**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 received the correct dose of Vitamin D3 (a dietary supplement to help maintain bone health and for vitamin deficiency) as written by the physician. LVN A failed to confirm the correct dose of Vitamin D3 prior to administration. This failure could place residents at risk of not receiving the intended therapeutic benefits of the medications. Findings included: Record review of Resident 1#'s face sheet dated 08/21/2024, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Wernicke's Encephalopathy (brain and memory disorder), cocaine dependence, schizoaffective disorder, anxiety disorder, vitamin deficiency, hypertension and vitamin D deficiency. Record review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 3 out of 15, indicating severe cognitive impairment. He required supervision or set up for ADL's. He was always continent of bowel and bladder. Record review of Resident #1's undated care plan reflected a nutritional risk related to advanced age and interventions to include administer medications as ordered. Further review reflected the diagnosis of vitamin D deficiency was not addressed. Record review of Resident #1's physician's orders as of 08/21/2024 reflected an order for Vitamin D3 125mcg 1 capsule daily by mouth related to vitamin deficiency. Record review of Resident #1's MAR for August 2024 reflected that LVN A documented administering Vitamin D3 125 mcg capsule on 8/21/2024. In an observation and interview during medication pass on 08/21/2024 at 8:15AM in the memory care unit, revealed LVN A prepared medications for Resident #1. LVN A prepared the following medications: Gabapentin 300mg one capsule, Bupropion HCL SR 150mg one tablet, Prezcobix 800mg/150mg one tablet, Loratadine 10mg one tablet, Folic acid 1mg tablet, multi-vitamin one tablet, thiamine vitamin B-1 100mg one tablet, Emtricitabine 200mg one tablet and Vitamin D3 25mcg 2 tablets. LVN A administered the medications to Resident #1. In an interview and observation on 08/21/2024 at 11:35AM, LVN A stated she started working at the facility around 06/26/2024 and was a full-time employee. Observation of the medication cart in the memory care unit revealed a bottle of Vitamin D3 25mcg. Further observation of the medication cart revealed there was no Vitamin D3 125mcg. LVN A stated she gave Resident #1 two tablets of Vitamin D3 25cmg and stated that the order was for 2 tablets. LVN A stated she missed reading the correct dose on the bottle. LVN A stated Resident #1 was receiving Vitamin D3 for a vitamin deficiency and the risk of not getting the correct dose was Vitamin D deficiency. LVN A stated when she prepared medication for administration to residents, she checked for the right medication, right dose, right amount and right patient/resident. LVN A stated it was important to give the correct medications as written by the physician so the resident would receive the adequate amount. LVN A stated she believed she did the medication competency checklist during orientation and that it was conducted by the DON and ADON. LVN A stated going forward she would be able to write a self-report in the eHR system for medication errors. LVN A stated she would notify the family and the MD of the med error. In an interview on 08/21/2024 at 2:00PM, the DON stated she expected the nursing staff to check the physician orders and make sure orders were still valid, current and nothing had changed. She stated she expected the nurses to check for the right resident, right dose, right medications, right time, no allergies, no contraindications and to check consents if needed prior to administering medications. The DON stated the nurse called the NP when she missed giving the correct dose and that the order could have been put in the system incorrectly, that it was probably supposed to read Vitamin D3 25mcg and not 125mcg as the facility did not have bottles of the 125mcg. The DON stated it was the responsibility of the person transcribing the order to have made sure what was entered was correct and of course when giving the medication, the nurse should have confirmed the dose. The DON stated Resident #1 was receiving Vitamin D3 as a supplement as he had several different diagnoses that would cause low Vitamin D levels also, he was not a big eater and needed to get more nutrients. The DON stated the risk of not receiving the correct dose of Vitamin D3 could be side effects of an overt dose especially if his labs are being regulated or there could have been a contraindication. Record review of the facility policy for Medication Administration, copyright 2024 reflected in part: .Medications are administered by licensed nurses .as ordered by the physician .Policy Explanation and Compliance Guidelines: .10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dose, c. Right route, e. Right time, f. Right documentation. 11. Review MAR to identify medication to be administered. 12. Compare medication source .with MAR to verify resident name, medication name, form, dose, route and time .

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened/preparation discarded after 96 Hours (4 days) per facility policy 2. The facility failed to keep food off the floor. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen on 08/20/24 at 8:15 AM revealed the following. 1. 5 chicken sandwiches in the walk in cooler had use by date 8/19/24. 2. A Plastic container of deli sliced ham in the walk-in cooler had no label/ no date 3. A plastic container - of shredded lettuce dated 8/12/24 and no use by date. 4. A quart of potato salad dated 8/9/24 , and a use by date of 8/15/24 5. 1case of produce - in the walk- in cooler was stored on the floor 6. 1case of chicken in- the walk- in freezer was stored on the floor 7. 1case of French fries- in walk- in freezer was stored on the floor 8. 2cases of breakfast sausage- in walk- in freezer were stored on the floor In an interview with the Dietary Food Service Manager on 08/20/24 at 8:30 AM, he stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. He stated the cases of food should be off the floor due to cross contamination. He stated he or designee , shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded prior to expiration date. Record review of facility's policies and procedures for Food Safety dated 2004 reflected in part .potentially hazardous leftover foods are properly covered, labeled, dated, and refrigerated immediately. They are discarded after 96 hours unless otherwise indicated. Record review of facility's policies and procedures for Food Safety Requirements dated 2004 reflected in part b. foods/beverages be stored in a clean, dry area off the floor to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure all drugs and biologicals were stored securely for one (Nurse Cart for B Hall/D Hall) of three medication carts reviewed for storage of medications. The Nurse Cart for B Hall/D Hall contained medications without resident identifiers. The Nurse Cart for B Hall/D Hall contained a narcotic medication blister pill card with a punctured protective seal. The failures could place all residents at risk of not receiving the therapeutic benefit of medications, infection, adverse reactions to medications and drug diversion. Findings included: Record review of Resident #2's face sheet dated 08/20/2024 reflected a [AGE] year-old female, admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included dementia, bipolar disorder, diabetes with diabetic neuropathy (nerve damage that can occur with diabetes), depression and chronic pain. Record review of Resident #2's physician's orders as of 08/20/2024 reflected an order for Cannabidiol Oral Solution, 15 drops at bedtime for anxiety/sleep, date started 04/05/2024. Observation on 08/21/2024 at 6:30 AM, revealed in the top drawer of the Nurse medication cart for B Hall/D Hall contained a bottle of Refresh Tears without a resident identifier, and a bottle of CBD (Cannabidiol) oil (a hemp supplement) without a resident identifier. The CBD oil bottle was in the compartment with eye drops. Further review of the top drawer revealed one insulin pen, Lispro (a fast-acting insulin that lowers blood sugar in people with diabetes) without a resident identifier and a second insulin pen, Aspart (a fast-acting insulin that lowers blood sugar in people with diabetes). Both insulin pens contained fluid. Interview on 08/21/2024 at 6:30AM, LVN B stated she was the charge nurse and worked the 7:00PM to 7:00AM shift. LVN B stated she did not use or open the cart on her shift and did not know why the insulin pens, refresh eye drops, and CBD oil were not labeled. LVN B stated the only resident she was aware who used the CBD oil was Resident #2. LVN B stated the Refresh Tears eye drops and the CBD oil should have been in the original boxes with pharmacy labels and resident names. LVN B stated the risk of medications without resident identifiers was that a resident could be given the incorrect medication and cross contamination from being used on another resident. LVN B stated it was the facility's policy to have resident identifiers on all medications. Observation and interview on 08/21/2024 at 9:00AM, the Nurse medication cart for B Hall/D Hall, revealed a narcotic lock box that contained a Hydrocodone-APAP 10-325mg blister pill card with pin holes on the back of one of the pill compartments (Compartment #5). RN C stated that yes there were 2 pin holes on the back of the blister pill card and that a contaminant could get into where the tablet was. RN C further stated that when ingested a resident may get sick and if the holes got larger the pill could fall out, someone could pick it up, eat it and get sick. RN C stated if there was a tear on the protective seal, she would not tape it but knew instead to waste the pill and that she did not know what to do if there were pin holes. RN C then stated that she would waste it with another nurse to be safe. In an interview on 08/21/2024 at 2:00 PM, the DON stated insulin pens should always have the resident name on the pen and on the bag including the date opened along with pharmacy labels. The DON stated the nurse in charge of the medication cart would be responsible for ensuring all medications were labeled and that ultimately all the nurses were responsible to ensure proper labeling of medications. The DON stated possibly the bags for the insulin pens were lost and that the nurses would not intentionally remove the labels. The DON stated that it was unfortunate that it happened and would expect the nurses to discard the pens when found. The DON stated the nurses just did not write the resident name on the bottle of Refresh Tears and the CBD oil did not come from a pharmacy, the original box may have been lost. The DON stated it would be ideal to have the box for the CBD oil or have the resident's name written on the bottle. The DON stated it would be important because not everyone would be familiar with Resident #2, especially agency staff and that it was facility policy to have all medications with resident identifiers. The DON stated it was the nurses assigned to the carts responsibility to maintain accuracy of the medications in the carts. The DON stated it ultimately fell on the DON and ADON to make sure the nurses were doing their duties. The DON stated she expected the nurses to check the carts at the beginning and end of shift during counting. The DON stated she expected the nurse coming on shift to also ensure everything was in order with the medication carts. The DON stated she expected the nurse leaving and the nurse coming on shift to make sure the cart had been checked for any errors. The DON stated she taught the nurses to check the protective seals were intact on the blister pill cards and ensure it did not look tampered with. The DON continued by stating that if the seal were broken, the pill could fall out, get lost, could be tampered with and may not be the correct pill as a result a resident could be harmed and possible harm to nurse licenses as well. Record review of the facility policy for Medication Storage, dated 2023 reflected in part: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .and sufficient to ensure proper sanitation .security .1a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts .2b. Scheduled II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area . Record review of the facility policy for Injection Safety - Drug Diversion, dated 2023 reflected in part: .Definitions: Drug Diversion refers to the theft or other deviations that removes a prescription drug from its intended path form the manufacturer to the patient .2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications .3. Staff with access to controlled medications are trained on the facility's policy for the administration and accountability of controlled substances .5. Ongoing supervision and auditing are conducted in accordance with facility policy to verify that staff are following policies as written .

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage . This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 08-20-24 at 8:45 am, revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and dumpster door was open. In an interview on 08-20-24 at 8:45 am, with the Food Service Manager, he stated the dumpster door when not in use should have doors closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. He stated housekeeping, and nursing also discarded their waste garbage in the dumpster. It was the responsibility of staff from dietary, nursing and housekeeping for ensuring the dumpster doors are kept closed when not in use. Record review of facility's Policies and Procedures on disposal of garbage and refuse dated 2024 read in part 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors or covers. Containers and dumpster shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 (Resident #1) of 6 residents reviewed for changes of condition. The facility failed to notify Resident #1's physician when she experienced a change of condition, including developing a small bump on the back of the head after she fell out of her wheelchair and hit her head on [DATE]. This failure placed residents at risk experiencing a delay in medical treatment and worsening of condition/symptoms. Record review of Resident #1 ' s face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks); Dementia (the loss of cognitive functioning — thinking, remembering, and reasoning — and behavioral abilities to such an extent that it interferes with a person ' s daily life and activities); Type 2 Diabetes with Diabetic Chronic Kidney Disease (damaged blood vessels and other cells in the kidneys caused by diabetes); Restless Leg Syndrome (a condition that causes a very strong urge to move the legs); and Hypertension (or high blood pressure, is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #1 ' s MDS assessment dated [DATE], revealed no interview for mental status was conducted, which indicated the resident was rarely or never understood, and rarely or never made decisions regarding daily life. Resident #1 required limited assistance with bed mobility, transfer, eating, and extensive assistance with toileting. The resident required one-person physical assist with bed mobility, transfer, eating and toileting. Further review of the MDS did not reveal whether the resident used a wheelchair. Record review of Resident #1's care plan revealed she had an Actual Communication Problem related to being Hard of Hearing. Interventions included a communication board for the resident to use to communicate; ensure availability and functioning of adaptive communication equipment. Other interventions included allowing the resident adequate time to respond; repeat as necessary; do not rush; request clarification from the resident to ensure understanding; face when speaking; make eye contact; turn off TV/radio to reduce environmental noise; ask yes/no questions if appropriate; use simple, brief, consistent words/cues; use alternative communication tools as needed. The resident was at risk for falls related to poor safety awareness and weakness. The resident had impaired cognitive function and impaired thought processes related to Alzheimer's Disease and Dementia. Interventions included observations for any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Interventions included fall mat to the floor when in bed, and a medication review. The resident had a 'Do Not Resuscitate' code status, per her hospice provider. Interventions included not starting CPR if the resident was found with no pulse, respirations, or blood pressure. Record review of the facility 24-hour report, dated [DATE], did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the 24-hours report revealed the following: Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro ' s started NP, RP and DON notified. Record Review of Resident #1 ' s Progress Notes, did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress note revealed, at 3:30 PM on [DATE], did not reveal mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress notes revealed, LVN A wrote Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro ' s started NP, RP and DON notified. In an interview with the DON on [DATE] at 2:06 PM, she said if a resident fell, hit their head, and sustained an injury, the nurses were to notify the resident's NP, family, and hospice, if necessary. She said the nurse was also responsible for documenting who they spoke to, whether it was the NP, the physician in charge or, the on call after hours physician. She said they also documented notification to the RP, hospice, nurse manager, who they spoke to and whatever orders or information given to them at the time of the notification. In an interview with the Nurse Practitioner on [DATE] at 2:42 PM, she said she thought she was contacted by the facility on [DATE] regarding Resident #1 falling. She said if the facility had told her the resident had a head injury, or a small bump on her head, she would have sent the resident out for a CT scan. She said she could not recall who contacted her regarding the resident's fall. She said she was currently reviewing her notes at that time and could not find any information on the resident's fall on [DATE]. She said if she did not have notes of the fall, no notification was made to her. She said she visited the facility every other day and remembered hearing about the resident's fall from the resident ' s nurse. She said she just reviewed everything entered in the resident's electronic health record, with the facility, regarding the fall incident on [DATE]. She said if she had been contacted, she would have ordered for the resident to be sent to the hospital for a CT scan. She said the resident was at risk for internal head bleeding and confusion by not receiving emergency medical services on [DATE]. She said it would have been important to send a resident whose baseline mental status was confused out to the hospital for evaluation because they would not be able to tell if there was anything going on internally. In an interview with the Weekend Supervisor on [DATE] at 3:14 PM, she said the nurse should have contacted the NP to get further instruction after Resident #1 fell. She said she did not know the resident had a small bump on the back of her head after she fell. She said the nurse should have contacted the NP and the DON and notified them about the bump on the back of Resident #1's head. She said LVN A was responsible for completing tasks related to the resident ' s fall because she was the primary nurse for the resident. She said the DON would have been responsible for reviewing the documentation from the incident. She said she could not recollect whether she notified the DON via text message or phone call about the resident's fall. She said when an incident occurred over the weekend, they were supposed to call the on-call phone to make notification to the on-call person. She said she did not call the on-call phone and did not know whether LVN A called the on-call phone to notify on call management about the resident's fall. She said if Resident #1 fell, hit her head, developed a small bump on the back of the head, and was not sent to the hospital for evaluation, the resident was risk of a subdural hematoma or an internal bleed. In an interview with LVN A on [DATE] at 10:53 AM, she said she sent a message to the NP regarding the resident falling. She said she had proof she sent a text message to the NP but could not remember when she sent the text message. She said she told the NP the resident fell and hit her head, but she was okay. She said the NP gave orders to continue to monitor the resident. She said she did not tell the NP the resident had a small bump on the back of her head because she did not initially have the bump when she notified the doctor. She said she did not know how long it was between the time she notified the NP of the fall and the time the resident developed the small bump on the back of the resident's head. She said when a physician gave an order for monitoring, it was for staff to monitor for changes in the resident's condition. She said she followed the NP ' s directives to monitor the resident. She said she said immediately began neuro checks and continued to monitor the resident. She said she did not think about notifying the NP the resident developed a small bump on the back of her head, after falling. She said she did not think the resident was at any sort of risk because she said a man who witnessed the resident ' s fall told her the resident may have hit her shoulder or another body part on the way down to the floor. She said that may have softened the blow if the resident did hit her head. She said she did not think the resident was put at any risk because the resident did not suffer from a bad fall. She said she probably should have notified the NP the resident had a small bump on her head. She said she could not recall whether she contacted to hospice to notify them of the incident. In an interview with the DON on [DATE] at 11:58 AM, she said they went through the resident's chart the next day, as a whole team. She said at that time, nothing stuck out to her about the nurse's documentation or concern because she saw the nurse noted she made notification. She said from what she read, they notified the NP and there were no new orders. She said she did not ask any of the nurses if the NP was notified about the bump on the back of the resident's head. She said she was notified by either LVN A or the Weekend Supervisor of the resident's fall on [DATE]. She said LVN A should have also communicated to the doctor the resident had a bump on the back of her head when LVN A notified the NP of the incident. She said the only thing that was concerning to her was LVN A did not tell Resident #1's NP the resident hit her head or had a small bump on the back of her head. She said the resident could have been at risk for not receiving appropriate care due to the physician not being notified the resident had a bump on the back of her head. Interview with the Administrator at 1:04 PM on [DATE], she said the assigned nurse was supposed to notify the DON, NP, family and then hospice. She said it was the responsibility of the nurse providing care to the resident to continue the care and communicate on behalf of the facility because they were the ones with the rapport with the family and doctor for that resident. She said as far as documentation, she reviewed the change of condition form and made sure all the pertinent information was there. She reviewed the incident/accident report to see what happened, if the nurse did an assessment, who the nurse notified, and reviewed the summary of the incident. She said the nurse was also to document any other assessments completed, whether neuro checks had been done, new orders received, and any changes of condition identified in the resident. She said she did not feel the resident was at risk or that the outcome would have been changed in any way because she had a bump on her head. She said the staff typically did not document anything when they communicated with physicians, unless a new order was given, or if they were asked to monitor the resident. She said the NP just said ' okay ' in response to being notified about the resident's fall. She said she had spoken to the NP since the incident and the NP said she would not have sent the resident out to the hospital. She said while the situation was handled appropriately, there was always room for improvement. She said the only thing she felt could have been improved on was more detail in documentation because documentation was key. She said she spoke the doctor about the situation and the doctor said he would not have sent the resident out, even if he had been notified the resident fell and had a small bump on her head. Record review of the undated policy, titled, Fall Prevention Program revealed the following: .9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident ' s care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury. Record review of the policy, revised February 2021, titled, Change in a Resident ' s Condition or Status revealed the following: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a(an): a. accident or incident involving the resident .3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form .8. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status . Record review of the undated policy, titled, Notification of Changes revealed the following: The facility must inform the resident .consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention . Record review of the undated policy, titled, Head Injury revealed the following: It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Guidelines: 1. Assess resident following a known, suspected, or verbalized head injury. The assessment tool shall include, at a minimum: a. Vital Signs. b. General condition and appearance. c. Neurological evaluation for changes in: i. physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech or slow to answer questions d. Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell or bleeding. e. Any injuries to head, neck, eyes, or face, including lacerations, abrasions, or bruising. f. Pain Assessment . 3. Notify physician and follow orders for care. a. Provide information from physical assessment. b. Describe how injury occurred and how situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. d. Any recent lab or diagnostic test results. 4. Perform neuro checks as indicated or as specified by the physician . 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify family and document all assessment, actions, and notifications. Record review of the policy, revised [DATE], titled, Falls-Clinical Protocol revealed the following: 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc . 6. Falls should be categorized as: a. Those that occur while trying to rise from a sitting or lying to an upright position; b. those that occur while upright and attempting to ambulate; and c. other circumstances such a sliding out of a chair or rolling from a low bed to the floor. 7. Falls should also be identified as witnessed or unwitnessed events. Monitoring and Follow-Up 1. The staff, with the physician ' s guidance, will follow up on any fall with associated injury until the resident is table and delayed complications such as fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. 2. The staff and physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling . Record review of the undated policy, titled, Incident and Accidents revealed the following: It is the policy of this facility to utilize the Risk Management Module in the electronic health records to report, investigate, and revie wany accidents or incident that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refer to any unexpected or unintentional incident, which results or may result in injury or illness to a resident . Policy Explanation The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care .Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines .5. The following incidents/accidents require an incident/accident report but are not limited to: .Equipment malfunction; Falls; Observed accidents/incidents . 6. In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm. 7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so . 8. The supervisor or other designee will be notified of the incident/accident . 9. The nurse will contact the resident ' s practitioner to inform them of the incident/accident, report any injuries or other finding, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). 10. In the event of .or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner . 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for quality of care. -The facility failed to complete an appropriate assessment for Resident #1 after she fell out of her wheelchair and a small bump to the back of the head was sustained. -The facility failed to send Resident #1 to the hospital after she fell out of her wheelchair, hit her head and developed a small bump on the back of her head. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings include: 1. Record review of Resident #1's face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks); Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - and behavioral abilities to such an extent that it interferes with a person's daily life and activities); Type 2 Diabetes with Diabetic Chronic Kidney Disease (damaged blood vessels and other cells in the kidneys caused by diabetes); Restless Leg Syndrome (a condition that causes a very strong urge to move the legs); and Hypertension (or high blood pressure, is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #1's MDS assessment dated [DATE], revealed no interview for mental status was conducted, which indicated the resident was rarely or never understood, and rarely or never made decisions regarding daily life. Resident #1 required limited assistance with bed mobility, transfer, eating, and extensive assistance with toileting. The resident required one-person physical assist with bed mobility, transfer, eating and toileting. Further review of the MDS did not reveal whether the resident used a wheelchair. Record review of Resident #1's care plan revealed she had an Actual Communication Problem related to being Hard of Hearing. Interventions included a communication board for the resident to use to communicate; ensure availability and functioning of adaptive communication equipment. Other interventions included allowing the resident adequate time to respond; repeat as necessary; do not rush; request clarification from the resident to ensure understanding; face when speaking; make eye contact; turn off TV/radio to reduce environmental noise; ask yes/no questions if appropriate; use simple, brief, consistent words/cues; use alternative communication tools as needed. The resident was at risk for falls related to poor safety awareness and weakness. The resident had impaired cognitive function and impaired thought processes related to Alzheimer's Disease and Dementia. Interventions included observations for any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Interventions included fall mat to the floor when in bed, and a medication review. The resident had a 'Do Not Resuscitate' code status, per her hospice provider. Interventions included not starting CPR if the resident was found with no pulse, respirations, or blood pressure. Record review of Resident #1's orders, dated [DATE], revealed no orders for neuro checks or fall risk interventions on [DATE]. Further review of orders revealed the resident was admitted to hospice for routine care on [DATE]. Interventions included pain monitoring using the pain numeric scale (0-10) or PAINAD (pain assessment in advanced dementia). Record review of the facility 24-hour report, dated [DATE], revealed the following: Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro's started NP, RP and DON notified. Record Review of Resident #1's Progress Notes, revealed no mode of communication used to make appropriate notifications, information provided during notifications, dates, times, individuals notified, or directives provided after notifications made. Review of the progress notes also did not reveal notification to hospice provider. Further review of the progress note revealed, at 3:30 PM on [DATE], LVN A wrote Resident was attending church service in dining room. A large group was gathered with loud singing for a long length of time. Resident was sitting in her locked w/c when fell back still in w/c. Head to assessment done only has a small bump to back of head skin intake and ice was applied. Neuro's started NP, RP and DON notified. Record review of the resident's Change in Condition, dated [DATE] did not reveal Resident #1's vital signs at the time the resident was assessed on [DATE]. Further review of the Change in Condition revealed, at 5:01 PM on [DATE], LVN A documented the following vital signs for Resident #1 At the time of this evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure 113/69 - [DATE] at 9:13 AM Pulse: 70 - [DATE] at 9:18 AM RR: 16.0 - 06/0724 at 8:38 AM Temp: 98.3 - [DATE] at 8:40 AM Pulse Oximetry: O2 99.0% - [DATE] at 8:46 AM Further review of the Change in Condition revealed, no responses to questions regarding the resident's pain was documented. Also, no responses to questions behavioral, respiratory, cardiovascular, abdominal, skin, and neurological status evaluations were documented. Record Review of Neuro Checks revealed, vital signs and neuro checks were to be completed every 15 minutes for one hour; every 30 minutes for one hour; every hour for four hours; then, every four hours for 24 hours. [DATE] at 3:30 PM, RN a noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-127/64; Pulse-87; Respiration-18; Temperature-97.7. [DATE] at 3:45 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-126/64; Pulse-88; Respiration-18; Temperature-97.7. [DATE] at 4:00 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-127/68; Pulse-86; Respiration-18; Temperature-97.7; Initials. [DATE] at 4:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-128/68; Pulse-86; Respiration-18; Temperature-97.7. [DATE] at 4:45 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-126/72; Pulse-84; Respiration-18; Temperature-97.7. [DATE] at 5:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-124/68; Pulse-86; Respiration-18; Temperature-97.7. [DATE] at 6:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-122/76; Pulse-88; Respiration-18; Temperature-97.6. [DATE] at 7:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-118/81; Pulse-90; Respiration-18; Temperature-97.6. [DATE] at 8:15 PM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-132/76; Pulse-87; Respiration-18; Temperature-97.7. [DATE] at 9:15 PM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-128/76; Pulse-84; Respiration-18; Temperature-97.7. [DATE] at 1:15 AM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-121/70; Pulse-78; Respiration-18; Temperature-97.7. [DATE] at 5:15 AM, RN B noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-122/68; Pulse-74; Respiration-18; Temperature-97.3. [DATE] at 9:15 AM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-116/64; Pulse-78; Respiration-18; Temperature-97.6. [DATE] at 1:15 PM, RN A noted the resident was fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-118/66; Pulse-76; Respiration-18; Temperature-97.6. [DATE] at 5:15 PM, RN A noted the resident fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-122/68; Pulse-78; Respiration-18; Temperature-97.6. [DATE] at 9:15 PM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-132/61; Pulse-78; Respiration-18; Temperature-98; Initials-RN B [DATE] at 1:15 AM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-127/61; Pulse-73; Respiration-18; Temperature-97.9; Initials-RN B [DATE] at 5:15 AM Fully conscious; movement of all 4 extremities; hand grasps equal and strong; fixed left and right pupil reactions; clear speech; BP-117/56; Pulse-87; Respiration-18; Temperature-97.9; Initials-RN B Record review of Hospice Nursing Clinical Note, dated [DATE], revealed the following: The resident was noted to have a hearing impairment, confusion, and disorientation. Summary: LVN B stated pt fell yesterday while trying to get out of w/c and has small bump on back of head. Facility doing neuro checks on pt. All WNL for pt. Assessment complete, vitals stable, blood pressure on the lower side of normal LVN B will recheck and continue to monitor . Record review of an undated text message from RN A , revealed the following: On [DATE], RN was called in to dining room by nurse aide. Upon arrival it was clear the resident, [Resident #1] was sprawled out on the floor next to her wheelchair lying face up. RN assessed resident head to toe before moving her. Because RN knows resident well, was able to quickly realize she was neurologically at her baseline from before this incident. She was able to track with both eyes, follow commands, move all extremities with no signs of pain. Skin assessment revealed no bleeding, skin warm dry and intact. Only a small bump of about 0.75 inch on back of head close to base of skull .It was reported to nurse by several bystanders that resident hit head after falling out of the wheelchair .RNs clinical decision she was safe to try sitting up. Then after explained what was going to happen next, RN and aide assisted her back into her chair .RN then wheeled resident back to nurse's station where vitals were checked by nurse in charge of her care and neuros protocol started . In an anonymous interview on [DATE] at 9:50 AM [DATE], they said they were present in the dining area of the facility when Resident #1 fell and hit her head. They said they could not remember the exact date or time, but the incident happened a few weeks ago, and a group was at the facility having church service in the dining area. They said the resident was not able to respond or actively participate in the activities taking place. They said the resident was sitting in a wheelchair near a table when the resident flipped backwards in her wheelchair. They said the resident's head hit the floor and it made a very loud sound. They said at the time the resident flipped backwards in the wheelchair, there were no facility staff present in the dining area. They said there were several people part of the group providing the service to residents, and several residents present, but they could only remember the resident who was right next to them at the time of the incident. They said the one resident right next to them at the time and everyone else in the dining area was shocked. They said someone ran and got facility staff to come help the resident. They said three women; one young and two older, all three were Hispanic or White, immediately, came into the dining area, picked the resident up off the floor, and put her back in her wheelchair. They said they told the staff they should not have moved the resident and that they needed to call 911. They said the resident next to them said something to the staff and was concerned about the staff picking the resident up off the floor immediately too. They said the women responded and said they were the professionals and knew what they were doing. They said once the three staff got the resident up, and into her wheelchair, one checked her pulse, and then took the resident out of the dining area. They said the facility did not call 911. They said they remained at the facility about 30 minutes after the resident's fall and never saw an ambulance show up. They said they were concerned because the resident should not have been moved right after hitting her head on the floor. In an interview with Resident #2 on [DATE] at 10:08 AM, she said she attended the church services in the dining area on Sundays. She said she saw Resident #1 fall in the dining area a few weeks back. She said she could not remember exactly when this took place. She said she did not see what was happening with the resident before she fell. She said she saw the resident go backwards out of her wheelchair onto the floor. She said the resident's head made such a loud noise when she hit the floor, she got worried. She said it was a lot of people in the dining area and everybody was concerned because the noise was so loud from the resident hitting her head. She said three staff came in and quickly got the resident up off the floor and back into her wheelchair. She said the staff did not do anything to the resident before they got her off the floor. She said they immediately picked her up. She said she did not know if a nurse checked the resident out after they got her back into her wheelchair. She said she was sure a nurse did not do anything to check on the resident before they moved her. She said it was a lot of people in the dining area when the resident fell and saw what happened, but she did not think there were any staff present when the resident fell. In an interview with Med Aide A on [DATE] at 12:55 PM, she said herself, CNA A, and a nurse were the staff that went into the dining area to help after Resident #1 fell out of her wheelchair. She said she could not remember exactly which nurse it was, but she thought it was RN A. She said the resident was lying on the ground on her back and the resident pointed to her side. She said the resident was not saying anything. She said the resident was not bleeding and did not have any visible injuries. She said she saw the nurse touching different parts of the resident's body. She said the nurse was probably checking for pain. She said then, the three of them (Med Aide A, CNA A and the nurse) grabbed the resident by her pants to pick her up off the ground and placed her back in her wheelchair. She said she thought the nurse might have checked the resident's vitals after they got the resident back into her wheelchair, but she was not sure. She said after they got the resident back into her wheelchair, she went back to the B hall because she had to finish administering meds. She said she did not have to write a statement or complete an incident report because she did not witness anything, and just went there to help get the resident up off the floor. She said staff were not to move a resident until a nurse said it was okay. She said the nurse decided it was okay to pick the resident up and put her back in her wheelchair. In an interview with CNA A on [DATE] at 1:09 PM, she said she was working on the day ([DATE]) Resident #1 fell out of her wheelchair. She said when she made it to the dining area the resident was lying on the ground, on her side. She said she did not observe any bleeding, nor was the resident crying. She said the resident was not speaking at all. She said the resident was mostly nonverbal and only spoke when she felt like it, so it was normal for her not to say anything. She said the resident had a knot on the back of her head, so she went to get an ice pack and a pillow for the resident. She said she knew the resident had a knot on the back of her head because the nurse said the resident did. She said the nurse was RN A. She said when she came back with the ice and the pillow, the nurse said it was okay to get the resident off the floor. She said she did not see RN A take vitals or assess the resident. She said she believed RN A at least assessed the resident because RN A gave the okay to get the resident up. She said CNA A, Med Aide A and RN A got the resident off the floor using her clothes. She said no staff was allowed to move a resident after a fall, unless a nurse said it was safe. She said RN A or the resident's assigned nurse could have taken the resident's vitals after they got the resident back into her wheelchair. In an interview with LVN A on [DATE] at 1:29 PM, she said she was in the middle of doing blood sugar checks on resident's when she found out Resident #1 fell. She said the resident was in the dining room. She said sometimes on Sundays, they were in the dining area for hours having church service. She said the resident had Dementia and Alzheimer's, and her attention span was not that long. She said the only thing she could think of as the cause for the resident's fall, was the resident got tired and wanted to go back to her room. She said the Weekend Supervisor and RN A were the nursing staff that went to the dining room after the resident fell. She said she thought one of the aides came and told her Resident #1 fell, but she was not sure. She said when she went into the dining area, she saw the resident sitting in her wheelchair and talking. She said she saw a nurse have the resident squeeze the nurse's finger, follow their finger with her eyes, and touch the resident's body to check for pain. She said she could not remember which nurse it was but felt like it was the Weekend Supervisor. She said she did not see a nurse check Resident #1's vitals. She said Resident #1 also had a small bump in the back of her head, but never complained of pain. She said she immediately began doing neuro checks on the resident, since she was her assigned nurse. She said neuro checks were performed for 24 hours. She said she was the one to place the call to the nurse practitioner, and the nurse practitioner said to continue to monitor the resident for any changes. She said she did not remember who she spoke to when she contacted the nurse practitioner. She said there were no significant changes in the resident's vitals or complaints of pain. She said the night shift staff was notified about the resident's incident, continued neuro checks and monitoring for changes. She said when a resident fell and had a head injury, she would do an assessment, call the nurse practitioner, begin neuro checks, and monitor the resident for changes in condition. She said she would ask the resident about pain, feel their head, see if there was any active bleeding. She said she would check their blood pressure, pulse, and look for rapid breathing. She said she would talk to the resident, see if they were able to follow her finger. She said Resident #1 was unable to tell you date/time but would tell if she was in any pain. In an interview with RN C on [DATE] at 1:50 PM, she said she worked at the facility for three years. She said if she was alerted a resident fell and hit their head, she would get help and then call 911. She said if the resident had any signs of a hematoma, they would be sent to the hospital. She said she would call emergency services, call the resident's family, NP, MD, administrator, and DON. She said she would also document a change in condition, incident report and fall assessment in the resident's electronic health record. In an interview with RN B on [DATE] at 1:53 PM, she said if she was notified a resident fell, hit their head, and had a small bump on back of their head, she would send the resident out to the hospital immediately via emergency services. She said it did not matter if the resident was on hospice. She said she would send the resident to the hospital and let hospice know after the fact. In an interview with the DON on [DATE] at 2:06 PM, she said she worked at the facility for three years. She said if a resident fell, hit their head, and sustained an injury, it was her expectation of the nurses not to move the resident. She said it was her expectation for the nurses to contact emergency services to transport the resident to the hospital, identify if the resident was on blood thinners, and send them out. She said the nurses were to also notify the resident's NP, family, and hospice, if necessary. She said the nurses would do neuro checks on the resident for three days; go through recent lab work; have a care plan meeting to see what was going on; and make changes to interventions. She said the nurse would fill out an incident report, change of condition, and other post fall documentation in the resident's electronic health record. She said all the documentation should be completed in a timely manner. She said if there was a change of condition observed after the fall, the resident would be sent to the hospital. She said even if the resident had a head injury after a fall, they would call hospice to notify, but the resident still needed to be sent to the hospital. She said the hall charge nurse would enter the incident information in a risk management report, complete a fall risk assessment, and a post fall assessment. She said the nurse was supposed to document what happened; how it happened; pain assessment; injuries; witnesses; any other notes and a signature section at the end. She said the nurse was also responsible for documenting who they spoke to, whether it was the NP, the physician in charge or, the on call after hours physician. She said they also documented notification to the RP, hospice, nurse manager, who they spoke to and whatever orders or information given to them at the time of the notification. She said there was no time it would be okay for a staff to move a resident with a head injury. She said even the fall was unwitnessed, if there was an obvious injury they needed to be kept as still as possible until emergency services arrived. She said if a resident fell and hit their head and the sound from them hitting their head was loud enough to be heard, and the resident had a small bump, that would still be considered a head injury. She said the resident needed to be sent to the hospital. She said a resident who fell, hit their head, and had a head injury not receiving emergency medical services were at risk of a bleed, contusion, concussion, hematoma under the skin, or something that would require a CT scan right away to catch. In an interview on [DATE] at 2:42 PM with the Nurse Practitioner, she said she thought she was contacted by the facility on [DATE] regarding Resident #1 falling. She said if the facility had told her the resident had a head injury, or a small bump on her head, she would have sent the resident out for a CT scan. She said she could not recall who contacted her regarding the resident's fall. She said she was reviewing her notes at that time and could not find any information on the resident's fall on [DATE]. She said if she did not have notes of the fall, no notification was made to her. She said she visited the facility every other day and remembered hearing about the resident's fall from the resident's nurse. She said she just reviewed everything entered in the resident's electronic health record, with the facility, regarding the fall incident on [DATE]. She said if she had been contacted, she would have ordered for the resident to be sent to the hospital for a CT scan. She said the resident was at risk for internal head bleeding and confusion by not receiving emergency medical services on [DATE]. She said it would have been important to send a resident whose baseline mental status was confused out to the hospital for evaluation because they would not be able to tell if there was anything going on internally. In an interview with the Weekend Supervisor on [DATE] at 3:14 PM, she said she worked at the facility for a little over a year. She said it was her expectation for nurses to provide immediate care to a resident who fell and hit their head. She said the nurses were supposed to check vitals, ensure the resident was not in any distress, and call the doctor to tell them what transpired. She said when the nurse got orders from a physician, the nurse should document in the electronic health record, then make notifications to the family and the DON. She said the nurse needed to do an assessment and find out if the resident was on any blood thinners. She said the nurse should check the resident's vital signs, level of consciousness, blood pressure, pulse, respirations, and pupils during an assessment. She said the nurse should assess the resident for pain and ask them if they were in pain. She said the nurse should do a skin assessment and check for range of motion. She said to check for range of motion, the nurse should ask the resident to move their arms and legs, see if they can stand, and bend over. She said if the resident was lying on the floor, the nurse needed to check for range of motion while the resident was still on the floor. She said if the resident had not broken any bones, the nurse and other staff could get them up off the floor, and into a chair or wheelchair. She said the nurse could also get the resident back in their bed, perform another assessment, begin neuro checks at that point, then contact the doctor. She said if the resident had a head injury it was standard for the facility to call the resident's doctor. She said if the doctor had a standing order for residents with a head injury to be sent out to the hospital, then they would send the resident out. She said she did not know what the facility's policy was on resident's who fell and sustained a head injury. She said she had not looked at the policy. She said she was working on [DATE] at the time Resident #1 fell. She said she was doing patient care when she came out of a resident's room, and a family member told her a resident had fallen. She said the nurse and the resident were not in the dining area by the time she found out about the incident. She said everything was already over and handled. She said the nurse should have contacted the NP to get further instruction after Resident #1 fell. She said she believed that it was only family members and residents in the dining hall at the time of the resident's fall. She said residents could not provide statements due to their inability to accurately recall or perceive things. She said there were no statements gathered from anyone who witnessed the incident. She said she did not remember speaking to any other staff to find out what happened and what was done for the resident. She said she only spoke to LVN A about what she had done with Resident #1. She said LVN A told her the resident had been assessed. She said she did not ask LVN A who assessed the resident. She said if LVN A did not assess Resident #1 then RN A likely assessed her. She said if RN A assessed the resident, she would have given LVN A the vital signs and other observations from her assessment. She said if RN A assessed the resident, LVN A would have been the nurse responsible for documenting RN A's assessment, what happened, and the care provided to the resident, according to RN A, in Resident #1's electronic health record. She said she did not know the resident had a small bump on the back of her head after she fell. She said the nurse should have contacted the NP and the DON and notified them about the bump on the back of Resident #1's head. She said LVN A was responsible for completing tasks related to the resident's fall because she was the primary nurse for the resident. She said the DON would have been responsible for reviewing the documentation from the incident. She said she could not recollect whether she notified the DON via text message or phone call about the resident's fall. She said when an incident occurred over the weekend, they were supposed to call the on-call phone to make notification to the on-call person. She said she did not call the on-call phone and did not know whether LVN A called the on-call phone to notify on call management about the resident's fall. She said if Resident #1 fell, hit her head, developed a small bump on the back of the head, and was not sent to the hospital for evaluation, the resident was risk of a subdural hematoma or an internal bleed. In an interview with LVN A on [DATE] at 10:53 AM, she said she was not the nurse who performed an assessment on Resident #1 right after the resident fell. She said she thought the Weekend Supervisor performed the assessment, but it was RN A who performed the assessment. She said RN A told her she was going to put all her information from her assessment of the resident in her electronic health record. She said she asked RN A if she assessed the resident and RN A told her yes. She said she sent a message to the NP regarding the resident falling. She said she had proof she sent a text message to the NP but could not remember when she sent the text message. She said she told the NP the resident fell and hit her head, but she was okay. She said the NP gave orders to continue to monitor the resident. She said she did not tell the NP the resident had a small bump on the back of her head because she did not initially have the bump when she notified the doctor. She said she did not know how long it was between the time she notified the NP of the fall and the time the resident developed the small bump on the back of the resident's head. She said when a physician gave an order for monitoring, it was for staff to monitor for changes in the resident's condition. She said she followed the NP's directives to monitor the resident. She said she said immediately began neuro checks and continued to monitor the resident. She said she did not think about notifying the NP the resident developed a small bump on the back of her head, after falling. She said she did not think the resident was at any sort of risk because she said man who witnessed the resident's fall told her the resident may have hit her shoulder or another body part on the way down to the floor. She said that may have softened the blow if the resident did hit her head. She said she did not think the resident was put at any risk because the resident did not suffer from a bad fall. She said she probably should have notified the NP the resident had a small bump on her head. She said she could not recall whether she contacted to hospice to notify them of the incident. In an interview with RN A on [DATE] at 11:19 AM, she said she worked at the facility for three years. She said she was clinically able to assess a resident from head to toe. She said if she was assessing a resident after a fall, she would do a neurological assessment. She said a neurological assessment consisted of checking for seizures, foaming at the mouth, eye irre[TRUNCATED]

**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 resident rights, that included measurable objectives and timeframes to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #44) reviewed for care plans. The facility failed to implement Resident #44's care plan by failing to ensure bed rails were installed on the resident's bed frame. This deficient practice could place residents at risk for not receiving appropriate care and services. Findings Include: Record review of Resident #44's face sheet, dated 07/12/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had diagnoses which included dementia with other behavioral disturbance (problems with memory, thinking, and behavior), morbid obesity (excess weight), polyneuropathy (damaged nerves), quadriplegia unspecified (pattern of paralysis), and lymphedema (tissue swelling caused by an accumulation of protein-rich fluid). Record review of Resident #44's Quarterly MDS, dated [DATE], revealed a BIMS score of 13 out of 15, which indicated she was cognitively intact. Resident #44 required two-person physical assist with bed mobility and one-person physical assist with transferring, toileting, and bathing. Record review of Resident #44's Care Plan, dated 08/02/2022, read in part .Focus: [Resident #44] utilizes an enabling device (1/4 bed rails) to help with positioning, provide a sense of comfort/security, and/or promote independence poor balance admit to [name of hospice] under the continued care of [physician's name], date initiated: 09/07/2022. Intervention: [Resident #44] will utilize 1/4 bed rails to promote increased independence Record review of Resident #44's orders, dated 04/26/2023, read in part .Bed Rail(s): bilateral one-quarter bed rail(s) installed as enabling device Record review of Resident #44's Informed Consent for Bed Rail Use revealed it was completed, signed, and dated on 04/24/2023 by the resident's family member. Record review of Resident #44's Bed Rail Safety Review, dated 04/24/2023, was completed and signed. Further review revealed recommendation to continue with bed rail(s). Observation and interview on 07/11/2023 at 10:01 a.m. of Resident #44 was completed. Resident was observed lying in bed reading a book. Her bed frame did not have attached bed rails. She said she wanted to know why she could not have bed rails. She said she used to have bed rails but did not know why she no longer had them. She said the bed rails helped her to reposition herself. Observation on 07/12/2023 at 12:30 p.m. revealed Resident #44's bed frame did not have attached bed rails. In an interview on 07/12/2023 at 4:56 p.m., the DON said Resident #44's assessment, consent, and orders for the bed rails were completed. He said the bed rails were also care planned. He said he did not know why the rails had not been installed. He said the resident's bed had switched a lot since she was admitted to the facility. He said the nurse was responsible for ensuring the bed rails were implemented. He said he talked with the nurses and was not able to determine who and when the bed was changed out last. He said the risk posed to the resident from not receiving the bed rails was that it could make it more difficult for them to turn . Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated March 2022, read in part . .4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. receives the services and/or items included in the plan of care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessment for 1 of 17 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan was revised to include interventions for falls to help prevent injuries. This failure could place residents at risk of not having their needs addressed and inconsistency of care. Findings include: Record review of Resident #7's face sheet, dated 07/13/2023, revealed a [AGE] year-old male who was admitted into the facility on [DATE]. The resident had diagnoses which included alcohol dependence with alcohol-induced persisting dementia, degenerative disease of nervous system, hypertension, and quadriplegia. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident was assessed to need substantiated to maximal assistance with transfer and the resident was assessed to have had a fall within the last month prior to admission. The resident's BIMS score was 7, which indicated the resident's cognition was severely impaired. Record review of Resident #7's care plan, last revised on 07/13/2023, revealed Resident #7 had actual falls related to poor balance, poor safety awareness and unsteady gait and actual falls occurred on 05/01/2023 due to sliding off the bed, and on 05/05/2023, 05/21/2023, 05/30/2023 and 06/08/2023. The intervention of a fall mat use for resident falls was added after State Surveyor intervention on 07/13/2023. Observation and interview on 07/11/2023 at 10:15AM, revealed Resident #7 was lying in bed with a fall mat to the side of his bed and stated he could get around okay on his own without assistance. In an interview on 07/13/2023 at 3:12PM, CNA T stated Resident #7 did not know how to use his call light and managed multiple times to transfer himself in his chair even with the wheelchair placed out of reach. She stated the resident had a fall mat since he was first admitted , in April 2023 and she believed the resident needed the mat to prevent him from acquiring bruises when he fell after scooting himself out of bed and onto the floor. In an interview on 017/17/2023 at 3:24PM, LVN A stated Resident #7 needed the fall mat because she believed he had a condition similar to restless leg syndrome which caused the resident to often scoot to the edge of his bed and increased his risk of falling. She stated the fall mat was used and should be listed on his care plan as one of his interventions for falls. In an interview on 07/17/2023 at 3:35 PM, the DON stated Resident #7's care plan needed to be updated to ensure all necessary interventions for falls were listed in his care plan to ensure he was not at increased risk for injuries. Record review of the facility's policy on Falls, revised March 2018, stated, . If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions Record review of the facility's policy on Care Plans, revealed, no information regarding revision timing of care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained periodically reconciled for 1 of 7 residents (Resident #15) reviewed for medication administration and 1 of 2 medication carts (B Hall medication cart) reviewed for accounting. 1. The facility failed to ensure an accurate recordkeeping of liquid Lorazepam (a controlled substance) from the B Hall medication cart. 2. The facility failed to check Resident #15's blood pressure prior to administering Metoprolol used to treat high blood pressure. 3. The facility failed to ensure Resident #15 received the prescribed nebulizer treatment by leaving the medication at the bedside for the resident to self-administer. The resident did not have an order to self-administer the medication. Findings include: 1. Observation and record review on 07/12/2023 at 9:35 AM revealed the B hall medication cart's locked narcotic compartment contained a bottle of Lorazepam 2mg/1ml which contained between 10ml and 12ml of fluid according to the measurements on the side of the bottle label. The controlled drug receipt/disposition form listed the following entries: -06/05/2023 at 5:30 PM, RN B documented 0.5ml was given and the amount left in the bottle was 16 ml. -06/10/2023 at 5:30 PM, RN A documented 0.5ml was given and the amount left in the bottle was 15.5ml. -07/07/2023 at 10:00 AM, RN A documented 0.5ml was given and the amount left in the bottle was 15ml. -07/07/2023 at 1:00 PM, RN A documented 0.5ml was given and the amount left in the bottle was 14.5ml. -The last entry was on 07/09/2023 at 10:00 AM, RN A documented that 0.5ml was given and the amount left in the bottle was 14ml. In an interview on 07/12/2023 at 9:35 AM, RN A stated the bottle of Lorazepam came from Hospice Services. RN A stated she would notify the DON about the discrepancy between the amount left in the bottle and the balance written on the narcotic sheet. In an interview on 07/13/23 at 9:45 AM, the DON stated the bottle of liquid Lorazepam 2mg/ml contained 11.5ml. The DON stated the nurses needed to track this more closely and that he did not think there would be any problems with controlled medications in liquid form. In an interview on 07/13/23 at 9:50 AM, RN B stated it was his signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 05/24/23 to 06/05/23. RN B stated the liquid in the bottle was hard to see and he always compares what was in the bottle to what was written on the form. RN B stated on 06/05/23 the count was correct and he did not know why there was a discrepancy on 07/09/23 because he did not sign anything out after 06/05/23. RN B stated the nurses were responsible for documenting accurately. In an interview on 07/13/23 at 10:50 AM, RN A stated it was her signature on the controlled drug receipt/disposition form for the Lorazepam 2mg/ml from 06/10/2023 to 07/09/2023. RN A stated the liquid tended to leak around the syringe and bottle whenever a dose was removed, and this would account for some liquid loss. RN A stated she was responsible for documenting accurately on the sheets. RN A stated when discrepancies were found, then corrections were made. RN A stated moving forward corrections would be made in time and hoped they would get prefilled syringes instead. In an interview on 07/13/23 at 1:30 PM, the DON stated the liquid Lorazepam estimated loss was 6 doses based on each administered dose being 0.5ml and the estimated volume remained was closer to 11ml. The DON stated moving forward it was decided a self-report would be submitted and all staff who had access to the box would be drug tested in case of drug diversion. The DON stated the facility would no longer accept multidose liquid bottles of controlled medications d/t the difficulty to accurately track the remaining volume of liquid. The DON stated the manufacturer label on the bottle read: approximate volume of solution was in the bottle. Record review of the NDC 0054-3532 Lorazepam label information solution, concentrate oral, details, usage, and precautions, ndclist.com, revised February 2017, read in part: .Lorazepam is a federal controlled substance (C-IV) because it can be abused or lead to dependence. Keep Lorazepam in a safe place to prevent misuse and abuse. Selling or giving away Lorazepam may harm others and is against the law . Record review of the facility's policy for Controlled Substances, revised April 2019, read in part: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift .10. Upon Administration: a. The nurse administering the medication is responsible for recording . (5) quantity of the medication remaining .12. At the end of each shift: A. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. B. Any discrepancies in the controlled substance count are documented and reported to the director nursing services immediately. C. The director of nursing services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties and reports the findings to the administrator. D. The director of nursing services consults with the provider pharmacy and the administrator to determine whether further legal action is indicated .1. Policies and procedures for monitoring-controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. Record review of the facility's policy for Medication ordering and Receiving from Pharmacy, revised August 2014, read in part: Medication Packaging, medications are provided in packaging to facilitate accurate administration and accountability of the medication. All packaging meets USP (United States Pharmacopeia) standards . 2. Record review of Resident #15's admission record face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included critical illness myopathy (a disease of limb and respiratory muscles observed during treatment in the intensive care unit), obstructive sleep apnea (a sleep related breathing disorder), HTN (elevated blood pressure), hyperlipidemia (elevated fats in the blood), morbid obesity, heart disease, atrial fibrillation (irregular, rapid heart rhythm), lymphedema (tissue swelling), depression, and urinary tract infection (an infection that affects any part of the urinary system). Record review of Resident #15's admission MDS, dated [DATE], revealed she had a BIMS score of 15, which indicated intact cognition. She required extensive assistance with most ADLs. She required oxygen therapy and non-invasive mechanical ventilator (BIPAP-therapy to treat sleep apnea). Record review of Resident #15's physician order summary report, as of 07/11/2023, revealed an order for Budesonide inhalation suspension 0.5/2ml, one application inhale orally two times a day for shortness of breath. The order date was 06/25/2023. Metoprolol succinate ER oral tablet extend release 24 hours 25mg, give one tablet by mouth two times a day for BP. Hold for SBP less than 110 and DBP less than 60 or HR less than 60. The order date was 06/25/2023. Further review of the physician order revealed there was no order for self-administration of medications. Record review of Resident #15's, undated, care plan revealed she had the potential for impaired gas exchange r/t exhibiting SOB/trouble breathing when laid flat. Interventions included: check O2 saturations and provide respiratory treatments as ordered. Further review of the care plan revealed there was no plan addressing the diagnosis of hypertension. During observation and interview of a medication pass on the evening of 07/11/2023 at 8:15 PM, LVN B administered medications to Resident #15 which included Metoprolol ER 25mg oral tablet. LVN B then checked Resident's BP on her right wrist using a wrist BP monitor. LVN B said the BP was 71/30 and it was too low. LVN B checked her oxygen saturation rate on her right hand, and it was 97% and the pulse was 61. LVN B checked Resident #15's BP on her left arm using a manual BP cuff and stethoscope. LVN B wrapped the BP cuff upside down around the resident's left forearm, instead of the upper arm and with the BP tubing pointing towards the shoulder. LVN B placed the bell of the stethoscope at the anterior aspect of the elbow joint. LVN B said the BP reading was 124/72. LVN B poured the liquid Budesonide inhalation suspension 0.5/2ml into the chamber of the nebulizer tubing, reattached the nebulizer face mask then hung the strap of the facemask onto a basket that was on the bedside table and moved the bedside table closer to the resident. LVN B asked the resident if she could reach the equipment. The compressor nebulizer machine was turned off and was on top of the nightstand within the resident's reach. Resident #15 stated she could reach the mask as well as the machine and would start the breathing treatment when she could bend her right arm after the IV was complete. LVN B walked out of the room and said he would check on her later. LVN B stated he forgot to check her BP before administering the Metoprolol. LVN B stated the risk to the resident was the BP could drop. LVN B stated he used a medium BP cuff because there was no larger cuff available. LVN B stated he was ex-military and checking BP on the lower arm was what was done out in the field. LVN B stated he knew checking the BP on the forearm would result in a reading that would be off and not as accurate. LVN B stated checking the BP this way was not facility policy. LVN B stated he should have re-checked using the wrist BP monitor on the resident's left wrist. LVN B had no explanation as to why he didn't do this instead of using the manual cuff. LVN B stated it was not the facility policy to leave the breathing treatment medication at the bedside and then walk away. LVN B did not have an explanation as to why he walked away with the medication at the bedside. LVN B returned to the resident's room and emptied the nebulizer chamber of the liquid Budesonide. LVN B stated he would return after the IV was completely infused, administer the nebulizer treatment, and make sure the resident took the medication correctly before walking out of room. LVN B stated he usually checked the resident's vitals before administering medications, but he was thrown off his routine d/t earlier issues with another resident. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurse was supposed to check Resident #15's BP before administering the Metoprolol and to use the manual BP cuff correctly by wrapping the cuff around the upper arm with the tubing pointing down the arm. The DON stated the facility did have a large BP cuff available but would check the cart to make sure. The DON stated LVN B was trained on the use of a BP cuff. The DON stated the nurse was not supposed to leave the Budesonide breathing treatment at the bedside and walk away. The DON stated, normally the facility staff went over self-administration of medications with the resident and then got an order from the physician. The DON stated the risks of leaving a breathing treatment for the resident to self-administer would be infection as it would be unsanitary to just leave it, the resident may not receive the full treatment and the nurse was supposed to monitor and ensure the resident was tolerating the treatment well. The DON stated LVN B did not follow policy. The DON stated he expected a self-administration order in place prior to leaving a resident with any medication. The DON stated he would conduct a one-on-one training with LVN B. The DON stated the facility did not have a written policy and procedure for the use of blood pressure cuffs. Record review of Resident #15's, blood pressure summary revealed LVN B rechecked her blood pressure on 07/12/2023 at 12:24 AM. The result was 121/72 lying down taken on the right arm. Record review of LVN B's Competency Checklist, dated 2/26/2023, revealed he did not require further training and the competency was completed on 3/23/2023. The checklist included medications administration and vital signs which included blood pressure. The checklist included performing nebulizer treatments. Record review of the facility's policy for Administering Medications, revised April 2019, read in part: Policy heading - Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame .11. The following information is checked/verified for each resident prior to administering medications .b. Vital signs, .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely Record review of the facility's policy for Administering Medications through a Small Volume (Handheld Nebulizer, revised October 2010, read in part: Purpose - the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Steps in the Procedure .13. Turn on the nebulizer and check the outflow port for visible mist .17. Remain with the resident for the treatment .18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness, and nervousness throughout the treatment

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for two of two medication carts (B Hall medication cart and medication cart in the secure unit) reviewed for storage of medications. 1. The facility failed to ensure B Hall medication cart and the medication cart in the secure unit did not contain torn protective seals on the back of narcotic medication blister pill cards. 2. The facility failed to ensure the B Hall medication cart did not have loose pills. 3. The facility failed to ensure eye drops were labeled and medications had the expiration dates in the B Hall medication cart. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and drug diversion. Findings include: 1. Observation on 07/12/2023 at 9:35 AM of B Hall medication cart revealed the locked narcotic storage compartment contained 10 tablets of Lorazepam 0.5 mg in a blister card. Blister compartment number 10 had a torn seal that was taped closed on the back of the blister card. The narcotic count for the Lorazepam was accurate. There were loose pills found at the bottom of the second drawer: one small round pink pill with number 1081 and one small round white pill with numbers 502. A packet of AZO Urinary Pain relief tablets in a blister type package contained 20 brown tablets were found in the top drawer. The package did not have an expiration date. The original package was not in the cart. There were 2 bottles of artificial tears lubricant eye drops in the top drawer. The bottles and the box for the eye drops did not have resident identifiers or an opened date. Both bottles contained fluid. In an interview on 07/12/2023 at 9:35 AM, RN A stated the Lorazepam was taped probably because the back of the package had a tear. RN A stated the tablet should be discarded d/t the risk of infection and the tablet could have been replaced with a different tablet that was not Lorazepam. RN A stated she would notify the DON and the tablet would be destroyed per facility policy. RN A stated the nurses were responsible for maintaining the medication carts and she cleaned the cart regularly. RN A stated the loose pills could fall out and someone could take it and it could cause harm to them. RN A stated the AZO Urinary Pain relief tablets should have expiration dates like all the other medications in the cart. RN A stated both bottles of artificial tears had been opened because the seals were gone and some of the liquid had been used. RN A stated she had not used the bottles and did not know how they got in the cart or which resident they would have been used for. RN A stated she would notify the DON and put the bottles and the packet of urinary pain relief tablets in the medication destruction box. RN A stated the risk of using these bottles of artificial tears on a resident would be eye infection because the same bottle of eye drops should not be used on different residents. 2. Observation on 07/12/2023 at 4:00 PM of the medication cart in the secure unit revealed the locked narcotic storage compartment contained 31 tablets of Lorazepam 0.5 mg in one blister card. Blister number 18 had a tear on the back of the package. A second Lorazepam 0.5 mg blister card contained 9 tablets. Blister number 8 had a tear on the back of the package. The narcotic count for the Lorazepam was accurate. In an interview on 07/12/2023 at 4:00 PM, LVN A stated the risk of having the Lorazepam with a tear in the packaging was the pill could fall out, a resident might pick it up, eat it and they may get harmed. LVN A stated the risk could also be loss of medication supply for the resident it was intended for. LVN A stated she would go to the DON for advice on what to do with the tablets. In an interview on 07/12/2023 at 4:00 PM, the DON stated the Lorazepam with the torn seal should be discarded. In an interview on 07/12/2023 at 6:50 PM, the DON stated the nurses were supposed to maintain the cart daily as needed. The DON stated if a medication should drop, they were supposed to destroy it and the risks would be someone could steal the Lorazepam tablet or someone could accidentally pick it up and ingest it. The DON stated his expectation was the nurses double checked the narcotic medication count against the count sheet for accuracy, loose pills and pills in torn controlled substance blister cards should be destroyed. The DON stated the nurses were responsible for discarding medications per facility policy and the DON or the ADON were responsible for conducting nursing staff in-services covering medications and controlled substances. The DON stated he was unsure when the last in-service took place. Record review of the facility policy for Controlled Substances, revised April 2019, read in part: Policy Statement: The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled medications. Policy Interpretation and Implementation .8. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift . Record review of the facility policy for Storage of Medications, revised November 2020, read in part: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Policy Interpretation and Implementation .2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Record review of the facility policy for Medication Storage in the Facility, revised August 2014, read in part: B. Drug dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date .D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1)The nurse shall place a 'date opened' sticker on the medication and enter the date opened and the new date of expiration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (Resident #33) of one resident who was fed by enteral means (a feeding tube) received the appropriate treatment and services to prevent complications of enteral feeding (tube feeding), including but not limited to, aspiration pneumonia. Specifically, the facility failed to ensure Resident #33's bed was not in a flat position when the resident's enteral feeding was actively running. Findings included: A review of the facility policy titled, Enteral Feedings - Safety Precautions, revised November 2018, revealed, Purpose: To ensure the safe administration of enteral nutrition .Preventing aspiration .3. Elevate the head of the bed (HOB) at least 30[degrees] during tube feeding and at least 1 hour after feeding. A review of the admission Record revealed the facility readmitted Resident #33 on 04/09/2022. Diagnoses included dysphagia, oropharyngeal phase; gastrostomy status; and adult failure to thrive. The quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed with the resident. The Staff Assessment for Mental Status indicated the resident was severely cognitively impaired. The resident required one person's physical assistance for bed mobility, eating, and personal hygiene. A review of the June 2022 physician's orders revealed the resident was NPO (nothing by mouth). A review of the June 2022 medication administration record (MAR) revealed the resident had a gastrostomy tube (G-tube) feeding order which indicated, Encourage and assist Resident to elevate head of bed as tolerated. A review of the undated care plan revealed the resident required a tube feeding related to swallowing disorder, dementia, and cancer. The interventions included to encourage and assist the resident to elevate the head of bed as tolerated. On 05/31/2022 at 12:10 PM, Resident #33 was observed in their room. The resident was connected to their enteral feeding system and the tube feeding was running. The observation revealed the resident's bed laid flat when their tube feeding was running. On 05/31/2022 at 12:20 PM, Registered Nurse (RN) E was observed to enter Resident #33's room. RN E acknowledged the resident's feeding tube was connected and running. Upon observing the resident in bed, RN E immediately got a hold of the bed's remote control and raised the head of the bed. RN E stated the bed was not at her preferred angle. RN E stated she preferred to have the head of the bed raised to an angle of between 30-45 degrees. She acknowledged the resident's head was on a pillow. However, the head of the resident's bed was flat. During an interview on 06/01/2022 at 12:42 PM, Licensed Vocational Nurse (LVN) P stated that she was in the resident's room to assist Certified Nurse Aide (CNA) F with turning the resident. She stated that RN E had turned off the tube feeding machine prior to when the repositioning was carried out with Resident #33. LVN P stated that the bed was adjusted to an angle of approximately 20 degrees during the repositioning. She stated the facility had no tool with which they measured the angle the bed was at. Per LVN P, she had never had a measuring tool to determine the angle of a bed from any facility before. LVN P stated she could not give a definitive angle she left the resident's bed after she completed care with the resident. She stated that she just knew the head of the bed was not flat. During a follow-up interview with RN E on 06/01/2022 at 1:12 PM, she stated she reported the observation on 05/31/2022 to the Assistant Director of Nursing (ADON) and that an in-service was started immediately. On 06/01/2022 at 1:14 PM, Administrator in Training (AIT) B and the Administrator were interviewed. AIT B stated the facility's attention was brought to the surveyor's observation related to Resident #33's bed angulation when the resident was actively feeding through their tube feeding machine. AIT B stated the Administrator instructed him to conduct an in-service with staff on the proper angle required of the head of bed when a resident was actively being fed through enteral means. AIT B stated the head of the bed should be at an angle of 30 to 45 degrees when a resident was actively connected to a running tube feeding machine. On 06/01/2022 at 2:05 PM, during an interview, the Director of Nursing (DON) stated that the tube feeding was administered via dual pump. The DON stated the machine function was such that one side was for feeding and the other was for flushing. Per the DON, the facility was to follow physician orders when providing care to residents on tube feeding. The DON indicated the requirement for tube feeding to include, but not limited to, keeping the head of the bed at an angle of 30-45 degrees when a resident was connected to an actively running tube feeding machine to help prevent aspiration. The DON clarified that if a resident's bed was completely flat, having the resident's head on just the pillow would not suffice for the required angulation. During an interview on 06/03/2022 at 2:09 PM, the facility Medical Director (MD) stated that it was important to have the head of the bed elevated to at least an angle of 30-45 degrees when a resident was actively feeding through enteral means. The MD stated that a few exceptions existed such as when the resident had decubitus and the angulation could affect the exertion of pressure to the area. He stated that regardless of any other underlying condition, the bed should not be completely flat to prevent the resident from aspiration. Texas Administrative Code (TAC) §554.901(6)(E), Tag 1466. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/03/2022, F693.

Based on observations, interviews, temperature log review, and facility policy and procedure review, the facility failed to ensure food was served in accordance with professional standards for food service safety. Specifically, the dishwasher did not reach the appropriate temperature to sanitize the dishes. The deficient practice affected 40 of 44 residents of the facility who received meals from the kitchen. Findings included: A review of the policy titled, Sanitization, revised October 2008, revealed, Dishwashing machines must be operated using the following specifications: Low-Temperature dishwasher (chemical sanitation) wash temperature (120 degrees F [Fahrenheit]). A review of the D2 TimeSaver dish machine specification sheet, undated, revealed the minimum water temperature of the dish machine should be 120 degrees F. Observations of the dishwasher in the kitchen on 06/02/2022 between 1:08 PM and 1:28 PM revealed the dishes from the lunch meal were being washed. During the observations, the dishwasher ran five loads of dishes and the thermometer of the dish machine did not read above 110 degrees F and ran as low as 95 degrees F during the first load. As the surveyor was exiting the kitchen, Dietary Aide (DA) A was loading a sixth load of dishes into the machine. During an interview with the Dietary Manager (DM) on 06/02/2022 at 1:33 PM, he stated he was not sure what the appropriate temperature of a low temperature machine should be. He stated the appropriate rinse temperature for low temperature machines should be 110-115 degrees F. He stated the registered dietitian provided guidance for the appropriate temperature of the dish machine. He stated it was important for the dish machine to rinse at the proper temperature to kill the germs and bacteria on the dishes and provide effective cleaning. During an interview with DA A on 06/02/2022 at 2:50 PM, she stated the dishwasher temperature should run at 120 degrees F for effective dish washing. She stated she checked the temperature of the machine after the fifth load of dishes, and it was reading low at 110 degrees F. She stated she informed the DM and continued to do dishes in the dish machine. She stated if the dishwasher was reading at a low temperature, it should not be used, and the dishes should be done by hand. She stated all the lunch dishes were run through the dishwasher and placed on the racks for use at the dinner meal. The dishes were not re-washed. During an interview with the Registered Dietitian (RD) on 06/02/2022 at 1:51 PM, she stated the low temperature dish machine rinse temperature should be 120 degrees F. She stated she checked the temperature weekly when she visited the facility. She stated there had been no issues brought to her attention about the temperature of the dish machine. She stated if an issue was suspected the facility had another thermometer that should be used to check rinse temperature. She stated 110 degrees F was not a safe rinse temperature. A review of the Temperature Log sheet, dated 6/02/2022, for the lunch meal dishes, indicated a dishwasher rinse temperature of 110 degrees F. No other temperatures for May 2022 or June of 2022 were out of range. During a follow-up interview with the DM on 06/02/2022 at 2:00 PM, he stated DA A informed him of the temperature being low but not as low as 110 degrees F. He stated the dish machine should have been stopped and the lunch dishes should have been washed by hand in the three-compartment dish sink. During an interview with the dishwasher Service Representative (SR) on 06/02/2022 at 2:31 PM, he stated the service provided to the dish machine at the facility included temperature monitoring. He stated he was in the facility to check the dish machine every two weeks. He stated there were no issues with the dish machine thermometer or temperature of the dish machine on 05/24/2022. He stated the dish machine usually ran at 125 degrees F. He stated the minimum temperature at which the facility dish machine should be run was 120 degrees F for effective cleaning and sanitization of the dishes. During an interview with the Director of Nursing (DON) on 06/02/2022 at 3:11 PM, he stated he was not familiar with safe dishwashing temperatures for the dishwasher in the kitchen. He stated any issues with the dish machine temperature were reported to the maintenance director and the dish machine service representative. During an interview with the Administrator on 06/03/2022 at 11:31 AM, she stated no residents had been sent out to the hospital with stomach issues in the past 24 hours. She stated if dietary staff members noticed the temperature of the dish machine was low, they were to notify the DM immediately and await further instructions. She stated washing dishes at improper temperatures could lead to improper sanitization. She stated no temperature issues had been brought to her attention in the past. Texas Administrative Code (TAC) §554.354(g)(1)(F), Tag 0820. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 06/03/2022, F812.