Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications, Resident #34 (R34). The findings include: For R34, the facility staff failed to ensure an antidepressant medication was administered for an appropriate diagnosis. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 12/7/2022, the resident was coded as having both short- and long-term memory difficulties, and being moderately impaired for making daily cognitive decisions. The physician order dated 12/14/2022, documented, Mirtazapine (Remeron) Tablet (used to treat depression) (1) 7.5 MG (milligrams); Give 1 tablet by mouth at bedtime for appetite stimulant. This order was written by the nurse practitioner. The comprehensive care plan dated 12/2/2022 and revised on 12/15/2022, documented in part, Focus: (R34) is at risk for compromised nutritional status and weight loss r/t (related to) cancer, hx (history) of weight loss, therapeutic diet, diabetes, cognitive impairment, Bell's Palsy, Parkinson's, new environment, variable po (oral) intake, malnutrition. 12/15/2022 - significant weight loss 4.3% x (within) 1 week. Dx (diagnosis) Mets CA (metastatic cancer). The Interventions dated, 12/19/2022, documented in part, Remeron started for appetite and mood. Monitor po (oral) intake, report changes in mood or po intake. Pharmacy reviews medication profile monthly. The review of the psychiatrist note dated 12/7/2022, documented a diagnosis of mild cognitive impairment. There was no documentation of a diagnosis of depression. The nurse practitioner was unavailable for interview. An interview was conducted on 1/11/2023 at 11:38 a.m. with ASM (administrative staff member) #3, the medical director. When asked what Remeron is indicated for, ASM #3 stated, depression. When asked if it is prescribed to stimulate appetite, ASM #3 stated, normally the people who have a loss of appetite are depressed, so Remeron is to treat the depression. A side effect of the drug is it increases the appetite so it's side effects benefits the person. The facility policy, Psychotropic Medication Use documented in part, Procedure: 1. Psychotropic medication is prescribed for a diagnosed condition and not being used for convenience or discipline .5. Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 1/11/2023 at 2:30 p.m. No further information was provided prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a697009.html

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to secure hair in a hair restraint in one of two kitchens in the facility. The findings include: Observation was made on 1/10/2023 at 10:56 a.m. of OSM (other staff member) #1, the food and beverage director, walking through the kitchen. There was a staff member making food on the prep tables where she walked by. OSM #1 did not have any type of hair covering on her head. When asked if she had a hair restraint on, OSM #1 stated she usually wore a cap. When asked if she was supposed to have one on while in the kitchen, OSM #1 stated, yes. The facility policy, Uniforms and Personal Hygiene for Food Service documented in part,, Approved Hair Restraints are hair nets, (facility name) logo baseball caps, solid black or white skull caps, or white toques .Hair is neat and clean, and worn pulled away from the face. An approved hair restraint is worn at all times while preparing or plating food. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above findings on 1/11/2023 at 2:30 p.m. No further information was provided prior to ext.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to ensure resident rights by accommodating the needs of one of 25 residents in the survey sample, Resident #9. The facility staff failed to ensure accommodation of Resident #9's need for a thick wheelchair cushion. The findings include: Resident #9 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: acute respiratory failure (inability of the heart and lungs to maintain an adequate level of gas exchange) (1), diabetes mellitus (inability of insulin to function normally in the body) (2), below the left knee amputation [LBKA] (surgical removal of the limb-below the left knee) (3) and pneumonia (inflammation of the lungs usually caused by infection with bacteria) (4). Resident #9's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as extensive assistance with bed mobility, transfers, dressing, locomotion and supervision for eating, hygiene and bathing. Walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always incontinent for bowel and as having a foley for bladder. On 8/10/21 at 8:45 AM, during the initial resident observations, Resident #9 was observed in bed. He had a wheelchair with two approximately one-inch cushions in the seat of the wheelchair. Resident #9's wife was in room and Resident #9 and his wife were interviewed at this time. When asked how often he got out of bed, Resident #9 stated, Since I came back from the hospital about one week ago, I get up for physical and occupational therapy. Before I went to the hospital, I had a black thick cushion in the wheelchair and I could tolerate being up in the wheelchair. When I came back from the hospital, someone had taken the black cushion and given me these two smaller yellow ones. I can't sit on those cushions for long period of time because it hurts my coccyx. Resident #9's wife stated, We've asked for the cushion back, and were told someone else needed it. He doesn't get out of bed because he is not comfortable. Resident #9 was hospitalized from [DATE] to 8/3/21 with Pneumonia. A review of the physician's orders dated 6/10/21 and 8/3/21, documented in part, Wheelchair pressure relief cushion. A review of the comprehensive care plan for Resident #9 dated 8/4/21 and revised 8/7/21, documented in part, FOCUS- The resident is at risk for falls related to left BKA, diabetes mellitus and muscle weakness. INTERVENTIONS-Anticipate and meet the resident's needs daily. Check and ensure that wheelchair, positioning equipment are in use. A review of Resident #9's ADL (activities of daily living) form for August 2021, documented in part, Locomotion on Unit-total dependence with one person physical assist for five of eight days (8/4/21, 8/5/21, 8/6/21, 8/7/21, 8/11/21). Locomotion on Unit-NA documented for three of eight days (8/8/21, 8/9/21, 8/10/21). An interview was conducted on 8/11/21 at 9:10 AM with OSM (other staff member) #2, the occupational therapist assistant. When asked if she had worked with Resident #9, OSM #2 stated, Yes, I used to work with him before he went to the hospital. He was out of bed most days and putting on his pants (sweat like pants) with a little assistance. He had a thick black cushion in his wheelchair. I did not know that it was gone. I have not worked with him since his return from the hospital. I will look for it and if I can't find the cushion, I will order another one from supply. An interview was conducted on 8/11/21 at 9:22 AM with OSM #3, the physical therapist. When asked if she had worked with Resident #9, OSM #3 stated, Yes, I did. He had a black cushion in the wheelchair. I did not realize he did not have it anymore. He should be getting up more, but I don't want him to have a skin breakdown because he doesn't have the right cushion. An interview was conducted on 8/11/21 at 9:43 AM with Resident #9. When asked how often he used to get up into the wheelchair, Resident #9 stated, Yes, I used to get up a lot more when I had the thick black cushion in the wheelchair before I went to the hospital. Now I get up to go to OT and PT because the yellow cushions hurt by coccyx. They told me they only had one black cushion in the building and when I went into the hospital, they took it for another resident. I only got up yesterday for PT/OT in the afternoon. On 8/11/21 at 11:15 AM, OSM #2 was observed bringing a black cushion into Resident #9's room. Resident #9 stated, Yes, that is it! I'm so glad you found it. On 8/11/21 at 1:08 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the concern. On 8/11/21 at 2:00 PM, Resident #9 was observed out of bed in wheelchair. When asked how he was feeling, Resident #9 stated, It feels good sitting up in this chair with this cushion. I had a cheeseburger for lunch. It is going well. On 8/11/21 at 2:11 PM, an interview was conducted with CNA (certified nursing assistant) #1. When asked what the N/A mean on the ADL sheets, CNA #1 stated, It can mean that the resident is refusing to do the activity. Resident #9 did not want to get up because the chair did not have the correct cushion in it. On 8/11/21 at 3:00 PM, Resident #9 was observed sitting in wheelchair in main lobby area participating with the singing activity and at 4:00 PM was observed participating in the facility cocktail hour. ASM #2 provided the team with the facility policy Care Standards dated 2/29/16, which documented in part, The Director of Nursing directs in accordance with care and services standards of clinical practice. For the purposes of this policy, the Clinical Operations Department follows standards as outlined in the practice/program/procedures and physician orders. [NAME] & [NAME]: Clinical Nursing Skills & Procedures. According to [NAME] & [NAME], which documents in part, First complete a thorough patient assessment including individual needs. Ultimately the features of the support surface must match a patient's unique needs. (4) A review of the facility's admission packet, Exhibit 7- Resident Rights (Federal) dated 10/25/2018, which documents in part, The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: include an assessment of the resident's strengths and needs. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 502. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 160. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 29. (4) [NAME] & [NAME] Clinical Nursing Skills, 8th edition, [NAME], Elsevier Publishers, page 274.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to implement the comprehensive care plan for Resident #21 to provide pressure ulcer treatment as ordered. Resident #21 was admitted to the facility with diagnoses that included but were not limited to diabetes (2), heart failure (3) and end stage renal disease (4). Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of skin breakdown. Dated Initiated: 08/08/2021. Administer medication and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. The physician's order summary for Resident #21 documented in part the following: Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm [centimeter]) 6.0, Width (cm) 15.0, Depth (cm) UTD [unable to determine], Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size .His wounds are doing well. We will continue the present treatment for now. I will follow up with him next week. The goal will be to resolve his wounds . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the care plan gave everyone a general idea of the care a resident required. LPN #6 stated that pressure ulcers and skin care were documented on the care plan. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the order for Resident #21 which documented, Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. LPN #6 stated that the care plan was not being implemented if the treatment was not being performed as ordered. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable PS on the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit showed that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete the evening shift treatment. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. ASM #2 stated that the care plan was not being implemented for treatments as ordered if staff were not completing the treatment on day and evening shift. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on implementing the care plan. The facility policy Individualized Care Plan dated 2/29/16 documented in part, .The IDT (interdisciplinary team) develops comprehensive care plan addressing the resident's most acute problems. The comprehensive care plan will include: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . On 8/10/2021 at approximately 10:48 a.m., ASM (administrative staff member) #2 stated that the facility followed [NAME] & [NAME] as their nursing standard of practice. Basic Nursing, Essentials for Practice, 6th edition, ([NAME] and [NAME], 2007, pages 119-127), was a reference for care plans. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care and listing outcome criteria to be used in the evaluation of nursing care. The written care plan communicates nursing care priorities to other health care professionals. The care plan also identifies and coordinates resources used to deliver nursing care. A correctly formulated care plan makes it easy to continue care from one nurse to another . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 2. Diabetes: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. 3. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. 4. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm. Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement the comprehensive care plan for the use of fall mats for one of 25 residents in the survey sample, Resident # 17; and for the provision of pressure ulcer treatment per physician orders for one of 25 residents in the survey sample, Resident # 21. The findings include: 1. The facility staff failed to implement Resident # 17's comprehensive care plan for the use of fall mats while in bed. Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [1], fracture of the right Ilium [2] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living. On 08/10/21 at 8:40 a.m., an observation of Resident # 17 revealed the resident lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was observed leaning against the wall at the foot of the bed. On 08/11/21 at 7:40 a.m., an observation of Resident # 17 revealed the resident lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was leaning against the wall at the foot of the bed. The care plan for Resident # 17 dated 09/21/2020 documented in part, Focus. The resident has had more than one actual fall with h/o [history of] multiple falls, and is at risk for falls r/t [related to] impaired mobility, debility and multiple fractures to lumbar and sacrum with the use of back brace. Use of Antidepressant with risk for side effects. Halo bar to improve pt. [patient] mobility. Fall on 1/17/21 with no apparent injuries. Date Initiated: 09/21/2020. Under Interventions it documented in part, Floor mat to floor when in bed. Date Initiated: 01/17/2021. On 08/10/2021 at 7:42 a.m., an interview was conducted with Resident # 17. When asked about the placement of the fall mats, Resident # 17 stated that both fall mats were supposed to be down when they are in bed. On 08/11/21 at 750 a.m., an interview and observation of Resident # 17's room was conducted with LPN [licensed practical nurse] # 6. After observing the floor around Resident # 17's bed, LPN #6 was asked about the fall mats. LPN # 6 stated that there was one fall mat on the floor next to Resident # 17's bed. LPN # 6 further stated, There should be two fall mats down, one on each side of the bed. On 08/11/21 at 10:46 a.m., an interview with LPN # 6. LPN #6 reviewed Resident # 17's comprehensive care plan for falls After completing the review, LPN # 6 was asked if the comprehensive care plan was being followed based on the observations above. LPN # 6 stated, Not as it should be. There was only one fall mat down and there should be two. On 08/11/2021 at approximately 1:08 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [2] The broad, dorsal, upper, and largest of the three principal bones composing either half of the pelvis. This information was obtained from the website: https://www.merriam-webster.com/dictionary/ilium

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to accurately transcribe a physician's order into the electronic medical record for Resident #21. Resident #21 was admitted to the facility on [DATE] with a readmission on [DATE], with an unstageable pressure ulcer (1) on the sacrum/buttocks. The physician's orders for treatment to the pressure ulcer documented the treatment was to be completed on day and evening shift however, the facility staff transcribed the scheduled times for the treatment as day shift only resulting in Resident #21 receiving the treatment only once a day. Resident #21 was admitted to the facility with diagnoses that included but were not limited to diabetes (2), heart failure (3) and end stage renal disease (4). Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The comprehensive care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of skin breakdown. Dated Initiated: 08/08/2021. Administer medication and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. The physician's order summary for Resident #21 documented in part the following: Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 6.0, Width (cm) 15.0, Depth (cm) UTD, Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size .His wounds are doing well. We will continue the present treatment for now. I will follow up with him next week. The goal will be to resolve his wounds . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the wound physician came to the facility once a week to see residents. LPN #6 stated that the nurses provided the pressure ulcer care when the wound physician was not in the facility. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the order for Resident #21 which documented, Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable to the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit shows that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete it. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. On 8/11/2021 at approximately 2:40 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that nursing staff received telephone orders from the physician and documented them on the telephone order sheet. ASM #2 stated that the nursing staff used the telephone order sheet to transcribe the order into the computer. ASM #2 stated that every night the nurse checked every chart for new telephone orders and compared them to the computer to ensure that they were transcribed correctly. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on transcribing physician orders. The facility policy Physician/Prescriber Authorization and Communication of Orders to Pharmacy dated 12/01/07 documented in part, .Facility staff should read back verbal orders to Physician/Prescriber or Physician's/Prescriber's agent to ensure accuracy and avoidance of sound alike medications. Facility should ensure that the person receiving a verbal order immediately records it in the resident's chart or electronic order system, including the date and time of the order, the name of Physician/Prescriber, and the signature of the person recording the order. All verbal orders should be recorded by a licensed nurse . On 8/10/2021 at approximately 10:48 a.m., ASM #2 stated that the facility followed [NAME] & [NAME] as their nursing standard of practice. According to Basic Nursing, Essentials for Practice, 6th edition ([NAME] and [NAME], 2007, pages 349-360) A medication order is required for you to administer any medication to a patient. Once you receive and process a medication, place the physician's or health care provider's complete order on the appropriate medication form, the MAR. The MAR includes the patient's name, room, and bed number, as well as the names, dosages, frequencies, and routes of administration for each medication. When transcribing orders, ensure the names of medications, dosages, routes, and times are legible. The nurse checks all orders for accuracy and thoroughness. When orders are transcribed, the same information needs to be checked again by the nurse. It is essential that you verify the accuracy of every medication you give to the patient with the patient's orders. To ensure safe medication administration, be aware of the six rights of medication administration. 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 2. Diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. 3. Heart failure A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. 4. End-stage kidney disease The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm. Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for the administration of medication for one of 25 residents in the survey sample, Resident # 17; and failed to follow professional standard for the provision of pressure ulcer treatment per physician's orders for one of 25 residents, Resident # 21. The findings include: 1. The facility staff failed to accurately transcribe the physician's order of metoprolol [1] for Resident # 17. Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [2], fracture of the right Ilium [3] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living. The physician's telephone order dated 09/25/2020 for Resident # 17 documented, Increase Toporol [metoprolol] to 50mg QD [every day] hold for SBP < [less than] 110 or < 60 pulse. Order received: 9/25/2020. The physician order for Resident # 17 documented, Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG [milligram]. Give 1 [one] tablet by mouth one time a day for HTN [hypertension]. Hold for SBP [systolic blood pressure] less than 110 and pulse less than 60. Order Date: 9/25/2020. The eMARs [electronic medication administration records] for Resident # 17 dated January 2021 through August 11, 2021 documented in part, Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG [milligram]. Give 1 [one] tablet by mouth one time a day for HTN [hypertension]. Hold for SBP [systolic blood pressure] less than 110 and pulse less than 60. Order Date: 9/25/2020. On 8/10/2021 at approximately 12:10 p.m., an interview was conducted with ASM [administrative staff member] #2, the director of nursing. After reviewing the eMARs dated January 2021 through August 11, 2021, ASM # 2 provided a copy of the physician's telephone order dated 09/25/2020 for Resident # 17. ASM # 2 stated that the orders on the eMARs were not transcribed correctly from the physician's telephone order. On 8/11/2021 at approximately 2:40 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that nursing staff received telephone orders from the physician and documented them on the telephone order sheet. ASM #2 stated that the nursing staff used the telephone order sheet to transcribe the order into the computer. ASM #2 stated that every night the nurse checked every chart for new telephone orders and compared them to the computer to ensure that they were transcribed correctly. The facility's policy Care Standards documented in part, Policy Statement: It is the policy of the center to provide necessary care and services to assist each resident to attain or maintain his/her highest practicable level of physical, mental and psychosocial wellbeing in accordance with physician orders, a comprehensive assessment and plan of care. Care is documented in the medical record in accordance with State and Federal regulations. On 08/11/2021 at approximately 1:08 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] Used alone or in combination with other medications to treat high blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682864.html. [2] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [3] The broad, dorsal, upper, and largest of the three principal bones composing either half of the pelvis. This information was obtained from the website: https://www.merriam-webster.com/dictionary/ilium

Based on observations, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide assistive devices and failed to ensure an environment free from accident hazards for one of 25 residents in the survey sample, Resident # 17. The facility staff failed implement physician ordered fall mats on the floor while Resident #17 was in bed. The facility staff failed to place fall mats on the floor to the right and left sides of Resident #17's bed, while the resident was lying in bed. The findings include: Resident # 17 was admitted to the facility with diagnoses that included but were not limited to: hypertension [1], Fracture of the right Ilium [2] and muscle weakness. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/23/2021, coded Resident # 17 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living. On 08/10/21 at 8:40 a.m., an observation of Resident # 17 revealed they were lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was leaning against the wall at the foot of the bed. On 08/11/21 at 7:40 a.m., an observation of Resident # 17 revealed they were lying in their bed. Further observation revealed one fall mat on the floor to the resident's right side of the bed. Observation of the floor to the resident's left side failed to evidence a fall mat on the floor. Observation of Resident # 17's room revealed another fall mat was leaning against the wall at the foot of the bed. The physician's order for Resident # 17 documented, Floor mats to Floor when in bed every shift. Order Date: 4/4/2020. The care plan for Resident # 17 dated 09/21/2020 documented in part, Focus. The resident has had more than one actual fall with h/o [history of] multiple falls, and is at risk for falls r/t [related to] impaired mobility, debility and multiple fractures to lumbar and sacrum with the use of back brace. Use of Antidepressant with risk for side effects. Halo bar to improve pt. [patient] mobility. Fall on 1/17/21 with no apparent injuries. Date Initiated: 09/21/2020. Under Interventions it documented in part, Floor mat to floor when in bed. Date Initiated: 01/17/2021. On 08/10/2021 at 7:42 a.m., an interview was conducted with Resident # 17. When asked about the placement of the fall mats Resident # 17 stated that both fall mats were supposed to be down when they are in bed. On 08/11/21 at 750 a.m., an interview and observation of Resident # 17's room was conducted with LPN [licensed practical nurse] # 6. LPN #6 observed the floor around Resident # 17's bed. After completing the observation, LPN #6 was asked about the fall mats. LPN # 6 stated that there was one fall mat on the floor next to Resident # 17's bed. LPN # 6 further stated, There should be two fall mats down, one on each side of the bed. On 08/11/2021 at approximately 1:08 p.m. ASM (administrative staff member) # 1, the administrator and ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: [1] High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. [2] The broad, dorsal, upper, and largest of the three principal bones composing either half of the pelvis. This information was obtained from the website: https://www.merriam-webster.com/dictionary/ilium

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services consistent with professional standards of practice for one of 25 residents in the survey, Resident #235. The facility staff failed to obtain an order for Resident #235's use of an incentive spirometer and failed to ensure the spirometer was stored in a sanitary manner. The findings include: Resident #235 was admitted to the facility on [DATE]. Resident #235's diagnoses included but were not limited to: heart failure (inability of the heart to pump enough blood to maintain normal body requirements) (1), atrial fibrillation (random and rapid contractions of the atria of the heart) (2) and fracture of the left femur (break in the left thighbone) (3). Resident #235's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 7/20/21, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. MDS Section G- Functional Status: coded the resident as extensive assistance with bed mobility, limited assistance with transfers, locomotion, dressing, bathing; supervision with personal hygiene and independence with eating. Walking did not occur. A review of MDS Section H- Bowel and Bladder: coded the resident as always continent for both bowel and bladder. During the initial resident observation on 8/10/21 at 8:17 AM, an incentive spirometer was observed on Resident #235's over bed table uncovered. The incentive spirometer was also observed uncovered on 8/10/21 at 3:35 PM and on 8/11/21 at 8:45 AM and 10:20 AM. A review of Resident #235's comprehensive care plan dated 7/22/21 failed to evidence documentation of the incentive spirometer. A review of the physician orders dated 7/14/21-8/10/21 failed to evidence orders for the incentive spirometer. A review of the facility's Service and Health Systems assessment dated [DATE] failed to evidence incentive spirometer use. An interview was conducted on 8/10/21 at 8:17 AM with Resident #235. When asked if she used the incentive spirometer, Resident #235 stated, Yes, I use it frequently throughout the day. When asked if the incentive was covered, Resident #235 stated, No, it has not been covered. An interview was conducted on 8/11/21 at 10:20 AM with Resident #235. When asked if she was still using the incentive spirometer, Resident #235 stated, Yes, I use it a lot. Now I don't use it the ten times an hour like when I was in the hospital after surgery, but I use it a lot. An interview was conducted on 8/11/21 at 10:41 AM with LPN (licensed practical nurse) #2 regarding resident use of an incentive spirometer. LPN #2 stated, There should be a physician order and it should be on the care plan. It should be in a plastic bag to keep it clean. When asked about Resident #235's incentive spirometer, LPN #2 stated, I didn't even notice that she had an incentive. Let's go look. At this time LPN #2 was accompanied to Resident #235's room. LPN #2 entered the resident's room, and asked Resident #235 if she used an incentive spirometer. Resident #235 stated, Yes, I use it a lot, it helps my lungs stay good. LPN #2 then asked Resident #235 where the incentive spirometer came from, and Resident #235 answered, I brought it with me from the hospital and I have one at home also. On 8/11/21 at 1:08 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the concern. ASM #2 provided the team with the facility policy Care Standards dated 2/29/16, which documented in part, The Director of Nursing directs in accordance with care and services standards of clinical practice. For the purposes of this policy, the Clinical Operations Department follows standards as outlined in the practice/program/procedures and physician orders. [NAME] & [NAME]: Clinical Nursing Skills & Procedures. According to [NAME] & [NAME], which documents in part, The skill of assisting a patient to use the incentive spirometer can be delegated to nursing assistants. The nurse is responsible for patient assessment, monitoring and evaluating the patient response. Review health care provider's order for incentive spirometer. (4) In Fundamentals of Nursing 7th edition, 2009: [NAME] A. [NAME] and [NAME]: Mosby, Inc; Page 648. Box 34-2 Sites for and Causes of Health Care-Associated Infections under Respiratory Tract -- Contaminated respiratory therapy equipment. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 259. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 54. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and [NAME], page 232/219. (4) [NAME] & [NAME] Clinical Nursing Skills, 8th edition, [NAME], Elsevier Publishers, page 597-599.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer medications in a sanitary manner for 1 of 3 residents in the Medication Administration task; Resident #93. The findings include: Resident #93 was admitted to the facility on [DATE] with the diagnoses of but not limited to osteoporosis, Barrett's esophagus, cardiac arrhythmia, high blood pressure, heart failure, atrial fibrillation, infection of right hip prosthesis, and macular degeneration. The admission MDS had not been completed as of survey. The admission BIMS (Brief Interview for Mental Status) assessment dated [DATE] coded the resident as being cognitively intact in ability to make daily life decisions. The admission nursing assessment dated [DATE] documented the resident as requiring extensive assistance for bed mobility, transfers, dressing, toileting, hygiene and bathing; and independent for eating. On 8/10/21 at 8:52 AM, LPN #2 (Licensed Practical Nurse) was observed preparing and administering medications to Resident #93. LPN #2 was observed touching the pill cards, keys to open the medication cart, and laying pill cards on top of the medication cart before returning them to the cart. During preparation, LPN #2 dropped the Aldactone (1) on top of the medication cart. She then without washing or sanitizing her hands, picked up the Aldactone pill with her bare fingers and put it in the medication cup with other medications to be administered to Resident #93. The Aldactone was the 6th of 8 medications she prepared for this resident, having had the medication cards laying on top of the cart prior to dropping the pill on top of the cart. Once preparation of medications was completed, LPN #2 without sanitizing her hands, was then observed picking up the medication cup with her thumb down inside the cup and her index finger on the outside of the cup to hold it. She then went to the resident's room and administered the medications, to Resident #93, including the Aldactone that had been dropped on top of the medication cart. On 8/10/21 at 11:25 AM, an interview was conducted with LPN #2. When asked about dropping the Aldactone on top of the cart and then picking it up and administering it to the resident, LPN #3 stated that she should not have done that and as it was a risk of infection. She stated that she did sanitize the top of the cart and her hands before starting med [medication] pass. However, when asked about all the items that she had touched as observed above, i.e. the pill cards, keys to open the medication cart, etc., that had been in contact with the top of the cart prior to the Aldactone dropping on it (pill cards, etc.), she did not respond other than to repeat that the cart was sanitized prior to med [medication] pass. LPN #2 then stated that she normally lays a clean tissue on top of the cart to prepare the meds. When asked if she had done that for this resident, she stated she could not recall. LPN #2 was not observed following this routine during this observation. When asked about holding the medication cup with her thumb down inside it, she stated that was an infection control issue and that she should not have done that. She stated she did not recall doing that. A review of the facility policy, General Dose Preparation and Medication Administration documented, 2. Prior to preparing or administering medications, authorized and competent facility staff should follow facility's infection control policy (e.g. handwashing) 3.4 Facility staff should not touch the medication when opening a bottle or unit dose package. 3.5 If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy According to [NAME] and Perry's, Fundamentals of Nursing, 6th edition, page 847, For safe administration, the nurse uses aseptic technique when handling and giving medications. Skill 1: Administering Oral Medications: 6. Prepare the required medications: b. Multidose containers: When removing tablets or capsules . pour the necessary number into the bottle cap and then place the tablets or capsules in a medication cup. Do not touch tablets or capsules with hands. Rationale: Pouring capsules or tablets into your hand is unsanitary. 12. Transport medications to patient bedside carefully . 14. Perform hand hygiene and put on PPE [personal protective equipment] if indicated. Rationale: Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission based precautions. 20. Administer the medications. [NAME] Photo Atlas of Medication Administration, Sixth Edition, [NAME] B [NAME], EdD, MSN RN, Wolters Kluwe, 2019, pages 2, 3, 4 and 6. On 8/11/21 at approximately 1:00 PM, ASM #1 and ASM #2 (Administrative Staff Member - the Administrator and Director of Nursing, respectively) were made aware of the findings. No further information was provided by the end of the survey. (1) Aldactone - is used to treat certain patients with hyperaldosteronism (the body produces too much aldosterone, a naturally occurring hormone); low potassium levels; heart failure; and in patients with edema (fluid retention) caused by various conditions, including liver, or kidney disease. It is also used alone or with other medications to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682627.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the treatment as ordered by the physician to promote healing of a pressure ulcer for one of 25 residents in the survey sample, (Resident #21). Resident #21 was admitted to the facility on [DATE] with a readmission on [DATE], with an unstageable pressure ulcer (1) on the sacrum/buttocks. The physician's orders for treatment to the pressure ulcer documented the treatment was to be completed on day and evening shift however, the facility staff transcribed the scheduled time for the treatment as day shift only resulting in Resident #21 receiving the treatment only once a day and not twice a day as ordered by the physician from 8/4/21 through 8/10/21. The findings include: 1. Resident #21 was admitted to the facility with diagnoses that included but were not limited to diabetes (2), heart failure (3) and end stage renal disease (4). Resident #21's most recent MDS (minimum data set) assessment, a 5 day assessment with an ARD (assessment reference date) of 7/25/2021 coded Resident #21 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section G coded Resident #21 requiring extensive assistance of one person for bed mobility and toileting and two persons for transfers. Section M coded Resident #21 having one unstageable pressure ulcer that was present on admission. On 8/10/2021 at approximately 10:45 a.m., an interview was conducted with Resident #21. Resident #21 stated that the facility staff applied a cream to the sore on their buttocks. Resident #21 stated that the nurses changed the dressing every day and they had seen the wound doctor earlier that morning prior to them getting out of bed. Resident #21's comprehensive care plan dated 8/3/2021 documented in part, I have an unstageable sacral wound. Date Initiated: 08/03/2021. The care plan further documented, The resident has unstageable pressure ulcer and potential for pressure ulcer development r/t (related to) disease process, immobility. Date Initiated: 08/08/2021. Under Interventions it documented in part, Adhere to the resident's treatment plan for the prevention/treatment of skin breakdown. Dated Initiated: 08/08/2021. Administer medications and treatments as ordered and monitor for effectiveness. Date Initiated: 08/08/2021 . The physician's order summary for Resident #21 documented in part the following: Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 . Under the Scheduling Details of the order it documented in part, Frequency: every day shift, Schedule Type: Everyday; Facility Time Code 0700-1500 (7:00 a.m.-3:00 p.m.); Start on: 8/4/2021 Day 7-3 . The eTAR for Resident #21 dated 8/1/2021-8/31/2021 documented the physician treatment orders as documented above, to the unstageable pressure ulcer and documented it was completed on Day shift (between 7:00 a.m.-3:00 p.m.) each day from 8/4/2021 through 8/10/2021. The eTAR for Resident #21 failed to evidence documentation of the pressure ulcer treatment being completed on the evening shift as ordered by the physician. The progress notes for Resident #21 documented in part, - 7/11/2021 19:33 (7:33 p.m.) Note Text: Resident head to toe status post second skin assessment done after admission with following noted MASD (moisture associated skin damage) to both under arm pit, dry scaly skin to bilateral upper extremities and bilateral lower extremities, rash all over buttock area, groin area. Buttock area is black. Resident son is aware of skin issues . - 7/16/2021 15:53 (3:52 p.m.) Note Text: Weekly skin assessed, no new skin noted. Antifungal cream to bilateral buttock and groin. Sooth and cool to dry scaly skin to both BUE (bilateral upper extremities) and BLE (bilateral lower extremities). No worsening noted. - 7/19/2021 21:54 (9:54 p.m.) admission Note . Resident arrived at the facility on the 7/19/2021 at 6:20 pm, on a stretcher accompanied by 2 paramedics and his son .Resident has a stage two pressure ulcer . - 7/21/2021 14:23 (2:23 p.m.) Note Text: Resident head toe second skin check after readmit done 07/20/2021 with the following noted: Unstageable to include bilateral buttocks, dry skin lower extremities, DTI (deep tissue injury) to right heel, Fistula (dialysis access) noted to left arm with RP (responsible party) made aware of skin issues. - 7/22/2021 13:41 (1:41 p.m.) Note Text: At risk meeting held today. Resident reviewed and discussed .Resident admitted from hospital with unstageable pressure injury to sacrum to include bilateral buttocks, DTI (deep tissue injury) to right heel and very dry skin. Resident is noted to be refusing care from noc (night) shift. Treatment in place, currently has low air loss mattress to prevent further skin breakdown . - 8/3/2021 23:44 (11:44 p.m.) admission Note: .Arrived on 8/3/2021 at 9:35 pm from [Name of Hospital] in the company of transportation team and son alert and oriented x 3 (person, place and time), denies pain. sacral wound . - 8/5/2021 11:50 (11:50 a.m.) At risk meeting held today. Resident reviewed and discussed .At risk for skin breakdown r/t (related to) unstageable pressure injury to sacrum to include bilateral buttocks . The Braden Scale for Predicting Pressure Sore Risk dated 7/8/2021 and 7/19/2021 for Resident #21 documented in part, At Risk . The Skilled Wound Care Communication Log for Daily Rounds for Resident #21 dated 7/27/2021 documented in part, .Location: Sacrum; Etiology: pressure unstag (unstageable); Pre-Op L x W x D (length, width, depth): 6 x 15 x UTD (unable to determine) . The Skilled Wound Care Communication Log for Daily Rounds for Resident #21 dated 8/10/2021 documented in part, Location: Sacrum; Pre-Op L x W x D (length, width, depth): 7 x 10.5 x .3 . The Weekly Wound Evaluation Skilled for Resident #21 dated 7/21/2021 documented in part, . Location: Unstageable include bilateral buttock . admitted . Date Acquired 7/19/20221 .Unstageable pressure injury .Wound measurements: Length- 10.0 cm (centimeters), Width- 15.5 cm, Depth- 0.0 cm .Wound progress: Undetermined: First Visit . The Weekly Wound Evaluation Skilled for Resident #21 dated 7/28/2021 documented in part, .Seen by wound physician [Name of wound physician] .Location: Sacrum extending to the right buttock .unstageable pressure injury .Wound measurements: Length- 6.0 cm (centimeters), Width- 15.0 cm, Depth- 0.0 cm .Wound progress: Undetermined: First Visit . The Weekly Wound Evaluation Skilled for Resident #21 dated 8/11/2021 documented in part, .Seen by wound physician [Name of wound physician] .Location: Sacrum extending to the bilateral buttock .unstageable pressure injury .Wound measurements: Length- 7.0 cm (centimeters), Width- 10.0 cm, Depth- 0.3 cm .Wound progress: Wound has decreased in size . The Weekly Evaluation for Resident #21 dated 7/12/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Weekly Evaluation for Resident #21 dated 7/26/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Weekly Evaluation for Resident #21 dated 8/9/2021 documented in part, .Skin: New skin concerns identified in the last 7 days- No; Current treatment(s) for wounds or pressure ulcers- Yes; Improvement or change in wound or pressure ulcer based on current treatment- Yes . The Surgical Note for Resident #21 dated 7/27/2021 documented in part, .Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 6.0, Width (cm) 15.0, Depth (cm) UTD, Wound Area (cm2) 90; Wound progress: Undetermined: First Visit. The Surgical Note for Resident #21 dated 8/10/2021 documented in part, Wound Location: Sacrum; Etiology: Pressure injury/ulcer- Wound Stage: Unstageable pressure injury .Size: Length (cm) 7.0, Width (cm) 10.5, Depth (cm) 0.3, Wound Area (cm2) 73.5; Wound progress: Wound has decreased in size . On 8/11/2021 at approximately 12:30 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that the wound physician came to the facility once a week to see residents. LPN #6 stated that the nurses provided the pressure ulcer care when the wound physician was not in the facility. LPN #6 stated that pressure ulcer treatments were documented as completed on the eTAR (electronic treatment administration record). LPN #6 reviewed the physician order for Resident #21 which documented, Cleanse unstageable to include bilateral buttocks with wound cleanser, pat dry, apply soothe and cool mix with calazime every day and evening shift and cover with boarder gauze until resolved. Order Date: 08/03/2021. Start Date: 08/04/2021 and stated that the eTAR should reflect the treatment being completed on the day shift and the evening shift. LPN #6 reviewed the eTAR for Resident #21 and stated that there was only documentation of the treatment being completed on the day shift. LPN #6 stated that the treatment was not scheduled on the eTAR for the evening shift so they were not aware that it was to be done twice a day. On 8/11/2021 at approximately 12:55 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that Resident #21's order for the pressure ulcer treatment to the unstageable to the buttocks was written for day and evening shift and should be completed twice a day. ASM #2 stated that the order audit shows that the order was scheduled to be completed on day shift only and was not being done on the evening shift. ASM #2 stated that unless the order was entered with a schedule of day and evening shift it would not show on the eTAR for the nurses to complete it. ASM #2 stated that they would change the scheduling to reflect the treatment order of day and evening shift. On 8/11/2021 at approximately 1:00 p.m., a request was made to ASM #1, the administrator for the facility policy on pressure ulcer care. The facility policy Skin Care & Pressure Injury Management Program documented in part, .Pressure injuries are a serious concern, especially in compromised residents. Using evidence-based treatments, standards of practice, and the APIE (Assess, Plan, Implement & Evaluate) methodology, this guideline helps the resident interdisciplinary team to: Provide standardized treatment and interventions that promote pressure ulcer healing and prevent infection . On 8/11/2021 at approximately 1:15 p.m., ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concerns. No further information was presented prior to exit. References: 1. Pressure ulcer A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. 2. Diabetes mellitus: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. 3. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. 4. End-stage kidney disease: The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/000500.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide written notification of a facility initiated transfer to the ombudsman, the resident and/or the resident's representative for two of 30 residents in the survey sample, Residents # 13 and # 19. 1. The facility staff failed to notify the ombudsman and provide Resident # 13 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to notify the ombudsman when Resident # 19 was transferred to the hospital on [DATE]. The findings include: 1. The facility staff failed to notify the ombudsman and provide Resident # 13 or the resident's representative written notification when the resident was transferred to the hospital on [DATE]. Resident # 13 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: hemiplegia (1), benign prostatic hyperplasia (2), anemia (3) and hypertension (4). Resident # 13's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/22/19, coded Resident # 13 as scoring a 4 (four) on the brief interview for mental status (BIMS) of a score of 0 - 15, 4 (four) - being severely impaired of cognition for making daily decisions. Resident # 13 was coded as being totally dependent of one staff member for activities of daily living. The nurse's Progress Notes, dated 02/09/2019 for Resident # 13 at 10:40 p.m. documented, At around 6:45 pm (p.m.) after dinner, resident wife came to writer that her husband has not [sic] pass urine in the Foley bag since breakfast. This writer assessed pt (patient), abdomen is big with some distension noted. Pt c/o (complained of) pain when abdomen been palpated, pt has suprapubic cath (catheter) for dx (diagnosis) of BPH (benign prostatic hyperplasia). MD (medical doctor) made aware, new order to transfer pt to ER (emergency room) to eval (evaluate) and treat via (by) non-emergence. (Name of Transport) call and came pickup resident at about 8:45 PM (p.m.). Report given to ER nurse (Name of Nurse). The nurse's Progress Notes, dated 02/10/2019 for Resident # 13 at 02:31 (2:31 a.m.) documented, Resident returned to unit at 0200 (2:00 a.m.) from (Name of Hospital) with an 18 Fr (French) pubic catheter with 10cc (cubic centimeters) balloon in place and draining well at this hour. Resident appears comfortable with no distress observed at this hour. New order for cefixime 400 mg (milligrams) 1 (one) cap (capsule) po (by mouth) daily for UTI (urinary tract infection) x (times) 10 days and to discontinue Trimethoprim while resident is [sic] no cefixime and resume post ABT (antibiotic) therapy. Denies pain, no distress observed. Nursing staff will continue to monitor. The facility's Transfer / Discharge Summary -V2 form for Resident # 13 with the Effective Date: 02/09/2019 22:25 (10:58 p.m.) documented, F. Signature/Acknowledgement. My signature below indicates that Discharge Instructions were reviewed with me in a language I understand and my questions answered. I have received the medication list or prescriptions identified and have been notified of any medication(s) dispensed in containers that are not child-proof. Review of the headings 1. Signature of Person Receiving Instructions, 2. Relationship to Resident/Guest and 3.Date Signed revealed they were left blank. On 03/27/19 at approximately 5:25 p.m., during the end of the day meeting with ASM (administrative staff member) # 1, administrator , a request was made for evidence that the ombudsman was notified of Resident # 13's transfer to the hospital on [DATE]. On 03/28/19 at approximately 8:30 a.m., ASM # 1 provided a copy of a facsimile to the ombudsman for Resident # 13 dated MAR -27 0841 PM (March 27, 2019 at 8:41 p.m.). On 03/28/19 at 8:51 a.m., an interview was conducted RN (registered nurse) # 2, acting director of nursing and the administrator, ASM (administrative staff member) # 1. When asked who is responsible for notifying the ombudsman at the time of a resident's transfer to the hospital RN # 2 stated, The nurses or designee. When asked about the facsimile to the ombudsman for Resident # 13 dated 3/27/19, ASM # 1 stated that the facsimile was sent after the request was made the day before. When asked how the resident or the resident's responsible party is notified of the resident's transfer to the hospital ASM # 1 stated, It is documented on the transfer form. After reviewing the Transfer / Discharge Summary -V2 form for Resident # 13 with the Effective Date: 02/09/2019 22:25 (10:58 p.m.) ASM # 1 was asked if section F of the form was complete. ASM # 1 stated no. When asked if there was evidence that, the resident or the resident's responsible party was notified of the transfer on 02/09/19, ASM # 1 stated, No. The facility's policy Transfer, Discharge & Bed Hold Notices documented, 3. The SSC (social services coordinator)/designee will complete the following steps before the community transfers or discharges a resident (voluntary or involuntary): a. Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move, in writing, in a language and manner they understand. On 03/28/19 at approximately 3:00 p.m. ASM (administrative staff member) # 1, the administrator was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) An enlarged prostate. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/enlargedprostatebph.html. (3) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html. (4) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 2. The facility staff failed to notify the ombudsman when Resident # 19 was transferred to the hospital on [DATE]. Resident # 19 was admitted to the facility on [DATE] and a re-admission on [DATE] with diagnoses that included but were not limited to: hemiplegia (1), peripheral vascular disease (2), depressive disorder (3) and syncope and collapse (4). Resident # 19's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 02/12/19, coded Resident # 19 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 19 was coded as requiring extensive assistance of one staff member for activities of daily living. The nurse's Progress Notes, dated 02/02/19 at 03:25 (3:25 a.m.) documented, Event: Fall. Action/Intervention: Resident was assessed, pressure applied to bleeding site and dry dressing applied to open area on back. Order obtained to send to ER (emergency room) and resident sent to (Name of Hospital) via (by) 911 for further observation and Tx (treatment). The nurse's Progress Notes, dated 02/05/19 at 21:45 (9:45 p.m.) documented, Resident Arrived: (Resident # 19) arrived 2/5/19 at 4:15 pm (p.m.) via ambulance from (Name of Hospital). He was accompanied by his wife. On 03/27/19 at approximately 5:25 p.m., during the end of the day meeting with ASM (administrative staff member) # 1, administrator, a request was made for evidence that the ombudsman was notified of Resident # 19's transfer to the hospital on [DATE]. On 03/28/19 at approximately 8:30 a.m., ASM # 1 provided a copy of a facsimile to the ombudsman for Resident # 19 dated MAR -27 0827 PM (March 27, 2019 at 8:27 p.m.). On 03/28/19 at 8:51 a.m., an interview was conducted RN (registered nurse) # 2, acting director of nursing and the administrator, ASM (administrative staff member) # 1. When asked who is responsible for notifying the ombudsman at the time of a resident's transfer to the hospital, RN # 2 stated, The nurses or designee. When asked about the facsimile to the ombudsman for Resident # 19 dated 3/27/19, ASM # 1 stated that the facsimile was sent after the request was made the day before. On 03/28/19 at approximately 3:00 p.m. ASM (administrative staff member) # 1, the administrator was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) The vascular system is the body's network of blood vessels. It includes the arteries, veins and capillaries that carry blood to and from the heart. Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html. (3) Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. Clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or more. This information was obtained from the website: https://medlineplus.gov/ency/article/003213.htm. (4) Fainting. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/003092.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to send a copy of the bed hold policy to the hospital with Resident #20, at the time of transfer on 01/16/2019. Resident #20 was admitted to the facility on [DATE]. Her most recent readmission to the facility was on 01/22/2019 following a hospitalization. Resident #20's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (1), Parkinson's disease (2), Hypertension (elevated blood pressure) and fracture of the femur (the long bone of the thigh). Resident #20's most recent Minimum Data Set (MDS) Assessment was a 30-Day Assessment with an Assessment Reference Date (ARD) of 02/19/2019. The Brief Interview for Mental Status (BIMS) scored Resident #20 at a 2, indicating profound impairment. A review of Resident #20's Progress Notes revealed the following note dated 01/16/2019 at 4:34a.m: Transfer/Discharge - Unable to Meet Needs Reason for Transfer/Discharge indicate specific resident need(s) that cannot be met: Resident is alert and verbally responsive to care, was noted laying on her left side on the floor calling for help. Bedside table also on floor partially over resident. Upon assessment, deformity of the right leg was noted with c/o (complaint of) pain and limited ROM (range of motion). Neuro (neurological) checks initiated. MD (medical doctor) and RP (responsible party) notified. 911 called and resident was transferred to ER. ([HOSPITAL NAME]) for evaluation and Tx (treatment). Facility attempts to meet the resident need(s) - include all attempted interventions: Neuro checks initiated. Resident transferred to Hospital due to unable to meet resident needs at this time Discharge Plan include services available at receiving facility: [HOSPITAL NAME] Family/Physician notification and new orders: [DAUGHTER] and on call [MD NAME] Additional Comments: (none) A further review of Resident #20's medical record revealed no evidence that a copy of the bed hold policy was provided to either Resident #20 or their representative at the time of Resident #20's transfer to the hospital on [DATE]. On 03/28/2019 at 8:51 a.m., an interview was conducted RN (registered nurse) # 2, Acting Director of Nursing and ASM (administrative staff member) # 1, the facility Administrator. When asked to describe the process for providing a copy of the facility's bed hold policy at the time of a transfer, RN # 2 stated, It is the responsibility of the social worker and if they are not available the responsibility falls to a designee, which may be the nurse. When asked if a bed hold policy was provided to Resident #20 or their representative at the time of transfer on 01/16/2019, ASM # 1 stated, No. Based on resident interview, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide a bed hold policy to the resident or the resident's representative upon transfer to the hospital for two of 30 residents in the survey sample, Residents # 19 and # 20. 1. The facility staff failed to provide Resident # 19 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on [DATE]. 2. The facility staff failed to send a copy of the bed hold policy to the hospital with Resident #20, at the time of transfer on 01/16/2019. The findings include: 1. The facility staff failed to provide Resident # 19 or the resident's representative written notification of the bed hold policy when the resident was transferred to the hospital on [DATE]. Resident # 19 was admitted to the facility on [DATE] and a readmitted on [DATE], with diagnoses that included but were not limited to: hemiplegia (1), peripheral vascular disease (2), depressive disorder (3), and syncope and collapse (4). Resident # 19's most recent MDS (minimum data set), a 5-day assessment with an ARD (assessment reference date) of 02/12/19, coded Resident # 19 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 19 was coded as requiring extensive assistance of one staff member for activities of daily living. The nurse's Progress Notes, dated 02/02/19 at 03:25 (3:25 a.m.) documented, Event: Fall. Action/Intervention: Resident was assessed, pressure applied to bleeding site and dry dressing applied to open area on back. Order obtained to send to ER (emergency room) and resident sent to (Name of Hospital) via (by) 911 for further observation and Tx (treatment). The nurse's Progress Notes, dated 02/05/19 at 21:45 (9:45 p.m.) documented, Resident Arrived: (Resident # 19) arrived 2/5/19 at 4:15 pm (p.m.) via ambulance from (Name of Hospital). He was accompanied by his wife. Review of the clinical record for Resident # 19 failed to evidence documentation that a bed hold policy was provided to the resident or the resident's representative upon transfer to the hospital on [DATE]. On 03/28/19 at 8:51 a.m., an interview was conducted RN (registered nurse) # 2, acting director of nursing and the administrator, ASM (administrative staff member) # 1. When asked to describe the process for providing a copy of the facility's bed hold policy at the time of a transfer, RN # 2 stated, It is the responsibility of the social worker and if they are not available the responsibility falls to a designee, which may be the nurse. When asked if a bed hold policy was provided to Resident # 19 or their representative at the time of transfer on 02/02/19, ASM # 1 stated, No. The facility's policy Transfer, Discharge & Bed Hold Notices documented, 3. The SSC (social services coordinator)/designee will provide written information to the resident, family member or legal representative before transfer of a resident to a hospital or for therapeutic leave, consisting of a Discharge, Transfer & Bed Hold Notice Policy that includes: a. The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the community. B. The reserve bed payment policy in the state plan, if any, c. The community's policies on the duration of the bed-hold. On 03/28/19 at approximately 3:00 p.m. ASM (administrative staff member) # 1, the administrator was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) The vascular system is the body's network of blood vessels. It includes the arteries, veins and capillaries that carry blood to and from the heart. Arteries can become thick and stiff, a problem called atherosclerosis. Blood clots can clog vessels and block blood flow to the heart or brain. Weakened blood vessels can burst, causing bleeding inside the body.) This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/vasculardiseases.html. (3) Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods. Clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or more. This information was obtained from the website: https://medlineplus.gov/ency/article/003213.htm. (4) Fainting. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/003092.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement the comprehensive care plan for one of 30 residents in the survey sample, Resident # 146. The facility staff failed to implement Resident #146's comprehensive care plan for the administration of a PRN (as needed) pain medication for complaints of pain following the resident's fall with injury on 03/17/18. The findings include: Resident # 146 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus (1), heart failure (2), hypertension (3) and chronic kidney disease (4). Review of the clinical record revealed a comprehensive MDS (minimum data set) for Resident # 146 could not be completed before her discharge from the facility on 03/17/18. Resident # 146's Post Fall Assessment dated 03/17/2018 documented, Alert. Orientated to Person and Place. The POS (physician's order sheet) for Resident # 146 dated 03/01/2018 - 03/31/2-18 documented the following: - Aspirin EC (enteric coated) [delayed release] [5] Tablet Delayed Release 81 MG (milligram). Give 1 (one) tablet by mouth one time a day for pain. Start Date: 03/13/2018. - Gabapentin [6] Capsule 300 MG. Give 3 (Three) capsules by mouth at bedtime for pain. Start Date: 03/13/2018. - Oxycontin ER (extended release) [7] Tablet 20 MG. Give 1 tablet two times a day for pain. Order Date: 03/13/2018. Start Date: 03/13/2018. - Tylenol [8] Extra Strength Tablet 500 MG (Acetaminophen). Give 2 (two) tablet by mouth three times a day for pain. Order Date: 03/13/2018. Start Date: 03/13/2018. - Oxycodone [7] Tablet 5 (five) MG. Give 1 (one) tablet by mouth every 6 (six) hours as needed for pain. May take 1-2 (one to two) tablets. Order Date: 03/13/2018. Start Date: 03/13/2018. The eMAR (electronic medication administration record) for Resident # 146 dated Mar (March) 2018 documented, the above medication orders. Review of the eMAR dated March 2018 revealed Resident # 146 received scheduled pain medications on 03/17 18: Aspirin 81 mg at 11:00 a.m., Oxycontin 20 mg refused at 6:00 a.m., Tylenol 1000 mg at 11:00 a.m., and Oxycodone 5 mg at 3:47 a.m. and at 11:02 a.m. Further review of the eMAR revealed that Resident # 146 did not receive any more PRN (as needed) pain medication for the remainder of the day. The comprehensive care plan for Resident # 146 dated 03/14/2018, documented, Focus: The resident has chronic pain. Date Initiated 03/14/2018. Under Interventions it documented, Administer medication per MD (medical doctor) orders, pain assessment every shift. Date Initiated: 03/14/2018. The facility's Safe Resident Movement Program Resident Evaluation Form for Resident # 146 dated 03/1/3/18 documented, Gait Belt. Resident bears weight on both legs and sits independently. Ambulates and transfers with physical assistance of 1 (one). Under Comments it documented, One person assist (assistance). The facility's Fall Investigation Worksheet for Resident # 146 dated 03/17/18 at 1:15 p.m., documented, Activity: Unassisted transfer. Under Resident Interview: it documented, I felt like voiding before therapy, I think I could it, lost balance and fell. Under Interventions immediately after fall it documented, Resident assessed for pain treatment done to skin. Advise to always call for help. The nurse's Progress Notes for Resident # 146 dated 03/17/2018 17:34 (5:34 p.m.) documented, Writer was on the hallway heard resident screaming for help, arrived observed resident on the floor on her right side. Resident assessed noted skin tear to right forearm area 0.1 x 0.1 cm (0.1 length by 0.1 width centimeters) (upper) 0.5 x 0.5 (lower). Range of motion done able to move extremities. Resident complaining of pain to right elbow and hip area. (Name of Physician) made aware of resident complaining of pain to right hip after falling order to transfer resident to ED (emergency department) for further evaluation. Resident left facility at 1720 (5:20 p.m.) via (by) stretcher alert and oriented x (times) 3 (three), accompanied by daughter. The facility's PT (physical Therapy) Daily Treatment Note written by OSM (other staff member) # 7, physical therapy assistant, dated 03/17/2018 documented, Pt (patient) was found on the floor in the bathroom after her lunch having been seen by OT (occupational therapy) for proper safety sequencing for commode tf (transfer). Pt had attempted to tf herself without help from staff, using a transport chair by standing at the sink to side step to the commode. OT had been aware of this maneuver and advised pt against using the unsafe technique. PTA (physical therapy assistant) provided floor to wc (wheelchair) tf after (RN [registered nurse] # 4) performed Facility Fall Recovery (unwitnessed) Assessment and directed PTA to employ transfer technique. Pt was mod (moderate) Max (maximum) for floor to wc tf and pain level was 10/10 (ten out of ten) according to pt, but the [NAME] Facial Features (9) would indicate 5/10 (five out of ten) and with proper pain reduction technique, decreased to 2/10 (two out of ten), with nursing meds (medications) from (RN # 7). (RN [registered nurse] # 7) called POA (power of attorney). On 03/27/19 at approximately 12:23 p.m., an interview was conducted with RN # 4. When asked if he completes a pain assessment when a resident falls, RN # 4 stated, Any time someone falls we do a pain assessment. When asked if a pain assessment was done for Resident # 146, RN #4 stated Yes. When asked if Resident # 146 was yelling or screaming in pain after the fall, RN # 4 stated, No. When asked if he gave Resident # 146 any pain medication following the fall, RN # 4 stated, No because she was already on scheduled pain medication. (*Note the MAR above documented Resident #146 refused and did not receive the scheduled pain medication at 6:00 a.m., before her fall). An attempt to interview OSM (other staff member) # 7, physical therapy assistant was unsuccessful due to the fact that he was no longer employed with the facility. On 03/27/19 at 2:05 p.m., an interview was conducted with RN # 2, acting director of nursing. When asked about the process staff follow if a resident has a fall and is cognitively intact stating they are having a ten out of ten for pain, RN # 2 stated, I would give pain medication based on the physician's orders for prn (as needed) pain medication. It should be documented in the nurse's progress notes. On 03/28/19 at 3:05 p.m., an interview was conducted with LPN (licensed practical nurse) # 3 regarding care plans. When asked to describe the purpose of a resident's care plan, LPN # 3 stated, So we can set goals, interventions and for progress and what is expected of the resident. When asked if an intervention documented on the care plan should be followed, LPN # 3 stated, Yes. When asked if the comprehensive care plan is being followed if it documents to administer medication as ordered and a PRN pain medication is not administered when a resident states they are having pain, LPN # 3 stated, No. On 03/28/19 at approximately 3:00 p.m. ASM (administrative staff member) # 1, the administrator was made aware of the findings. No further information was provided prior to exit. Complaint deficiency References: (1) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (2) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. (3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (4) Kidneys are damaged and can't filter blood, as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (5) Prescription aspirin is used to relieve the symptoms of rheumatoid arthritis (arthritis caused by swelling of the lining of the joints), osteoarthritis (arthritis caused by breakdown of the lining of the joints), systemic lupus erythematosus (condition in which the immune system attacks the joints and organs and causes pain and swelling) and certain other rheumatologic conditions (conditions in which the immune system attacks parts of the body). Nonprescription aspirin is used to reduce fever and to relieve mild to moderate pain from headaches, menstrual periods, arthritis, colds, toothaches, and muscle aches. Nonprescription aspirin is also used to prevent heart attacks in people who have had a heart attack in the past or who have angina (chest pain that occurs when the heart does not get enough oxygen). Nonprescription aspirin is also used to reduce the risk of death in people who are experiencing or who have recently experienced a heart attack. Nonprescription aspirin is also used to prevent ischemic strokes (strokes that occur when a blood clot blocks the flow of blood to the brain) or mini-strokes (strokes that occur when the flow of blood to the brain is blocked for a short time) in people who have had this type of stroke or mini-stroke in the past. Aspirin will not prevent hemorrhagic strokes (strokes caused by bleeding in the brain). Aspirin is in a group of medications called salicylates. It works by stopping the production of certain natural substances that cause fever, pain, swelling, and blood clots. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682878.html. (6) Used to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). Gabapentin extended-release tablets (Horizant) are used to treat restless legs syndrome (RLS; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html. (7) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. (8) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. (9) This tool was originally created with children for children to help them communicate about their pain. Now the scale is used around the world with people ages 3 and older, facilitating communication and improving assessment so pain management can be addressed. This information was obtained from the website: https://wongbakerfaces.org/.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to follow professional standards of practice for one of 30 residents in the survey sample, Resident #22. The facility staff failed to clarify Resident #22's physician orders for pain medications of tramadol (1) and oxycodone (2) to determine which and when medication should be administered based on pain level parameters. The findings include: Resident #22 was initially admitted to the facility on [DATE] with a most recent readmission on [DATE], with diagnoses that included but were not limited to: Osteoarthritis (3), anemia (4), and hypertension (5). Resident #22's most recent MDS (minimum [NAME] set) an admission assessment with an ARD (assessment reference date) of 2/18/19 coded the resident as scoring a 15 on the brief interview for mental status (BIMS) out of a score of zero to15, 15 indicating that the resident is cognitively intact for daily decision making. Resident #22 was coded as requiring extensive assistance of two staff members for activities of daily living, and as independent with eating. The POS (physician's order sheet) dated 3/27/19 for Resident #22 documented the following: - OxyContin Tablet ER (extended release) 12 Hour Abuse-Deterrent 10 MG (milligram) [Oxycodone HCL (hydro-chloride) ER] Give 10 mg by mouth every 12 hours as needed for pain. Order Dated: 2/12/2019. - Tramadol HCL (hydrochloride) Tablet 50 MG Give 1(one) tablet by mouth every 6 (six) hours as needed for pain. The comprehensive care plan for Resident #22 dated 2/11/19 documented, under focus area, The resident is on pain medication therapy. Under interventions it documented, Administer pain medication as ordered by the physician. Monitor/document side effects and effectiveness q (every) shift. Review of Resident #22's progress notes revealed the following documentation: - On 2/6/19 [22:33] 10:33 p.m., oxycodone HCl 5mg one tablet for pain level not specified. - On 2/6/19 [18:35] 6:35 p.m., oxycodone HCl 5mg one tablet for left hip pain for pain level six out of 10. - On 2/12/19 [06:56] 6:56 a.m., oxycodone 5mg one table given for pain level five out 10 for general discomfort - On 2/12/19 [16:52] 4:52 p.m., oxycodone HCl 5mg 1 tablet left hip pain for pain level five out 10 - On 2/12/19 [20:45] 8:45 p.m., oxycodone HCl 5mg 1 tablet pain level was zero out 10 - On 2/13/19 [08:44] 8:44 a.m., oxycodone HCl 5mg 1 tablet for both legs pain for pain level five out 10 - On 2/13/19 [11:31] 11:31 a.m., oxycodone HCl 5mg 1 tablet left hip pain level zero out of 10 - On 2/12/19 [21:00] 9:00 p.m.; oxycodone HCl 5mg 1 tablet left hip pain for pain level five out 10 - On 2/13/19 [22:53] 10:53 p.m., oxycodone HCl 5mg 1 tablet left hip pain for pain level five out 10 - On 2/16/19 [17:54] 5.54 p.m., Tramadol HCl 50 mg 1 tablet given for pain level zero out 10 - On 2/17/19 [21:31] 9:31 p.m., Tramadol HCl 50 mg 1 tablet given pain level zero out 10 - On 2/14/19 [21:48] 9:48 p.m., Tramadol HCl 50 mg 1 tablet given pain level zero out 10 - On 3/20/19 [04:07] 4:07 a.m.; tramadol HCl 50 mg one tablet for general discomfort with a pain scale five out of 10. On 3/27/19 at approximately 2:36 p.m., an interview was conducted with RN (register nurse) #2, regarding the process staff follows when residents complain about pain. RN #2 stated, I ask the resident for the pain level from zero to ten, the pain location, and the quality of their pain before I give them their pain medication. When asked about the facility process staff follows for administering PRN (as needed) medication, RN #2 stated, I look at the doctor's order to determine what pain medication the resident has order for before I give it to the resident. When asked how the staff know which medication to administer if a resident has two as needed pain medications ordered, RN #2 stated the order should be rated on the pain scale with parameters indicating which one to give. RN #2 added the resident's pain is rated on the pain scale of zero - ten, zero is no pain, and ten is the highest pain level. RN #2 continued to state, A cognitively intact resident will tell the nurse what pain medication they desire. When asked if Resident #22's as needed pain medication orders should have parameters, RN #2 stated, Yes. RN # 2 stated, I will call the physician to clarify the order parameters before giving the pain medication. On 3/27/19 at 4:49 p.m., an interview was conducted with ASM (administrator staff member) #2, regional director of resident care, RN, regarding the process staff follows for administering as needed pain medications. ASM #2 stated, The order should be written as an example for mild pain from one to five give one tablet or for pain level from five to ten give two tablets. After reviewing Resident #22's physician orders for as needed pain medication (as documented above), ASM #2 was asked if Resident #22's as needed OxyContin Tablet ER and Tramadol orders should have parameters. ASM #2 stated, Yes, there are no parameter and the orders should have a parameter. In Resident #22's case there was no distinction when to administer tramadol or OxyContin. On 3/28/19 at 8:52 a.m., a follow up interview was conducted with RN #2. When asked if Resident #22's orders should have been clarified, RN #2 stated, Yes, the orders needed to be clarified. The physician needed to be called to add parameter to the orders. When asked which standard of practice the facility follows for the administration of pain medications. RN #2 stated, We follow the facility policies and procedures manual. On 3/28/19 at approximately 10:30 a.m., the review of the facility policies documented, Pharmacy will hold medication orders until Physician/Prescriber is able to clarify the order. Facility should explain the issue to the Physician/Prescriber document the clarification and document any new orders received. Facility staff should then communicate the result and any new orders or directions to the Pharmacy. On 3/28/19 at approximately 12:00 p.m., ASM (administrative staff member) #1, the administrator, and RN #2, acting director of nursing, RN were made aware of the findings. No further information was provided prior to exit. References: 1. Tramadol is used to relieve moderate to moderately severe pain, including pain after surgery. The extended-release capsules or tablets are used for chronic ongoing pain. Tramadol belongs to the group of medicines called opioid analgesics. It acts in the central nervous system (CNS) to relieve pain. This information was obtained from the website: https://www.mayoclinic.org/drugs-supplements/tramadol-oral-route/description/drg-20068050 2. OxyContin® (oxycodone HCl) is indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate. This information was obtained from the website: https://oxycontin.com/ 3. The most common form of arthritis. It causes pain, swelling, and reduced motion in your joints. It can occur in any joint, but usually it affects your hands, knees, hips or spine. This information was obtained from the website: https://medlineplus.gov/osteoarthritis.html. 4. Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html. 5. High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, and in the course of a complaint investigation, it was determined that the facility staff failed to implement a pain management program for one of 30 residents in the survey sample, Resident # 146. The facility staff failed to administer a PRN (as needed) pain medication to address Resident #146's complaints of pain following the residents fall with injury on 03/17/18. The findings include: Resident # 146 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: diabetes mellitus (1), heart failure (2), hypertension (3) and chronic kidney disease (4). Review of the clinical record revealed a comprehensive MDS (minimum data set) for Resident # 146 could not be completed before her discharge from the facility on 03/17/18. Resident # 146's Post Fall Assessment dated 03/17/2018 documented, Alert. Orientated to Person and Place. The POS (physician's order sheet) for Resident # 146 dated 03/01/2018 - 03/31/2-18 documented the following: - Aspirin EC (enteric coated) [delayed release] [5] Tablet Delayed Release 81 MG (milligram). Give 1 (one) tablet by mouth one time a day for pain. Start Date: 03/13/2018. - Gabapentin [6] Capsule 300 MG. Give 3 (Three) capsules by mouth at bedtime for pain. Start Date: 03/13/2018. - Oxycontin ER (extended release) [7] Tablet 20 MG. Give 1 tablet two times a day for pain. Order Date: 03/13/2018. Start Date: 03/13/2018. - Tylenol [8] Extra Strength Tablet 500 MG (Acetaminophen). Give 2 (two) tablet by mouth three times a day for pain. Order Date: 03/13/2018. Start Date: 03/13/2018. - Oxycodone [7] Tablet 5 (five) MG. Give 1 (one) tablet by mouth every 6 (six) hours as needed for pain. May take 1-2 (one to two) tablets. Order Date: 03/13/2018. Start Date: 03/13/2018. The eMAR (electronic medication administration record) for Resident # 146 dated Mar (March) 2018 documented, the above medication orders. Review of the eMAR dated March 2018 revealed Resident # 146 received scheduled pain medications on 03/17 18: Aspirin 81 mg at 11:00 a.m., Oxycontin 20 mg refused at 6:00 a.m., Tylenol 1000 mg at 11:00 a.m., and Oxycodone 5 mg at 3:47 a.m. and at 11:02 a.m. Further review of the eMAR revealed that Resident # 146 did not receive any more PRN (as needed) pain medication for the remainder of the day. The comprehensive care plan for Resident # 146 dated 03/14/2018 documented, Focus: The resident has chronic pain. Date Initiated: 03/14/2018. Under Interventions it documented, Administer medication per MD (medical doctor) orders, pain assessment every shift. Date Initiated: 03/14/2018. The facility's Safe Resident Movement Program Resident Evaluation Form for Resident # 146 dated 03/13/18 documented, Gail Belt. Resident bears weight on both legs and sits independently. Ambulates and transfers with physical assistance of 1 (one). Under Comments it documented, One person assist (assistance). The facility's Fall Investigation Worksheet for Resident # 146 dated 03/17/18 at 1:15 p.m., documented, Activity: Unassisted transfer. Under Resident Interview: it documented, I felt like voiding before therapy, I think I could it, lost balance and fell. Under Interventions immediately after fall it documented, Resident assessed for pain treatment done to skin. Advise to always call for help. The nurse's Progress Notes for Resident # 146 dated 03/17/2018 17:34 (5:34 p.m.) documented, Writer was on the hallway heard resident screaming for help, arrived observed resident on the floor on her right side. Resident assessed noted skin tear to right forearm area 0.1 x 0.1 cm (0.1 length by 0.1 width centimeters) (upper) 0.5 x 0.5 (lower). Range of motion done able to move extremities. Resident complaining of pain to right elbow and hip area. (Name of Physician) made aware of resident complaining of pain to right hip after falling order to transfer resident to ED (emergency department) for further evaluation. Resident left facility at 1720 (5:20 p.m.) via (by) stretcher alert and oriented x (times) 3 (three), accompanied by daughter. The facility's PT (physical Therapy) Daily Treatment Note written by OSM (other staff member) # 7, physical therapy assistant, dated 03/17/2018 documented, Pt (patient) was found on the floor in the bathroom after her lunch having been seen by OT (occupational therapy) for proper safety sequencing for commode tf (transfer). Pt had attempted to tf herself without help from staff, using a transport chair by standing at the sink to side step top the commode. OT had been aware of this maneuver and advised pt against using the unsafe technique. PTA (physical therapy assistant) provided floor to wc (wheelchair) tf after (RN [registered nurse] # 4) performed Facility Fall Recovery (unwitnessed) Assessment and directed PTA to employ transfer technique. Pt was mod (moderate) Max (maximum) for floor to wc tf and pain level was 10/10 (ten out of ten) according to pt, but the [NAME] Facial Features (9) would indicate 5/10 (five out of ten) and with proper pain reduction technique, decreased to 2/10 (two out of ten), with nursing meds (medications) from (RN # 7). (RN # 7) called POA (power of attorney). An attempt to interview OSM (other staff member) # 7, physical therapy assistant was unsuccessful due to the fact that he was no longer employed with the facility. On 03/27/19 at approximately 12:23 p.m., an interview was conducted with RN # 4. When asked if he completes a pain assessment when a resident falls, RN # 4 stated, Any time someone falls we do a pain assessment. When asked if a pain assessment was done for Resident # 146, RN #4 stated Yes. When asked if Resident # 146 was yelling or screaming in pain after the fall, RN # 4 stated, No. When asked if he gave Resident # 146 any pain medication following the fall, RN # 4 stated, No because she was already on scheduled pain medication. (*Note the MAR above documented Resident #146 refused and did not receive the scheduled pain medication at 6:00 a.m., before her fall). On 03/27/19 at 2:05 p.m., an interview was conducted with RN # 2, acting director of nursing. When asked to describe the procedure staff follow for an unwitnessed fall, RN # 2 stated, We do an assessment, head to toe, checking for any injuries, suspected fractures and skin tears, level of consciousness, alertness, being able to follow directions and verbally communicate, bleeding and stopping it if it occurs. We ask the patient to move their arms and leg, squeeze our hand and if they cannot do theses it may be indications of possible fractures. If they are able to move them, then you transfer them to the bed or a wheelchair. Call the doctor if there is an injury or if there is not an injury to let them know the resident fell. If we suspect a fracture we don't move them, we call 911 and keep the patient comfortable. When asked about pain, RN # 2 stated, We also assess for pain while doing the head to toe assessment by using the pain scale zero to10, zero being no pain and 10 being extreme pain and the location of the pain. We check vital signs as well. RN #2 was asked how often staff would check vitals signs and where they would be documented. RN # 2 stated, They are taken for the first 15 minutes, for one hour, then, 30 minutes for an hour, then every hour for four hours, then every four hours for 48 hours, then every eight hours every shift for three days and it is documented on the neurological assessment. When asked if a resident is cognitively intact and they state they are having a ten out of ten for pain, RN # 2 stated, I would give pain medication based on the physician's orders for prn (as needed) pain medication. It should be documented in the nurse's progress notes. On 03/28/19 at 1:13 p.m., an interview was conducted with RN # 2, acting director of nursing. When asked if Resident # 146 should have been offered a pain medication following her fall, RN # 2 stated Yes. RN # 2 was further asked if there was documentation that the prn pain medication was offered and or if the resident refused it, RN # 2 re-reviewed the fall assessment, eMAR and nurse's notes for Resident #146 and stated, No. The assessment was done and the monitoring was done but they didn't manage her pain. On 03/28/19 at approximately 3:00 p.m. ASM (administrative staff member) # 1, the administrator was made aware of the findings. No further information was provided prior to exit. Complaint deficiency References: (1) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (2) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. (3) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (4) Kidneys are damaged and can't filter blood, as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (5) Prescription aspirin is used to relieve the symptoms of rheumatoid arthritis (arthritis caused by swelling of the lining of the joints), osteoarthritis (arthritis caused by breakdown of the lining of the joints), systemic lupus erythematosus (condition in which the immune system attacks the joints and organs and causes pain and swelling) and certain other rheumatologic conditions (conditions in which the immune system attacks parts of the body). Nonprescription aspirin is used to reduce fever and to relieve mild to moderate pain from headaches, menstrual periods, arthritis, colds, toothaches, and muscle aches. Nonprescription aspirin is also used to prevent heart attacks in people who have had a heart attack in the past or who have angina (chest pain that occurs when the heart does not get enough oxygen). Nonprescription aspirin is also used to reduce the risk of death in people who are experiencing or who have recently experienced a heart attack. Nonprescription aspirin is also used to prevent ischemic strokes (strokes that occur when a blood clot blocks the flow of blood to the brain) or mini-strokes (strokes that occur when the flow of blood to the brain is blocked for a short time) in people who have had this type of stroke or mini-stroke in the past. Aspirin will not prevent hemorrhagic strokes (strokes caused by bleeding in the brain). Aspirin is in a group of medications called salicylates. It works by stopping the production of certain natural substances that cause fever, pain, swelling, and blood clots. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682878.html. (6) Used to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). Gabapentin extended-release tablets (Horizant) are used to treat restless legs syndrome (RLS; a condition that causes discomfort in the legs and a strong urge to move the legs, especially at night and when sitting or lying down). Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a694007.html. (7) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html. (8) Acetaminophen is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. Acetaminophen may also be used to relieve the pain of osteoarthritis (arthritis caused by the breakdown of the lining of the joints). Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html. (9) This tool was originally created with children for children to help them communicate about their pain. Now the scale is used around the world with people ages 3 and older, facilitating communication and improving assessment so pain management can be addressed. This information was obtained from the website: https://wongbakerfaces.org/.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication pour and pass observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to store medications in a safe manner for one of 4 nursing hallways, [NAME] hallway. On 3/27/19, during a medication pour and pass observation on the [NAME] hallway, LPN (licensed practical nurse) #2 left medication packets on top of the medication cart unsecured and the medication cart was out of LPN #2's the line of sight. The findings include: Resident #41 was admitted to the facility on [DATE], with diagnoses that include but are not limited to: high blood pressure, peripheral vascular disease, arrhythmia, abdominal aortic aneurysm, obstructive uropathy, chronic kidney disease, diverticulosis, benign prostatic hyperplasia, and aortic valve disorder. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 3/1/19. The resident was coded as cognitively intact in ability to make daily life decisions. On 3/27/19 07:56 a.m., LPN #2 (Licensed Practical Nurse) was observed preparing and administering medications to Resident #41. The following medications were prepared and administered: Norvasc (1) 5 mg (milligrams), 1 tab (tablet) Aspirin (2) 81 mg, 1 tab Flexeril (3) 5 mg, 1 tab Colace (4) 100 mg, 1 tab Dymista (5) 137/50 mcg (micrograms), 1 spray each nostril Claritin (6) 10 mg, 1 tab Metoprolol (7) 50 mg, 1 tab Thera Multivitamin (8) 400 mcg, 1 tab Miralax (9) 17 gm (gram), 1 cap full On 3/27/19 at 8:11 a.m., LPN #2 went into the resident's room leaving all the medication packs and the Dymista on top of cart unsupervised. On 3/27/19 at 8:12 a.m., LPN #2 returned to cart to get the Dymista nasal spray, and then went back in room, leaving all the medication packs on top of cart, unsupervised. A staff member passed by the cart. The cart was mainly in front of the doorway of the room, however the door was halfway closed, causing the majority of the cart to be out of line of sight; and LPN #2 never looked back at the cart from the resident's bedside. In addition, LPN #2 was also in the bathroom at one point washing her hands, wherein the cart was completely out of line of sight. On 3/27/19 at 8:15 a.m., in an interview with LPN #2, she stated that she should not leave medications unsupervised on top of the medication cart, and that it was an oversight on her part. A review of the facility policy General Dose Preparation and Medication Administration documented, 3.9 Facility staff should not leave medications or chemicals unattended. On 3/27/19 at 5:30 PM, ASM #1 (Administrative Staff Member, the Administrator) was made aware of the findings. No further information was provided by the end of the survey. References: (1) Norvasc - Used to treat high blood pressure Information obtained from https://medlineplus.gov/druginfo/meds/a692044.html (2) Aspirin - is also used to prevent heart attacks in people who have had a heart attack in the past or who have angina to reduce the risk of death in people who are experiencing or who have recently experienced a heart attack to prevent ischemic strokes .or mini-strokes .in people who have had this type of stroke or mini-stroke in the past. Information obtained from https://medlineplus.gov/druginfo/meds/a682878.html (3) Flexeril - to relax muscles and relieve pain and discomfort caused by strains, sprains, and other muscle injuries. Information obtained from https://medlineplus.gov/druginfo/meds/a682514.html (4) Colace - Used to relieve constipation Information obtained from https://medlineplus.gov/druginfo/meds/a601113.html (5) Dymista - Used to treat allergy symptoms Information obtained from https://medlineplus.gov/druginfo/meds/a697014.html and from https://medlineplus.gov/druginfo/meds/a695002.html (6) Claritin - Used to treat allergy symptoms Information obtained from https://medlineplus.gov/druginfo/meds/a697038.html (7) Metoprolol - Used to treat high blood pressure Information obtained from https://medlineplus.gov/druginfo/meds/a682864.html (8) Thera Multivitamin - Multivitamins are a combination of many different vitamins that are normally found in foods and other natural sources. Multivitamins are used to provide vitamins that are not taken in through the diet. Multivitamins are also used to treat vitamin deficiencies (lack of vitamins) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions. Information obtained from https://www.drugs.com/mtm/multivitamins.html (9) Miralax - Used to treat constipation Information obtained from https://medlineplus.gov/druginfo/meds/a603032.html

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to serve food in a sanitary manner for one of one dining rooms; the main dining room. 1. OSM (other staff member) #2 was observed touching food served to residents with bare fingers. OSM #2 and RN (registered nurse) #3 also were observed touching the food surface of residents' plates while assisting and serving residents the lunch meal in the main dining room. 2. OSM (other staff member) #6, dietary aide failed to keep his fingers from touching the food surface of plates while serving the resident's lunch in the main dining room. The findings include: 1. OSM (other staff member) #2 was observed touching food served to residents with bare fingers. OSM #2 and RN (registered nurse) #3 also were observed touching the food surface of residents' plates while assisting and serving residents the lunch meal in the main dining room. On 3/26/19 between 12:36 p.m., and 12:43 p.m., an observation of the main dining room meal service was conducted. OSM (other staff member) #2 was observed placing a tray of plates on the tables as she served each table. OSM #2 was observed grabbing the plates from the tray touching the top of the rim of the plates with her bare fingers and then placed the plates in front of the residents. OSM #2 did not sanitize her hands before grabbing each plate with her bare fingers touching the top of the rim of the plates and serving the plates to each resident. On 3/26/19 at 12:42 p.m., OSM #2 was observed bringing a tray of plates to a table in the dining room. OSM #2 then grabbed a crab cake off a plate on the tray with her bare fingers and placed it on a resident's plate. OSM #2 did not sanitize her hands before grabbing the crab cake with her bare fingers or use a utensil such as tongs. On 3/26/19 at 12:42 p.m., RN (registered nurse) #3 was observed sitting at a table with residents and was asked to feed a resident at a different table. RN #3 did not wash or sanitize her hands after leaving the table she was at before going to the new table to feed the resident. OSM #2 brought a tray of plates to the table in the dining room and was serving the residents but not the Resident RN #3 was going to assist with eating. RN #3 was observed grabbing the resident's plate she was going to feed; she touched the top of the rim of the plate with her bare fingers and placed the plate in front of the resident. RN #3 then began feeding the resident. RN #3 did not sanitize her hands before grabbing the plate with her bare fingers touching the top of the rim of the plate and feeding the resident. On 03/27/19 at approximately 10:41 a.m., an interview was conducted with OSM #1, dietary manager. When asked how a resident's plate of food should be handled when it is served, OSM #1 stated, The hands and fingers should not be on the eating surface of the plate. On 3/27/19 at 10:53 a.m., an interview was conducted with RN #3. When asked about feeding a resident in the dining room, RN #3 stated, I am new here and I was asked to help feed a resident. She is on a pureed diet and needs assistance with eating. I was not there the whole time and they pulled me to help feed her. When asked to describe her actions when OSM #2 brought the resident's plate to the table, RN #3 stated, I was there when she (OSM #2) brought the food. When asked how she handled the plate, RN #3 stated, I lifted from the bottom and put it in front of her (the resident), the cover was not on it the server (OSM #2) lifted the cover. RN #3 demonstrated using a plastic plate by holding the plastic plate with her thumbs on the top of the rim of the plate. When asked if it was okay for bare fingers to touch the top of the rim of the plate, RN #3 said, I did not have my thumb were the food is at. When asked if she should have her bare fingers on the top of the rim of the plate, RN #3 said, No. Review of facility's policy, Dining Room Service documented, Policy .Residents should be encouraged to receive dining room service whenever possible, be served with dignity and promptly assisted .Procedure .Eating surfaces of plates should not come in contact with staff clothing or hands. Cups and glasses should be handled on the outside of the containers, Knives, forks, and spoons should be handled by the handles. On 3/27/19 at approximately 5:15 p.m., ASM (administrative staff member) #1 the Administrator and RN #2 the acting DON (Director of Nursing) were made aware of the findings. No further information was provided by the end of the survey. 2. OSM (other staff member) #6, dietary aide failed to keep his fingers from touching the food surface of plates while serving the resident's lunch in the dining room. On 03/26/19 at approximately 12:10 p.m., an observation of lunch being served to the residents was conducted in the facility's dining room. Observations during the meal service revealed OSM (other staff member) #6, dietary aide served five residents their lunch. Four residents received dinner plates containing several food items and one resident received a bowl of fruit and a bowl of cottage cheese. Further observation of OSM # 6's service revealed that after removing the plastic covering over each plate, OSM # 6 picked up the plate from the serving tray by placing his thumbs on the food surface portion of each plate and bowl he served. On 03/27/19 at approximately 10:23 a.m., an interview was conducted with OSM (other staff member) # 6, dietary aide. When asked to describe his responsibilities, OSM # 6 stated, I serve the residents in the dining room. I take the resident's orders for what they want to eat, take the lid off the plate, take the plate off the tray and place it in front of them. When asked where he places his fingers when serving a plate of food for the resident, OSM # 6 stated, Under the plate not on the edge. When informed of the observation on 03/26/19 during the lunch meal, OSM # 6 stated, It was my mistake I was in a hurry. On 03/27/19 at approximately 10:41 a.m., an interview was conducted with OSM (other staff member) #1, dietary manager. When asked how a resident's plate of food should be handled when it is served, OSM # 1 stated, The hands and fingers should not be on the eating surface of the plate. On 03/27/19 at approximately 5:25 p.m., ASM (administrative staff member) # 1, administrator, was made aware of the above findings. No further information was provided prior to exit.