxygen should not be free and loose. He stated the storage problem was with the nurses. He further stated staff were trained to know oxygen should be secured. He stated he corrected improperly stored oxygen if seen. He further stated that he was not aware of any issues with hospice staff related to oxygen storage. <BR/>Record review of the maintenance logbook revealed that between October 2022 and 1/9/23 there were 38 requests documented for facility repairs/maintenance services. There was only written documentation of four of the requests being completed. None of the identified maintenance issues discovered during the survey were documented in the maintenance log.<BR/>On 1/13/23 at 1:06 PM the shower bed/gurney was observed in the Station 2 corridor and the foam overlay still had an approximately 3-inch split on the underside, exposing the foam interior.<BR/>On 1/13/23 at 3:30 PM an interview was conducted with the DON. She stated she talked to staff about oxygen storage and did an in-service.<BR/>Record a review of the In-Service Training Report dated 10/5/22 revealed the Subject: E Cylinder, which was conducted by the DON/ADON/designee. Summary of in-service: the E cylinder . when in use, empty or full, must never be freestanding. They must be in a proper stand, container or rolling stand. Take empty tanks out to the proper locked area. Freestanding E cylinders are dangerous if they fall over! . The attached document to this in-service further stated, . Oxygen Guidelines. E cylinders should never be left standing on the floor anywhere. <BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator. Regarding the storage of oxygen and repairs she stated she expected staff to report repairs. She was asked what could result from these issues and she stated safety issues.<BR/>Record review of the facility policy, titled Operation Policy and Procedure Manual for Long-Term Care, Revised December 2009, Physical Environment - Maintenance, revealed following documentation, Maintenance Service. Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation, and Implementation. <BR/>1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. <BR/>2. Functions of maintenance personnel include, but are not limited to: <BR/>a. Maintaining the building in compliance with current federal, state and local laws, regulations, and guidelines. <BR/>b. Maintaining the building in good repair and free from hazards. <BR/>f. Establishing priorities in providing repair service. <BR/>i. Providing routinely schedule maintenance service to all areas. <BR/>j. Others that may become necessary or appropriate. <BR/>3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner <BR/>Record review of the facility policy, titled, Operational Policy and Procedure Manual for Long-Term Care, Revised May 2011, Physical Environment - Fire Ants, Life Safety, revealed the following documentation, Fire Safety and Prevention. Policy Statement. All personnel must learn methods of fire prevention and must report conditions that could result in a potential fire hazard. Policy Interpretation, and Implementation. <BR/>Oxygen Safety . <BR/>f. Store, oxygen cylinders in racks with chains, sturdy, portable carts, or approve stands. Never leave oxygen cylinders, freestanding. Do not store oxygen cylinders in any resident room or living area. <BR/>p. Ensure that staff using oxygen equipment is adequately trained in its operation and in oxygen safety and has the knowledge of the manufactures instructions for using the equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on a comprehensive assessment, that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for 1 of 24 residents on psychoactive medications (Resident #22), in that:<BR/>1)The facility failed to ensure that Resident #22 had orders for psychotropic medications (Lorazepam) that did not contain PRN orders beyond 14 days without a stop date and reassessment.<BR/>This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. <BR/>The findings include:<BR/>Record review of the 1/10/23 physician Order Summary Report and face sheet revealed the Resident #22 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Malignant Neoplasm Of Unspecified Part Of Left Bronchus Or Lung (Lung Cancer), Squamous Cell Carcinoma Of Skin Of Left Lower Limb, Including Hip(Skin Cancer), Depression, Unspecified, Type 2 Diabetes Mellitus With Hyperglycemia(High Blood Sugar), Chronic Obstructive Pulmonary Disease, Unspecified(Breathing Disorder), Personal History Of Transient Ischemic Attack (Tia - Mini Stroke), And Cerebral Infarction Without Residual Deficits (Stroke), Colostomy Status (Bowel Reroute), Acute Upper Respiratory Infection, Unspecified, And Anxiety Disorder, Unspecified.<BR/>Record review of the admission MDS dated [DATE] for Resident #22 revealed the resident had received an antidepressant in the last seven days and a hypnotic in the last five days. The resident had a BIMS score of 14.<BR/>Record review of the current undated care plan for Resident #22 revealed a problem listed as, The resident uses anti-anxiety medications Lorazepam 1 MG r/t (related to) Anxiety disorder. Date Initiated: 12/19/2022. Revision on: 01/11/2023. The gold reflected, The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Date Initiated: 12/19/2022. Revision on: 01/11/2023. Target Date: 02/19/2023. Interventions reflected, Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 12/19/2022 .Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy . Date Initiated: 12/19/2022 <BR/>Record review of the Order Summary Report for Resident #22 dated 1/10/23 revealed the following order, LORazepam Tablet 1 MG Give 1 tablet by mouth every 6 hours as needed for Pain - Mild related to MALIGNANT NEOPLASM OF UNSPECIFIED PART OF LEFT BRONCHUS OR LUNG (C34.92) Prescriber Written. Status: Active. Order Date:12/14/2022. Start date:12/14/2022 <BR/>Record review of the Medication Administration Report dated 1/11/23 for 1/1/23 through 1/31/23 revealed Resident #22 received Lorazepam 1 mg from the PRN order for the first time on 1/07/23 (7:32 PM) and again on 1/08/23 (9:47 PM).<BR/>Record review of the Consultant Pharmacist Medication Regimen Review dated 1/8/2023 revealed the following for Resident #22, Priority: normal. <BR/>This resident is currently receiving lorazepam 1 mg Q6 hours PRN 'pain'. This order began 12/14/22.<BR/>Please evaluate current diagnosis, behaviors and usage patterns and evaluate continue need.<BR/>PRN, psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the resident's medical record and indicate the duration of the PRN order.<BR/>Please consider:<BR/>-Discontinue PRN lorazepam.<BR/>-New order for PRN: lorazepam 1 mg Q6 hours PRN____ (reason for use) for ____ days.<BR/>-Adjust routine order to _____. <BR/>Effective 11/28/17:<BR/>483.45 (e)(3) residents do not receive psychotropic drugs, pursuant to a PRN order, unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and,<BR/>483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5) if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rational in the resident's medical record and indicate the duration of the PRN order .<BR/>Record review of the Progress Notes for Resident #22 from 12/14/22 through 1/10/23 revealed no documentation of a reassessment for the PRN lorazepam order by the physician.<BR/>On 1/13/23 at 3:30 PM an interview was conducted with the DON regarding the PRN Lorazepam order for Resident #22. She stated she had talked to staff about their psychoactive medication procedures. She stated the ADON was responsible for making sure the resident did not have PRN psychoactive medication orders. She stated the current ADON had only been employed a week. She stated previously the ADON monitored this, but she had been gone several months. She further stated that in the interim, she (DON) tried to monitor psychoactive medication orders. She stated she expected staff to have caught the PRN psychoactive medication issue and followed up on it. She stated residents could be at risk of becoming dependent on the PRN psychoactive medication if used beyond the 14 days. <BR/>On 1/13/23 at 4:32 PM an interview was conducted with the Administrator regarding PRN psychoactive medication use beyond 14 days. She stated she expected that staff should have a stop date on the psychoactive medications. She stated the PRN use of psychoactive medications beyond 14 days could affect the resident's overall health.<BR/>Record review of the facility policy, titled Operational Policy and Procedure Manual For Long-Term Care, revised December 2016, Quality Of Care - Medication, Administration, Antipsychotic Medication Use, revealed the following documentation, Policy Statement. Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior. Symptoms have been identified and addressed.<BR/>Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation, And Implementation . <BR/>13. Residents will not receive PRN doses of psychotropic medication to unless that medication is necessary to treat a specific condition that is documented in the clinical record. <BR/>14. The need to continue PRN orders for psychotropic medications. Beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order <BR/>Record review of the facility policy, titled Nursing Services Policy and Procedure Manual for Long-Term Care, Revised July 2016, Orders, Receiving and Transcribing, revealed the following documentation, Medication and Treatment Orders. Policy Statement. Orders for medication and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation, and Implementation . <BR/>9. Orders for medications must include. <BR/>b. Number of doses, start and stop date, and/or a specific duration of therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans.<BR/>This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails.<BR/>This failure could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Findings include:<BR/>Resident #9<BR/>Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). <BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #9 was understood and had a BIMS score of 00 indicating that the resident's cognition was severely impaired. <BR/>Record review of the current care plan for Resident #9, undated, revealed there was no specific care plan regarding bedrails. <BR/>Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have &frac14; side rails on right and left side of bed. <BR/>Resident #11<BR/>Record review of the admission record for Resident #11, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (problem in the brain), acute and chronic respiratory failure (lung disease), and pneumonia (lung infection).<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #11 was understood and had a BIMS score of 12 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #11, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #11, dated 02/27/24, revealed the following order: May use siderails for positioning and ease of mobility as an enabler every shift for siderails with an order start date of 09/29/22.<BR/>Resident #160<BR/>Record review of the admission record for Resident #160, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (motor disability), seizures (neurological disorder), and muscle weakness.<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #160 was usually understood and had a BIMS score of 15 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #160, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #160, dated 02/27/24, revealed the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20.<BR/>During an interview on 02/29/24 at 12:07 PM, the DON and the ADON stated they were both responsible for ensuring the care plans for the residents were completed. The DON and the ADON stated they were unsure why Residents #9, #11 and #160 were missing care plans for bed rails. The DON and ADON stated the care plans were audited last week but they did not look for bedrails in the care plan at that time. The DON stated the potential negative outcome to the residents was the bed rails would not be followed up on and assessed to see if they were still appropriate for the residents. <BR/>During an interview on 02/29/24 at 12:16 PM, the ADM stated the DON and ADON were responsible for ensuring the care plans were completed. The ADM stated the facility had a change in nursing management last year and ensuring bed rails were care planned fell through the cracks. The ADM stated the potential negative outcome to the residents was staff could not be aware and it could cause a possible injury of some sort. <BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following:<BR/>Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident with a mental disorder was accurately screened prior to admission for 2 of 3 of (#18 and #23) residents reviewed for PASRR: <BR/>The facility did not correctly identify Resident #18 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. <BR/>The facility did not correctly identify Resident #23 on the PASRR Level 1 Screening Form as having a mental illness and did not submit a request to correct their PASRR negative screening. <BR/>This failure could affect residents with mental illness that were not considered to be a positive PASRR level one and could result in a failure to receive a PASRR level two evaluation and individually specialized services to meet their needs.<BR/>The Findings were:<BR/>Resident #18:<BR/>Record review of Resident #18's electronic facesheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included recurrent major depressive disorder (onset date of 04/10/2019), anxiety disorder due to know physiological condition (onset date of 04/10/2019), and psychosis not due to a substance or know physiological condition (onset date of 04/10/2019). Dementia was not listed in the diagnosis information.<BR/>Record review of Resident #18's Quarterly MDS, dated [DATE], revealed under section I Active Diagnoses, psychiatric/mood disorder revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 <BR/>Record review of Resident #18's most recent care plan dated 01/04/2023 revealed a focus area which reflected in part that Resident #18 is at risk for adverse consequences r/t receiving antidepressant medication for treatment of depression. He takes Cymbalta BID (twice daily) and Wellbutrin XL BID with interventions in place that included Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and or EPS (extrapyramidal symptoms - side effects from antipsychotics). Monitor Resident #18's mood and response to medication. Pharmacy consultant review. Additionally, the care plan contained a focus area which reflected The resident uses antidepressant medication Cymbalta r/t Depression with interventions in place that included Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. <BR/>Record review of Resident #18's Preadmission Screening and Resident Review Level (PL1) One form dated 04/10/2019 and completed prior to admission revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. <BR/>During an interview with Resident #18 conducted on 01/13/2023 at 1:20 PM, he said he had his diagnosis of major depressive disorder (MDD) going on ten years or so, prior to being admitted to the facility. He said he lost both parents and two brothers as well and those events made his depression worse. He said he did not get any specialized services pertaining to his diagnosis of MDD at the facility. He said other than taking medication for his MDD, the facility was not doing anything else. He said some days he feels like the medication is helping and some days he feels like he could use some extra help.<BR/>During an interview with the MDS Coordinator conducted on 01/12/23 at 11:09 AM, she said she has been at the facility since October of 2022. She said some residents come in with the PL1 screening already done and said she was responsible for reviewing them to double check that they were accurate. She said if they were not accurate, she should have contacted the local mental health authority to verify diagnoses of the resident that are considered mental illnesses. She said that MDD is a mental illness that should be indicated as a yes for section C0100 on the PL1 screening form. She said she does not know why Resident #18's PL1 shows an answer of no for section C0100. She said she should have conducted a new PL1 and had a PL2 evaluation done for the resident. She said the risk of an inaccurate PL1 screening would be the resident missing out on extra services needed for them to receive optimal care. She said it could hinder the overall well-being of the resident.<BR/>During an interview with the MDS Coordinator conducted on 01/13/23 at 09:35 AM, she said she is in the process of updating the PL1 for Resident #18 to accurately reflect his diagnosis and will be contacting the local mental health care authority to have a level 2 evaluation done. She said she would provide a copy of the updated PL1 as well as a facility policy pertaining to PASRR Level 1 Screenings.<BR/>During an interview with the MDS Coordinator and the PASRR Coordinator from the local mental health authority conducted at 01/13/23 at 2:27 PM, they stated that Resident #18 was being evaluated this evening.<BR/>Resident #23:<BR/>Record review of the 1/10/23 Order Summary Report and face sheet revealed Resident #23 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Paranoid Schizophrenia, Generalized Anxiety Disorder, Anxiety Disorder, Unspecified, and Wandering In Diseases Classified Elsewhere. Further record review of the face sheet for Resident #23 revealed that one of her admitting diagnoses was paranoid schizophrenia on 1/08/20.<BR/>Record review of the admission MDS for resident #23 dated 1/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 13.<BR/>Record review of the quarterly MDS for resident #23 dated 11/16/22 documented that the resident had diagnosis of anxiety and schizophrenia. It was also documented that the resident had a BIMS score of 15.<BR/>Record review of the current undated care plan for Resident #23 revealed a problem that reflected, [Resident #23] is/has potential to be verbally aggressive, yelling at staff and suspicious behavior toward staff. She has the dx of Dementia and Paranoid Schizophrenia. She has auditory and visual hallucinations. She refuses counseling and psych. services . Date Initiated: 07/16/2020. Revision on: 08/06/2020. A documented Intervention reflected, Administer medications as ordered. Monitor/document for side effects and effectiveness <BR/>Record review of the PASRR Level 1 screening for Resident #23 dated 1/3/2020 revealed the resident was documented as negative for mental illness, intellectual disability, or developmental disability. This PASRR screening was conducted by the resident's discharging hospital.<BR/>A record review was conducted of the facility provided PASRR list dated 1/10/23. The list consisted of residents in the facility that were positive on a PASRR Level 1 screening for mental illness, intellectual disability, or developmental disability and had a PASRR Evaluation. There were 3 residents listed and Resident #23 was not on the list.<BR/>On 1/10/23 at 5:54 PM an observation and interview were conducted with Resident #23. During this conversation, the resident expressed delusional thoughts and her conversation was agitated and confused.<BR/>On 1/13/23 at 11:57 AM an interview was conducted with Resident #23's Appointed Guardian who stated he had been her guardian for a few years and that the resident had a history of mental illness.<BR/>On 1/11/23 at 5:20 PM an interview was conducted with the MDS Coordinator regarding Resident #23's PASRR Level 1 screening. She stated she thought Resident #23 had a diagnosis of schizophrenia after admission and was diagnosed with dementia at some time during her stay. She stated in 2020 the facility had a managing company change and she was not able to find a PASRR Evaluation developed from the PASRR Level 1 screening. She stated she had been the MDS Coordinator since 2022. She stated residents could miss out on mental health services if incorrect PASRR Level 1 screenings were conducted.<BR/>Further record review of the face sheet for Resident #23 dated 1/10/23 revealed that one of Resident 23's admitting diagnoses was paranoid schizophrenia on 1/08/20.<BR/>During an interview with the Administrator conducted on 01/13/23 at 9:48 AM, she said it was the MDS Coordinator's responsibility to review PL1 screenings for accuracy when residents come another facility. She said if a resident came from home, the MDS Coordinator or social worker should complete the PL1. When asked what the risks for a resident could be if they did not receive an accurate PL1 or subsequent PL2 evaluation, she said she couldn't really think of any risks because she thinks they offer the same services. <BR/>During an interview with the Administrator conducted on 01/13/23 on 1:27 PM, she said they currently do not have a full-time social worker at the facility. She said they have a part time social worker who comes to the facility in the evenings and is currently not at the facility. <BR/>Record review of Form 1012, Texas Health and Human Services Mental Illness/Dementia Resident Review found at https://www.hhs.texas.gov/regulations/forms/1000-1999/form-1012-mental-illnessdementia-resident-review (accessed on 01/17/2023) reflected in part, .Examples of MI (mental illness) are: a schizophrenic, mood disorder (bipolar, major depression, or other mood disorder), paranoid disorder; somatoform disorder; schizoaffective disorder; panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 19 residents (Residents #9, #11 and #160) reviewed for care plans.<BR/>This facility failed to develop a care plan for Residents #9, #11 and #160 to include bedrails.<BR/>This failure could place residents at risk of not receiving the care required to meet their individualized needs. <BR/>Findings include:<BR/>Resident #9<BR/>Record review of the admission record for Resident #9, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: urinary tract infection (bladder infection), fecal impaction (difficult bowel movements), and acute kidney failure (kidney disease). <BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #9 was understood and had a BIMS score of 00 indicating that the resident's cognition was severely impaired. <BR/>Record review of the current care plan for Resident #9, undated, revealed there was no specific care plan regarding bedrails. <BR/>Observation on 02/27/24 at 10:41 AM revealed Resident #9 was noted to have &frac14; side rails on right and left side of bed. <BR/>Resident #11<BR/>Record review of the admission record for Resident #11, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (problem in the brain), acute and chronic respiratory failure (lung disease), and pneumonia (lung infection).<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #11 was understood and had a BIMS score of 12 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #11, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #11, dated 02/27/24, revealed the following order: May use siderails for positioning and ease of mobility as an enabler every shift for siderails with an order start date of 09/29/22.<BR/>Resident #160<BR/>Record review of the admission record for Resident #160, dated 02/27/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral palsy (motor disability), seizures (neurological disorder), and muscle weakness.<BR/>Record review of the comprehensive MDS assessment dated [DATE] revealed that Resident #160 was usually understood and had a BIMS score of 15 indicating that the resident's cognition was intact. <BR/>Record review of the current care plan for Resident #160, undated, revealed there was no specific care plan regarding bedrails. <BR/>Record review of the active physician orders for Resident #160, dated 02/27/24, revealed the following order: 1/4 side rails for bed mobility and positioning with a start date of 06/29/20.<BR/>During an interview on 02/29/24 at 12:07 PM, the DON and the ADON stated they were both responsible for ensuring the care plans for the residents were completed. The DON and the ADON stated they were unsure why Residents #9, #11 and #160 were missing care plans for bed rails. The DON and ADON stated the care plans were audited last week but they did not look for bedrails in the care plan at that time. The DON stated the potential negative outcome to the residents was the bed rails would not be followed up on and assessed to see if they were still appropriate for the residents. <BR/>During an interview on 02/29/24 at 12:16 PM, the ADM stated the DON and ADON were responsible for ensuring the care plans were completed. The ADM stated the facility had a change in nursing management last year and ensuring bed rails were care planned fell through the cracks. The ADM stated the potential negative outcome to the residents was staff could not be aware and it could cause a possible injury of some sort. <BR/>Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, reflected the following:<BR/>Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident

Resident #29<BR/>Care Planning<BR/>04/09/25 02:41 PM record review shows discrepancies' with several of the care plan not being care planned. 04/10/25 12:26 PM It was determined that resident had several triggered MDS items that were not care planned. <BR/>Resident #40<BR/>Care Planning<BR/>04/10/25 12:25 PM It was determined that resident had several triggered MDS items that were not care planned. <BR/>Resident #145<BR/>Care Planning