**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation clinical record review, Resident interview, staff interview, facility document review, the facility staff failed to ensure one of 30 residents in the survey sample was free from neglect, Resident #63 The findings included: During this inspector's interview with Resident #63, Resident #63 stated that she had lost a lot of blood and confirmed she had been readmitted to the hospital. Prior to this incident, the clinical record contained documentation that Resident #63 complained that her menstrual was on for a month. For that one month period of time where Resident #63 made her documented complaint known, there was no documentation that services were provided to intervene with her excessive vaginal bleeding. The physician was not notified so that an assessment could be made about any needed services. This lack of intervention led to Resident # 63 having a critical hemoglobin and hematocrit and being hospitalized with a diagnosis of menorrhea and anemia which required a blood transfusion. This is harm. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, anemia, abnormal uterine and vaginal bleeding, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact. Section G of the MDS assesses functional status. In Section G0110, line I assessed toilet use. Toilet use assessment included but was not limited to, how the Resident #63 used the toilet room, commode, or bedpan; cleansed self after elimination, and changed pad. The facility staff documented that Resident # 63 was totally dependent requiring the assistance of two or more persons for toilet use. Section G0120 assessed bathing. The facility staff documented that Resident # 63 was totally dependent, requiring the assistance of two or more persons for bathing. On 10/10/19 at 1:28 pm, the surveyor was in Resident # 63's room conducting a Resident interview. The surveyor asked Resident # 63 if she had been readmitted to the hospital since her admission to the facility. Resident # 63 informed the surveyor that she had lost a lot of blood and was admitted to the hospital. Resident # 63 stated, I was as white as that sheet. The surveyor reviewed the progress notes for Resident # 63. The surveyor observed a SBAR-Change in Condition note that had been documented on 12/23/18 at 9:47 am. The note contained documentation that included but was not limited to .Situation: Resident is bleeding from vaginal area Assessment: Resident is bleeding from vaginal area with heavy bright blood with clots present. Resident states she feels weak Response: MD (medical doctor) notifies. New orders to send to ER (emergency room) ED (emergency department) notified of transfer). The surveyor observed a nurse's note that had been documented on 6/27/19 at 10:59 am. The nurse's note contained documentation that included but was not limited to .Resident alert and oriented, complained of menstrual was on for a month. She appears to be pale and states she felt weak. VS (vital signs) 96.5, 122/70, 73, 16, 98%. MD (medical doctor) notified of concern. The surveyor reviewed a SBAR- Change of Condition note for Resident # 63 that was documented on 6/27/19 at 2:42 pm. The note was documented as, Situation: Lab drawn today and had critical low HGB (hemoglobin) 5.0 and HCT (hematocrit) 16.0, albumin 2.9 Background: Resident stated her period was on for longer than a month and this was not the 1st time she experienced this. Assessment: VS 122/70, 96.5, 73, 16, 98%, MD notified to have CBC (complete blood count) which was already in place due to neurology appointment being schedule after results. Response: MD (physician's name withheld) stated send resident to hospital. The surveyor reviewed a nurse's note that had been documented on 6/27/19 at 10:18 pm. The nurse's note was documented as, Contacted (Facility name withheld) ER (emergency room) to check on rsd (resident) condition, Rsd admitted with menorrhea with anemia. The surveyor reviewed the clinical record for Resident # 63 further, specifically the progress notes, physician's orders, and consultations, and did not locate any documentation that reflected that Resident # 63 had vaginal bleeding for a month or more, or that the physician had been notified of the vaginal bleeding. On 10/16/19 at 10:05 am, the surveyor interviewed Cna # 2 (certified nursing assistant). The surveyor asked Cna #2 if Resident # 3 had excessive vaginal bleeding. Cna # 2 stated, Yes and she has blood clots. The surveyor asked Cna # 2 if she informed the nursing staff when Resident # 63 had excessive vaginal bleeding with blood clots. Cna # 2 stated, Yes. On 10/16/19 at 10:33 am, the surveyor interviewed the unit manager RN # 1 (registered nurse) and asked if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. RN # 1 informed the surveyor that she had been unaware that Resident # 63 had episodes of excessive vaginal bleeding until the nurse had informed her in June of 2019 that Resident # 63 was pale. RN # 1 stated that she instructed the nurse to inform the physician. The surveyor asked RN # 1 if she would expect the certified nursing assistants to inform the nurses if they noticed that Resident # 63 was having excessive vaginal bleeding. RN # 1 stated, Yes. The surveyor asked RN # 1 if she expected the nursing staff to document episodes of excessive bleeding in the clinical record and notify the physician. RN # 1 stated, Yes. The surveyor informed RN # 1 that there was no documentation in the clinical record for Resident # 63 that reflected that Resident # 63 had vaginal bleeding for a month or more prior to 6/27/19. On 10/17/19 at 3:35 pm, the surveyor interviewed LPN # 1 (licensed practical nurse) the surveyor asked LPN # 1 if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if the certified nursing assistants informed her when Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if information that Resident # 63 was having episodes of excessive vaginal bleeding should be documented in the clinical record and the physician be notified. LPN # 1 stated, Yes it should be. On 10/17/19 at 4:52 am, the administrator, the director of nursing, and the regional director of clinical services were made aware of the findings as stated above. The surveyor asked the administrative team if they would expect the nursing staff to document abnormal vaginal bleeding in the clinical record and notify the physician at the time the abnormality was noted. All three administrative team members agreed that abnormal vaginal bleeding should have been documented in the clinical record and the physician should have been notified at the time the abnormality was noted. The facility staff presented the following information to the survey team as the standard of practice for documentation. Information included but was not limited to .5. A deviation from protocol should be documented in the patient's chart with, clear, concise statements of the nurse's decisions, actions, and reasons for care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to less than accurate recollection of the specific events. Reference [NAME], S.M. (2013) [NAME] manual of nursing practice. 10th ed. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME]. On 10/18/19 at 3:45 pm, the surveyor provided the administrator, the director of nursing, and the regional director of clinical services the opportunity to ask further questions and provide additional information in response to the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. For Resident #77, the facility staff failed to assess and treat an area on the resident's right great toe. Resident #77's face sheet listed an admission date of 8/21/14 and a readmission date of 5/15/15. The resident's diagnosis list indicated diagnoses, which included, but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hypothyroidism, Essential Hypertension, and Heart Failure. The most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/04/19 assigned the resident a BIMS (brief interview for mental status) score of 15 out of 15 in section C, cognitive patterns. Resident #77 was also coded as being independent in bathing and requiring supervision only in dressing and personal hygiene. While interviewing Resident #77 on 10/10/19 at approximately 3:15pm, the resident stated her right big toe is sore and there is a place on it that looks like it is turning black. Resident stated she told a nurse about one month ago and no one has looked at it. Resident also stated the nurses check my skin for sores but they never look at my feet and I'm diabetic. The surveyor spoke with LPN #1 on 10/10/19 at approximately 3:20pm regarding resident's right great toe. Surveyor asked LPN #1 if Resident #77 had an area on her right foot, LPN #1 stated no, nothing had been reported but she would check it. Following the resident interview, the surveyor reviewed the medical record and did not locate any documentation related to an area on the resident's right great toe. On 10/11/19 at approximately 9:00am, the administrator provided the surveyor with a copy of a progress note for Resident #77 dated 10/10/19 15:30 written by LPN #1 stating in part, this nurse assessed pt and noted black area to R great toe 0.3 x 0.2 cm, skin cool and color wnl. Pt c/o of numbness r/t neuropathy, and noted weak pedal pulses. NP notified and new order for ABI to R extremity Surveyor reviewed Resident #77's Weekly Skin Integrity Check assessment in the medical record dated 10/05/19 which is checked for the statement Skin clear, no change of condition assessed. Surveyor requested and was provided with a copy of the facility policy Skin Assessment - Weekly which stated in part, A Licensed Nurse will complete a total body assessment on each resident weekly, paying particular attention to any skin tears, bruises, stasis ulcers, rashes, pressure ulcers, lesions, abrasions, reddened areas and skin turgor problems. The purpose of the Skin Assessment is to evaluate the condition of the resident's skin on a regular basis. The concern of the lack of assessment and treatment to the area on Resident #77's right great toe was discussed with the administrative staff (administrator, director of nursing and regional director of clinical services) on 10/17/19 at approximately 5:00pm. No further information was provided prior to exit conference on 10/18/19. Based on staff interview, clinical record review and facility document review, the facility staff failed to follow physician's orders for 4 of 30 residents (Resident #40, #103, #47 and #316 and failed to assess and monitor for 2 of 25 residents (Resident #77 and #63) in the survey sample. The findings included: 1. The facility staff failed to assess and monitor Resident # 63 for excessive vaginal bleeding, which lead to Resident # 63 having a critical hemoglobin and hematocrit and was subsequently admitted to the hospital with a diagnosis of menorrhea and anemia and required a blood transfusion. Resident # 63 was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, anemia, abnormal uterine and vaginal bleeding, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact. Section G of the MDS assesses functional status. In Section G0110, line I assessed toilet use. Toilet use assessment included but was not limited to, how the Resident #63 used the toilet room, commode, or bedpan; cleansed self after elimination, and changed pad. The facility staff documented that Resident # 63 was totally dependent requiring the assistance of two or more persons for toilet use. Section G0120 assessed bathing. The facility staff documented that Resident # 63 was totally dependent, requiring the assistance of two or more persons for bathing. On 10/10/19 at 1:28 pm, the surveyor was in Resident # 63's room conducting a Resident interview. The surveyor asked Resident # 63 if she had been readmitted to the hospital since her admission to the facility. Resident # 63 informed the surveyor that she had lost a lot of blood and was admitted to the hospital. Resident # 63 stated, I was as white as that sheet. The surveyor reviewed the progress notes for Resident # 63. The surveyor observed a SBAR-Change in Condition note that had been documented on 12/23/18 at 9:47 am. The note contained documentation that included but was not limited to .Situation: Resident is bleeding from vaginal area Assessment: Resident is bleeding from vaginal area with heavy bright blood with clots present. Resident states she feels weak Response: MD (medical doctor) notifies. New orders to send to ER (emergency room) ED (emergency department) notified of transfer). The surveyor observed a nurse's note that had been documented on 6/27/19 at 10:59 am. The nurse's note contained documentation that included but was not limited to .Resident alert and oriented, complained of menstrual was on for a month. She appears to be pale and states she felt weak. VS (vital signs) 96.5, 122/70, 73, 16, 98%. MD (medical doctor) notified of concern. The surveyor reviewed a SBAR- Change of Condition note for Resident # 63 that was documented on 6/27/19 at 2:42 pm. The note was documented as, Situation: Lab drawn today and had critical low HGB (hemoglobin) 5.0 and HCT (hematocrit) 16.0, albumin 2.9 Background: Resident stated her period was on for longer than a month and this was not the 1st time she experienced this. Assessment: VS 122/70, 96.5, 73, 16, 98%, MD notified to have CBC (complete blood count) which was already in place due to neurology appointment being schedule after results. Response: MD (physician's name withheld) stated send resident to hospital. The surveyor reviewed a nurse's note that had been documented on 6/27/19 at 10:18 pm. The nurse's note was documented as, Contacted (Facility name withheld) ER (emergency room) to check on rsd (resident) condition, Rsd admitted with menorrhea with anemia. The surveyor reviewed the clinical record for Resident # 63 further, specifically the progress notes, physician's orders, and consultations, and did not locate any documentation that reflected that Resident # 63 had vaginal bleeding for a month or more, or that the physician had been notified of the vaginal bleeding. On 10/16/19 at 10:05 am, the surveyor interviewed Cna # 2 (certified nursing assistant). The surveyor asked Cna #2 if Resident # 3 had excessive vaginal bleeding. Cna # 2 stated, Yes and she has blood clots. The surveyor asked Cna # 2 if she informed the nursing staff when Resident # 63 had excessive vaginal bleeding with blood clots. Cna # 2 stated, Yes. On 10/16/19 at 10:33 am, the surveyor interviewed the unit manager RN # 1 (registered nurse) and asked if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. RN # 1 informed the surveyor that she had been unaware that Resident # 63 had episodes of excessive vaginal bleeding until the nurse had informed her in June of 2019 that Resident # 63 was pale. RN # 1 stated that she instructed the nurse to inform the physician. The surveyor asked RN # 1 if she would expect the certified nursing assistants to inform the nurses if they noticed that Resident # 63 was having excessive vaginal bleeding. RN # 1 stated, Yes. The surveyor asked RN # 1 if she expected the nursing staff to document episodes of excessive bleeding in the clinical record and notify the physician. RN # 1 stated, Yes. The surveyor informed RN # 1 that there was no documentation in the clinical record for Resident # 63 that reflected that Resident # 63 had vaginal bleeding for a month or more prior to 6/27/19. On 10/17/19 at 3:35 pm, the surveyor interviewed LPN # 1 (licensed practical nurse) the surveyor asked LPN # 1 if she was aware that Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if the certified nursing assistants informed her when Resident # 63 had episodes of excessive vaginal bleeding. LPN # 1 stated, Yes. The surveyor asked LPN # 1 if information that Resident # 63 was having episodes of excessive vaginal bleeding should be documented in the clinical record and the physician be notified. LPN # 1 stated, Yes it should be. On 10/17/19 at 4:52 am, the administrator, the director of nursing, and the regional director of clinical services were made aware of the findings as stated above. The surveyor asked the administrative team if they would expect the nursing staff to document abnormal vaginal bleeding in the clinical record and notify the physician at the time the abnormality was noted. All three administrative team members agreed that abnormal vaginal bleeding should have been documented in the clinical record and the physician should have been notified at the time the abnormality was noted. The facility staff presented the following information to the survey team as the standard of practice for documentation. Information included but was not limited to .5. A deviation from protocol should be documented in the patient's chart with, clear, concise statements of the nurse's decisions, actions, and reasons for care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to less than accurate recollection of the specific events. Reference [NAME], S.M. (2013) [NAME] manual of nursing practice. 10th ed. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME]. On 10/18/19 at 3:45 pm, the surveyor provided the administrator, the director of nursing, and the regional director of clinical services the opportunity to ask further questions and provide additional information in response to the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. 2. For Resident #103, facility staff failed to ensure the resident received treatment and care based on the comprehensive assessment when it failed to ensure ordered pain medication oxycodone was available for administration. Resident #103 was admitted to the facility on [DATE]. Diagnoses included malignant carcinoid tumor of the rectum, major depression, low back pain, diabetes mellitus type 2 with ophthalmic complications, chronic pain, difficulty in walking, traumatic amputation of right lower leg, hypertension, anxiety, nicotine dependence, chronic obstructive pulmonary disease, and bipolar disorder. On the 14 day Minimum Data Set assessment with assessment reference date 9/23/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behavior affecting care. The resident was assessed as receiving scheduled pain medication and non-medication interventions for pain daily in the 5 days prior to the assessment. The resident reported being in pain almost constantly in the 5 days prior to the assessment and that the pain made it difficult to sleep. Pain intensity was assessed as 8/10. The Office of Licensure and Certification received a Facility Reported Incident (FRI) dated 6/4/19 concerning misappropriation of the resident's oxycodone. The FRI investigation revealed the nurse was unable to fill the order for oxycodone on 6/4/19. The facility was unable to discover what happened to the missing 15-16 doses of the medication. On 10/15/19 at 7:37 AM, resident said his pain is generally under control. He did state that there were several days a few months ago when oxycodone was unavailable. Medication administration notes for a physician order dated 9/28/18 for Oxycodone Hcl 15 mg tablet give 1 tablet by mouth four times a day for pain *do not change dose unless Blue Ridge Pain Management Associates is contacted were as follows: 6/1/19 00:48 nursing note awaiting pharmacy arrival 6/1/19 09:43 nursing note awaiting pharmacy arrival --coded 2=refused 6/1/19 12:38 nursing note awaiting pharmacy arrival 6/1/19 17:28 nursing note awaiting pharmacy arrival 6/1/19 20:29 nursing note awaiting pharmacy arrival-- --coded 2=refused 6/2/19 08:59 nursing note awaiting pharmacy arrival 6/2/19 12:16 nursing note awaiting pharmacy arrival 6/2/19 16:40 nursing note awaiting pharmacy arrival 6/2/19 21:03 nursing note awaiting pharmacy arrival 6/3/19 16:55 nursing note awaiting pharmacy arrival 6/3/19 20:35 nursing note awaiting pharmacy arrival 6/4/19 09:34 nursing note awaiting pharmacy arrival 6/3/19 for 09:00 and 13:00 no documentation in MAR and no nursing notes concerning resident status This review indicated the resident missed 14 consecutive doses of oxycodone. The pain assessments associated with those 14 doses were either 'X' or blank except for the 6/2 assessment at 21:00 was documented as '0' on the medication administration record. The clinical record included no indication that the physician was notified that the oxycodone was missing. The surveyor discussed the concern with the director of nursing (DON) on 10/16/19 at 8:44 AM. The DON said that the doctor on call would not write a replacement prescription or a prescription to pull doses from the stat box because the doctor wanted to avoid DEA scrutiny. The Pain clinic said that they would not replace the prescription and the resident could do without the drug until time for a new prescription to start. The DON stated the resident showed no signs of withdrawal. The DON provided hand written employee statements dated 10/16/19 from two LPNs stating they had contacted physician offices concerning the medication being unavailable. Surveyors discussed the failure to make pain medication available with the administrator and DON during individual discussions on 10/16/19. 3. The facility staff failed to follow physician's order with regard to Restoril administration for Resident # 47. Resident # 47 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety, major depressive disorder, traumatic brain injury, and hypertension. The clinical record for Resident # 47 was reviewed on 10/9/19 at 2:27 pm. The most recent MDS (minimum data set) assessment for Resident # 47 was a quarterly assessment with an ARD (assessment reference date) of 8/5/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 47 had a BIMS score (brief interview for mental status) of 15 out of 15, which indicated that Resident # 47 was cognitively intact. Resident # 47 had orders that included but was not limited to, Clonazepam tablet 0.5 mg (milligram) give 0.5 mg by mouth two times a day related to anxiety disorder give 2nd dose with dinner do not give w/n (within) 5 hours of restoril, which was initiated by the physician on 9/13/19. Resident # 47 also had orders for Restoril capsule 7.5 mg give 1 capsule by mouth at bedtime related to insomnia, which was initiated by the physician on 9/2/19. On 10/17/19 at 2:59 pm, the surveyor reviewed the September 2019 medication administration record for Resident # 47. The surveyor observed that Clonazepam 0.5 mg was scheduled to be administered at 1700 (5:00 pm) and Restoril 7.5 mg was scheduled to be administered at 2100 (9:00 pm). The surveyor observed that the documented administration times did not comply with physician's orders. The physician's orders specified that clonazepam was not to be administered within 5 hours of restoril and the documented administration times reflected a 4-hour period between administration of clonazepam and restoril. On 10/17/19 at 4:54 pm, the administrator, director of nursing, and regional director of clinical services were made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 10/18/19. 4. The facility staff failed to administer Xanax to Resident # 316 per physician's orders. Resident # 316 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, anxiety disorder, bipolar disorder, and major depressive disorder. The clinical record for Resident # 316 was reviewed on 10/9/19 at 9:38 am. Resident # 316 had orders for Alprazolam tablet 1 mg (milligram) by mouth at bedtime related to generalized anxiety, which was initiated by the physician on 9/18/18. The surveyor reviewed the September 2018 medication administration record for Resident # 316. The surveyor observed a 7 documented on the medication administration record for the 2100 (9:00 pm) dose of Alprazolam 1 mg tablet for Resident # 316. The surveyor observed documentation on the medication administration record that 7 = Other/see nurse's notes. The surveyor reviewed a nurse's note to Resident # 316 that had been documented on 9/19/18 at 8:43 pm. The nurse's note had been documented as, Alprazolam tablet 1 mg by mouth at bedtime related to generalized anxiety awaiting arrival from pharmacy MD (medical doctor) is aware. On 10/9/19 at 10:46 am, the surveyor reviewed the facility Stat box Listing. The surveyor observed that 4 tablets of Alprazolam 0.25 mg were available in the facility stat box and that the 4 tablets equaled the scheduled dose and could have been administered to Resident # 316 to prevent a missed dose of medication. On 10/10/19 at 3:54 pm, the administrator and director of nursing were made aware of the findings as stated above. The administrative team agreed that the Alprazolam could have been retrieved from the stat box and administerd to Resident # 316 to prevent a missed dose of medication. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. This is a complaint deficiency. 5. The facility staff failed to follow psychiatric physician recommendation for an increase in Resident #40's anxiety medication, Clonazepam. Resident #40 was readmitted to the facility with the following diagnoses of, but not limited to anemia, heart failure, diabetes, anxiety disorder, depression, manic depression and Schizophrenia. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/24/19, coded the resident as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #40 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. Resident #40 asked to speak to the surveyor during the dates of 10/8/19 through 10/18/19. The surveyor interviewed the resident on 10/15/19 at 10:30 am in the resident's room. The resident reported to the surveyor that her doctor that she sees for her psychiatrist issues ordered her anxiety medication to be increased. That was supposed to be done 2 weeks ago and it has not been increased yet. The resident stated, _____ (name of nurse) comes by my room each morning and tells me that the pharmacy is having issues in getting her anxiety medication increased and as soon as they resolve the issues, it will be done. She keeps telling me this over and over but nothing gets done about this. All I can do is sit in this bed and worry about everything. I feel helpless and I feel that I cannot get anything done to help me. So I lay in here and worry about this. The staff uses me as a sounding board and talks to me about everything that is going on with all the new changes in staff that has occurred. I don't mind because everyone needs someone to talk to but then the rest of the time, I think back over what they tell me and I think well if they are not doing this like they are supposed to then what makes me think they will do what the doctor wants then to do for me. So I worry about this consistently and I get myself worked up about all of this. I just feel helpless and I need some help in getting my medication increased so I can deal with all of the worries that I am having. The surveyor verbalized to the resident that these concerns would be investigated and resident would be notified of the findings of these concerns. The resident verbalized understanding of this to the surveyor. The surveyor performed a clinical record review of Resident #40's clinical record from 10/15/19 to 10/18/19. During this review, the surveyor noted the following documentation from the nurse practitioner with the _______ (name of the psychiatric medical group) dated for the following: 8/22/19 .Pt. reports feeling overwhelmed because she is trying to get to be able to go home for Christmas this year but she is having trouble participating in therapy. She is reporting anxiety r/t (related to) this .She is reportedly only getting 3 hours of sleep at night because the doctor recently decreased her Trazodone .Patient reports sleep as Not as good at all. Patient reports mood as anxious . Under Assessment/Plan .Anxiety-Currently stating it is uncontrolled and wants hers Valium back. I suggested Buspar 5 mg TID to start and she was agreeable to this plan . 9/13/19 .Pt (patient) is reporting that my nerves are real bad and she cannot relax. She reports that it started about a week after she met this provider for the first time. She is reporting that it is an 8/10 right now and that nothing seems to make it better. Says the only thing that has ever helped has been Valium. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of Medications .8/23/19 Buspar (1) 5 mg (milligram) Tablet TID (three times a day) . Assessment/Plan .Anxiety-Pt states her anxiety has gotten much worse since she was started on Buspar 2 or 3 weeks ago and that Buspar has not touched it. She reports that even 1 mg of Valium was helpful for her in the past and that her anxiety worsened 3 weeks to a month after stopping it in June. She was on Valium for about 3 years d/t (due to) her nerves. Will increase Buspar to 10 mg PO (by mouth) TID and if anxiety does not improve over next 2 weeks, I will consider restating low dose [NAME] (benzodiazepine) . Recommendations: .Increase Buspar to 10 mg PO TID for anxiety . 9/25/19 .I'm not good Pt is reporting that her anxiety is really bad. She has been in bed all weekend because of her anxiety. She shakes and has a horrible time dealing with people right now, she states she is really crabby. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of medication: .8/23/19 Buspar (1) 5 mg Tablet TID . Assessment/Plan .Anxiety. Pt states anxiety has gotten worse since she was started on Buspar. Is not working for her. I am going to decrease Buspar and then start Clonazepam .Will continue to get anxiety under control since the patient believes that is her most pressing issue and will readdress depression to the future . Recommendation only: .Decrease Buspar to 5 mg PO TID x (times) 7 days, then decrease to 5 mg PO BID (twice a day) x 7 days, and then d/c (discontinue) Start Clonazepam 0.25 mg PO BID for anxiety . 10/9/19 .Pt was started on Clonazepam and started it last Friday. She states it helps a little but not much and not for long. She states she feels like she is sitting on pins and needles and was wondering if the medication could be increased. Patient reports sleep as Not good at all. Patient reports mood as anxious . Review of medication . 5/24/19 Trazodone 0.5 50 mg Tablet TID 8/23/19 Buspar (1) 5 mg Tablet BID .9/25/19 Clonazepam 0.5 0.5 mg Tablet BID . Assessment/Plan Anxiety - Pt states her anxiety is about the same. She says the Clonazepam helps just a little bit but not much and not for long. She is asking for an increased dose or using it more frequently. I told her we can increase the dose to see if this helps .Will get anxiety under control since the patient believes that this is her most pressing issue and will readdress depression in the future. Insomnia - pt says she cannot sleep at all at night and wants to go back to her Trazodone. I explained to the patient that Trazodone is better for insomnia at a lower dose but the patient was not buying this so I told her if she thinks it will make her sleep better than we can try Trazodone 100 mg PO WHS (at bedtime) . Recommendations only: Increase Trazodone back to 100 mg PO QHS (at bedtime) for insomnia. Increase Clonazepam to 0.5 mg PO BID for anxiety . The surveyor reviewed the physician order sheets (POS) and noted the start date for each of these medications: Buspar 5 mg Give 10 mg by mouth three times a day -- start date of 9/13/19 Trazodone 50 mg Give 0.5 tablet by mouth at bedtime - start date of 5/24/19 The surveyor noted supplemental physician orders that were the following medications with orders dates as follows: Buspar 5 mg Give 5 mg by mouth three times a day related to anxiety disorder -- The order date for this medication was 10/3/19. Clonazepam 0.5 MG Give 0.25 mg by mouth two times a day - The order date for this medication was 10/3/19. The surveyor reviewed the MAR (medication administration record) for Resident #40 for the month of October 2019. It was noted that Clonazepam Tablet 0.5 mg Give 0.5 mg by mouth two times a day .Order date 10/15/19 1041 (10:41 am) . The surveyor also noted that Clonazepam 0.5 mg tablet Give 0.25 mg by mouth two times a day .D/C Date 10/15/19 1041 . This medication with dosage of 0.5 mg ½ tablet was d/cd on 10/15/19 and the dosage of 0.5 mg two times a day was started on 10/15/19. This was noted to be discontinued and started the correct dosage of Clonazepam after the surveyor began to investigate and ask the administrator and the director of nursing questions about the psychiatric recommendations that had occurred between 8/22/19 through 10/9/19. The surveyor notified the administrator and the director of nursing of the above documented findings on 10/15/19 at approximately 4:15 pm. The director of nursing stated that she was not the director of nursing for the facility until approximately 2 weeks before this survey had begun and that she was not aware of these incidents or recommendations for this resident. The assistant director of nursing (ADON) and regional corporate nurse and director of nursing (DON) came to the surveyor in the conference room and stated that they wanted to discuss the issue concerning the medication for _____ (name of Resident #40). This occurred on 1016/19 at 2 pm. The surveyor asked the ADON if the nurse practitioner that was in the psychiatric group ordered for a resident to start, increase, decrease or discontinue a medication could the nurses' not treat this as a regular order and order what the practitioner had ordered for the resident. The ADON stated that _____ (name of the psychiatric group that was contracted to see the residents in the nursing facility) started seeing the residents in August 2019. The FNP (Family Nurse Practitioner) would order the medications; the nurses would treat this as a regular order and put this order into the computer. The pharmacy would receive this order and send the medication as ordered for the resident. Then around 9/13 or 9/18, the FNP called and stated that his boss only wanted him to recommend what medications the resident would be needing then let the medical director at the facility to approve or disapprove and order the medications based upon the psychiatric group's recommendations. The medical director would sign off on it and then the nurses would order the medications from the pharmacy and administer it to the residents. The surveyor asked what is an appropriate time period that this process should take to get the Medical Director to sign off this recommended order and get this to the pharmacy then the resident receives the medication that was recommended for them to have. The ADON stated, I believe that 48 hours for this to occur would be an appropriate time period for this to occur. The surveyor asked what was the time period that all of this process occurred for Resident #40 to have and get the medications recommended for her to have for the anxiety that she was verbalizing to the psychiatric nurse practitioner in the above documented findings. The ADON did not respond to the surveyor's question. The ADON responded later and stated, The recommended changes in the resident's medications were faxed to the doctor. Then he responded and asked questions that I answered and faxed back to him several times. The final response from the doctor was on 9/30/19 which he stated no new orders. The surveyor asked if she had called or faxed and asked for a clarification to this since the psychiatric nurse practitioner had recommended an increase in Clonazepam due to the resident verbalizing increased anxiety that was to the point that she had remained in bed one whole weekend due to this anxiety she was experiencing. The ADON stated, The doctor stated no new orders. So I didn't ask him further if he wanted anything else for this resident. The surveyor again discussed the above documented findings on 10/18/19 at 4:15 pm with the administrator, director of nursing and the regional corporate nurse. No further information was provided to the surveyor prior to the exit conference on 10/18/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, resident interview and facility document review, the facility staff failed to prevent accident hazards for 6 of 30 residents and in (1) oxygen storage room in the nursing facility (Resident #9, #63, #68, #314, #13 and #97). The findings included: 1. The facility staff failed to ensure that Resident # 9 was positioned properly while in the lift, which resulted in Resident # 9 sliding out of the lift onto the floor and hitting her head on the foot rest of the lift. As a result of the fall, Resident # 9 experienced pain to the head and back and was transferred to the emergency room and was diagnosed with mechanical fall with head contusion, contusion to left hip and lumbar strain. This is harm. Resident # 9 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], and had a readmission date of 9/10/18. Diagnoses included but were not limited to, schizoaffective disorder, psychotic disorder, anxiety, and major depressive disorder. The clinical record for Resident # 9 was reviewed on 10/10/19 at 11:10 am. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/17/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 9 had a BIMS score (brief interview for mental status) of 11 out of 15, which indicated that Resident # 9's cognitive status was moderately impaired. Section G of the MDS assesses functional status. In Section G0110, the facility staff documented that Resident was totally dependent on staff requiring two or more persons to assist with transfers. The plan of care for Resident # 9 was reviewed and revised on 10/10/19. The facility staff documented a focus area for Resident # 9 as At risk for falls related to: Use of medication, history of falls, decreased mobility, bladder/bowel incontinence, requires maxi lift w(with)/staff assistance for transfers. Interventions included but were not limited to, Transfer using the Maxie Move lift with two person assistance at all times. The surveyor observed a SBAR-Change of Condition note that was documented on 4/1/19 at 11:55 pm. The note included documentation that included but was not limited to .Situation: Called to room by aid, resident was laying on floor, resident slide out of Hoyer lift during transfer. Assessment: resident c/o (complained of) mid and lower back pain and a headache, notice resident head was laying on foot rest of lift. The surveyor reviewed emergency department discharge instructions for Resident # 9 dated 4/1/19. The surveyor observed documentation on the discharge instructions that included but was not limited to .Diagnosis: mechanical lift fall with head contusion, contusion to lumbar hip, and lumbar strain. On 10/10/19 at, 12.10 pm, the surveyor reviewed the Fall Investigation from Resident # 9's fall on 4/1/19. The surveyor reviewed documentation on the fall investigation that included but was not limited to .10. Was a Hoyer lift used? (Surveyor observed a handwritten check mark next to Yes) Was resident positioned correctly? (Surveyor observed a handwritten check mark next to No) Were 2-3 assists used? (Surveyor observed a handwritten check mark next to No) Were legs of Hoyer lift in correct position? (Surveyor observed a handwritten check mark next to No). On 10/10/19 at 2:51 pm, the surveyor interviewed LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if she had documented the SBAR-Change of Condition note and fall investigation that was documented on 4/1/19 for Resident #9. LPN # 2 stated, Yes. The surveyor asked LPN # 2 to explain the events that happened with Resident # 9 on 4/1/19. LPN # 2 informed the surveyor that a CNA (certified nursing assistant) had gotten Resident # 9 up with the lift and the lift pad was not criss crossed at the bottom, which caused Resident # 9 to slide out of the lift pad onto the floor. LPN # 2 stated, She hit her head on the lift. She complained of back and head pain, and we sent her out. The surveyor asked LPN # 2 if two staff members had assisted with the lift transfer for Resident # 9 on 4/1/19. LPN #2 informed the surveyor that the CNA was working alone during the transfer on 4/1/19 when Resident # 9 slid from the lift. On 10/11/19 at 9:19 am, the surveyor interviewed CNA # 4. The surveyor asked CNA # 4 if she provided care for Resident # 9 on 4/1/19. CNA # 4 stated, Yes. The surveyor asked CNA # 4 to describe the events that led to Resident # 9's fall from the lift on 4/1/19. CNA #4 stated, That morning they had a different lift pad. I had never used that before. I asked for assistance, but the girl didn't come back. The lift I usually use was different. I was unaware that you had to criss cross. I started to get her up, and she slid out. On 10/17/19 at 4:52 am, the administrator, the director of nursing, and the regional director of clinical services were made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. 2. The facility staff failed to implement appropriate interventions for fall prevention for Resident # 314, which led to continued falls leading up to a fall on 7/3/18 in which Resident # 314 was transferred to the hospital and diagnosed with a fractured hip and brain bleed. This is harm. Resident # 314 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to, dementia, unsteadiness on feet, and muscle weakness. The clinical record for Resident # 314 was reviewed on 10/9/19 at 9:54 am. The most recent MDS (minimum data set) assessment for Resident # 314 was a discharge assessment with an ARD (assessment reference date) of 7/3/18. Section C of the MDS assesses cognitive status. In Section C1000, the facility staff documented that Resident # 314's cognitive status was severely impaired. On 10/9/19 at 9:54 am, the surveyor observed a general note for Resident # 314 that had been documented on 10/16/17 at 6:56 pm. The general note contained documentation that included but was not limited to .Resident is alert and oriented to person only, resident is not oriented to place or time. Resident is a high fall risk. Resident is a heavy wetter due to Lasix. The surveyor observed a general note for Resident # 314 that was documented on 10/26/17 at 12:35 pm. The note was documented as, Resident was found sitting on the floor by the CNA assigned to him. He sustained a large skin tear on the right elbow and a smaller skin tear on the right upper arm. Areas were cleaned with normal saline, triple antibiotic ointment applied, followed by a tegaderm. Resident tolerated procedure well. VSS (vital signs) T (temperature) 97.6 P (pulse) 52 R (respirations) 18 B/P (blood pressure) 146/78. The surveyor reviewed the plan of care for Resident # 314. The surveyor observed a focus area for Resident # 314 was initiated by facility staff on 10/26/17. The focus area was documented as, At risk for falls related to: new environment, use of medication. Interventions initiated on 10/26/19 were as follows: Assess for pain, Assess that wheelchair is of appropriate size, assess need for foot rests, assess for need to have wheelchair locked/unlocked for safety, anti-tippers, Call light or personal items available and in reach or private reacher, Keep environment well lit and free of clutter, Observe for side effects of medications, and Orientation to new room and roommate. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 10/26/17 that was completed on 10/27/17. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (The surveyor observed handwritten documentation) A&O x1 (alert and oriented times one), confused. (Indicate what may have caused the incident (The surveyor observed handwritten documentation) Confused and got out of the bed without assistance. The surveyor observed an intervention of Fall matt beside bed was initiated on 10/27/17. The surveyor observed a general note for Resident # 314 that had been documented on 10/26/19 at 11:04 am. The general note was documented as, MDS (minimum data set) assessment for ARD (assessment reference date)/14 day: Resident is alert and oriented at times. However, he experiences episodes of confusion at times as well. Resident needs assistance with transfer and completed ADLs (activities of daily living). He has problems with short and long term memory. He is able to express his needs to the staff. Resident stated that in the last two weeks he has experienced depression, feeling bad about himself, and trouble concentration on watching television. The total severity score is 06. BIMS (brief interview for mental status) score is 02. The surveyor observed a general note for Resident # 314 that was documented on 12/12/17 at 10:35 am. The note was documented as, MDS assessment for ARD/Medicare 60 day: Resident was in bed resting when SW (social worker) entered the room. Resident was alert and oriented. He is able to express his needs to the staff. Resident has short term and long term memory problems. Resident agreed to do the interview. During the mood interview, resident sated that he has experienced in the last two weeks depression, trouble falling asleep, tiredness, feeling bad about himself, and trouble concentrating on reading/watching television. Total severity score is 05. Resident received a BIMS of 05. The surveyor observed a nurse's note for Resident # 314 that was documented on 12/14/17 at 11:28 am, the note was documented as, Resident has a fall this am (morning) @ (at) 7:30 am. He was attempting to toilet himself unattended and fell in the bathroom, skin tear noted to right elbow and c/o pain, notified MD (medical doctor) orders given for xray of right elbow, neuro checks in place due to unsupervised fall. RP (responsible party) (name withheld) notified of incident. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 12/14/17 that was completed on 12/14/17. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert with confusion 7. When was the resident's last toileting time? (Handwritten) Toileting himself at the time of the incident 9. Is assistance required to transfer/ambulate? (Handwritten) Yes continuous reminders to call for assistance What intervention was implemented after the fall? (Handwritten) correct footwear Indicate what may have caused the incident (handwritten) Resident states he doesn't know he had one shoe on and one shoe off attempting to toilet self unattended. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on 12/14/17 as Ensure Resident has on both shoes when he is up ambulating. The surveyor observed a nurse's note that for Resident # 314 that was documented on 12/31/17 at 9:22 am. The note was documented as, Resident calling out for help and staff rushed to resident's room. Resident was found sitting upright on his buttocks with his feet up against the wall near the door. Scant amount of blood noted on the fitted sheet to his bed and on his right elbow. A nickel size skin tear was noted to his outer left wrist and a scabbed area about the size of a nickel was noted to have a scant amount of blood on it. Rsd (resident) stated he fell out of the bed but he has memory loss and he was far away from his bed. ROM WNL (range of motion within normal limits) vitals 132/100-56-18-97% RA (room air). Daughter of resident (daughter's name withheld) was called and a message was left for her to call the facility in regards to a non-urgent matter. Tx (treatment) rendered per standing order to left wrist and wright elbow and tol (tolerated) well. Resident assisted by two staff to his chair. No c/o (complaints of) pain at this time. Resident's MD was notified. Will continue to monitor. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 12/31/17 that was completed on 12/31/17. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert with confusion 12. Was the call bell in place (handwritten check mark beside) YES Can resident use it? (Handwritten check mark beside) NO (handwritten) Resident confused What intervention was implemented after the fall? (Handwritten) nonskid footwear given to prevent slipping Indicate what may have caused the incident (handwritten) ambulating unassisted. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on 12/31/17 as Footwear to prevent slipping, and Encourage resident to call for assistance when needed on 1/1/18. The surveyor observed a nurse's note that was documented on 4/12/18 at 11:23 pm. The nurse's note was documented as, Resident is alert with confusion noted, had ears washed out today. Resident states he can hear some better. Resident was noted sitting on the floor at bedroom door, stated he fell in the bathroom and scooted to the door, denies hitting his head, c/o pain to left back, notified MD, family MD ordered x-ray to back. Encourage resident to ask for assistance when he needs to go to the bathroom, reminded resident of urinal at his bedside. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 4/12/18 that was completed on 4/13/18. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) Alert, confusion What intervention was implemented after the fall? (Handwritten) encourage resident to use call light -assessed and placed back to bed Indicate what may have caused the incident (handwritten) tired and was ambulating by himself. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on 4/13/18 as Encourage resident to utilize call bell. The surveyor observed a nurse's note for Resident # 314 that was documented on 5/18/18 at 11:17 am. The note was documented as, Resident was found by nursing staff in the bath tub in resident's bathroom. Resident was attempting to use the bathroom and fell backwards. Resident had small blanchable area to the back of head. No c/o pain from resident. Neuro checks in place. ND notified. Called and spoke with (daughter's name withheld) about fall. Resident resting in bed at this time. VS WNL. Call light in reach. Will continue to monitor. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 5/18/18 that was completed on 5/18/18. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) confused What intervention was implemented after the fall? (Handwritten) medication review (Norco) assessed, placed in bed neuros started Indicate what may have caused the incident (handwritten) unsteady. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on 5/18/18 as Med review. The surveyor observed a SBAR-Change of Condition note for Resident # 314 that was documented on 6/27/18 at 6:59 am. The note was documented as, Situation: Resident fell in bathroom and hit head on wall Background: History of falls, hard of hearing Assessment: Resident has skinned up head on back and skin tear on right hand, resident is awake and alert Response: Sending resident to ER (emergency room) for test to make sure everything is ok. MD and RP notified 911 called. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 6/27/18/18 that was completed on 6/27/18. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) confused/alert What intervention was implemented after the fall? (Handwritten) education Indicate what may have caused the incident (handwritten) ambulating unassisted while sleepy. The surveyor noted that an intervention was added to the plan of care for Resident # 314 on 6/28/18 as Educate resident to ask for assist with toileting during early morning hours. The surveyor observed a SBAR-Change of Condition note for Resident # 314 that was documented on 7/3/18 at 9:50 pm. The note was documented as, Situation: Found resident on floor in room Background: unspecified combined systolic and diastolic congestive heart failure, unsteadiness on feet, benign prostatic hyperplasia without lower urinary tract symptoms, chronic kidney disease, vascular dementia without behavioral disturbance, essential hypertension, chronic obstructive pulmonary disease Assessment: Resident alert, yelling out. Resident is very hard of hearing. Skin warm and dry. Noted to have small hematoma above left eyebrow, laceration to right forehead, skin tear to right elbow. Also c/o right hip/leg pain, right leg rotated outward and shortened. C/O pain upon movement and touch. VS 97.4, 57, 20, 164/82, PEARL (pupils equal and reactive to light) Response: (Physician's name withheld) new order to send to ER for eval. RP (daughter's name withheld) notified. EMS (emergency medical services) notified. The surveyor observed a nurse's not for Resident # 314 that was documented on 7/4/18 at 3:03 am. The note was documented as, Called ER spoke to (name withheld) resident is being transferred to (facility name withheld) with DX (diagnosis) right hip fracture and brain bleed. DON (director of nursing) notified. The surveyor reviewed the facility Fall Investigation from Resident # 314's fall on 7/3/18 that was completed on 7/4/18. The fall investigation contained documentation that included but was not limited to, .3. What is the resident's cognition? (Handwritten) alert normally confused What intervention was implemented after the fall? (handwritten) sent to ER Indicate what may have caused the incident (handwritten) resident was ambulating while tired and sleepy and lost balance. On 10/10/19 at 1:15 pm, the surveyor and the MDS coordinator reviewed the clinical record for specifically nurse's notes, MDS, and plan of care for Resident # 314. The surveyor reviewed each of the falls and interventions put in place after the falls with the MDS coordinator. The surveyor and the MDS coordinator also reviewed documentation that Resident # 314's cognitive status was severely impaired; Resident # 314 often ambulated unassisted with an unsteady gait. After review of the documentation in the clinical record the MDS coordinator agreed that the interventions implemented for Resident # 314 following falls were not appropriate due to his cognitive status and level of confusion. On 10/17/19 at 4:54 pm, the administrator, director of nursing, and regional director of clinical services were informed of the incident as stated above. The administrative team was provided the opportunity to ask questions and provide additional information. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. This is a complaint deficiency 3. The facility staff failed to ensure that Resident # 63 was appropriately positioned in the lift during a transfer, which resulted in the lift tilting and Resident # 63 being lowered to the floor. Resident # 63 was a [AGE] year-old-female that was originally admitted to the facility on [DATE], and had a readmission date of 7/2/19. Diagnoses included but were not limited to, paraplegia, and muscle weakness. The clinical record for Resident # 63 was reviewed on 10/10/19 at 9:46 am. The most recent MDS (minimum data set) assessment for Resident # 63 was a quarterly assessment with an ARD (assessment reference date) of 8/21/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 63 had a BIMS (brief interview for mental status) score of 15 out of 15, which indicated that Resident #63 was cognitively intact. Section G of the MDS assesses functional status. In Section G0110, line B assessed transfer status. The facility staff documented that Resident # 63 was totally dependent requiring the assistance of two or more persons for transfers. The plan of care for Resident # 63 was reviewed and revised on 9/3/19. The facility staff documented a focus area for Resident # 63 as, At risk for falls related to: Use of medication, Dx's (diagnoses) of chronic inflammatory demyelinating polyneuropathy, morbid obesity, paraplegia, and due to fear of falling. Interventions included but were not limited to, Transfer using the Hoyer lift w/at least 2-staff persons assisting, and Education provided after fall 6/5/19. The surveyor observed a nurse's note for Resident # 63 that had been documented on 6/5/19 at 3:06 pm. The nurse's note was documented as, Resident was lowered to the floor during transportation to chair due to it overturning. She was not hurt during the incident. There were 3 CNAs present at the time I entered the room. Resident was still on part of the bed while the CNAs were holding her. DON (director of nursing) and unit manager came to witness the incident. Statements will be written in regards to the situation. On 10/10/19 at 3:30 pm, the surveyor requested to see the facility investigation of the incident on 6/5/19, which led to Resident # 63 being lowered to the floor. On 10/15/19 at 11:04 am, the surveyor reviewed a hand written statement that was written by the director of nursing on 6/5/19. The statement was documented as, Had (Three employee's name's withheld) concerning lowering Resident # 63 to the floor. Had CNAs re-inact the transfer with therapy, administration, and myself. CNAs stated that as they went to move Resident # 63 the lift tilted and they has to lower her to the floor. The re-inactment revealed that the CNAs did not have Resident # 63's weight balanced in the sling but had her feet on one side and her upper body on the other side which caused the lift to tilt to the side that had her upper body on it. On 10/16/19 at 10:32 am, the surveyor interviewed CNA # 2. The surveyor asked CNA # 2 if she was providing care to Resident # 63 on 6/5/19 when she was lowered to the floor. CNA # 2 stated, Yes. The surveyor asked CNA # 2 to describe the events that led to Resident # 63 being lowered to the floor. CNA # 2 stated, We were getting her out of bed and putting her in the chair. They didn't have her positioned properly, and the lift tilted, so we lowered her to the floor. On 10/17/19 at 4:54 pm, the surveyor reviewed the investigative findings of Resident # 63's fall on 6/5/19 with the administrator, director of nursing, and regional director of clinical services. No further information was provided to the survey team prior to the exit conference to 10/18/19. 4. The facility staff failed to ensure that a portable oxygen cylinder was properly secured on Resident # 68's wheelchair. Resident # 68 was a [AGE] year-old-male who was originally admitted to the facility on [DATE], and had a readmission date of 10/8/19. Diagnoses included but were not limited to, chronic obstructive pulmonary disorder and shortness of breath. The clinical record for Resident # 68 was reviewed on 10/17/19 at 2:52 pm. The most recent MDS (minimum data set) assessment for Resident # 68 was a quarterly review assessment with an ARD (assessment reference date) of 8/23/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 68 had a BIMS score (Brief interview for mental status) of 15 out of 15, which indicated that Resident # 68 was cognitively intact. Section O of the MDS assesses special treatments, procedures, and programs. In Section O0100, the facility staff documented that Resident # 68 had received oxygen therapy during the last 14 days during the look back period for the 8/23/19 ARD. Resident # 68 had orders that included but were not limited to, Oxygen at 3L/min (liters per minute) via NC (nasal cannula) continuous, which was initiated by the physician on 10/9/19. On 10/9/19 at 11:25 am, the surveyor observed Resident # 68 sitting in the hallway in his wheelchair. The surveyor observed a portable oxygen cylinder that was in a nylon holder on the back of Resident # 68's wheelchair. The surveyor observed that the bottom straps of the nylon holder that held the oxygen cylinder were not secured to the wheelchair frame. On 10/17/19 at 2:52 pm, the surveyor observed Resident # 68 sitting in his wheelchair in his room. The surveyor observed a portable oxygen cylinder held in a black nylon holder on the back of Resident # 68's wheelchair. The surveyor observed that the bottom straps of the nylon holder were not secured to the wheelchair frame. The manufacturer's instructions for W/C (wheelchair) Oxygen Tank Holder contained documentation that included but was not limited to, .Application Instructions: 1. Place the oxygen cylinder in the sleeve. 2. With the cylinder facing away from the backrest, hang the top straps on the push handles and secure the bottom straps to the wheelchair frame. 3. To secure and position the oxygen tank holder, tighten all four straps as desired. On 10/17/19 at 4:52 pm, the administrator, director of nursing, and regional director of clinical services were made aware of the findings as stated above. On 10/18/19 at 12:02 pm, the director of nursing informed the surveyor that the administrative team had reviewed the oxygen tank holder for Resident # 68 and agreed that the straps were not properly secured to the wheelchair for Resident # 68. No further information regarding this issue was presented to the survey team prior to the exit conference on 10/18/19. 5. For Resident #13 facility staff failed to ensure the environment remained free of accident hazards by securing oxygen tanks stored in the resident's room. Resident #13 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, cutaneous abscess of back, difficulty walking, chest pain, depression, angina, schizoaffective disorder, lymphedema, heart failure, hypertension, type 2 diabetes, and morbid obesity. On the quarterly Minimum Data Set assessment with assessment reference date 9/23/19, the resident scored 10/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting others. The resident was assessed as using oxygen in the 14 days prior to the assessment. During initial tour on 10/8/19, surveyors observed two unsecured full oxygen tanks without rack or stands in the resident's room. The full oxygen tanks stood in the floor between the resident's air conditioning unit and the resident's wheelchair, The resident was in bed and the tanks were close enough to the bed that they could be bumped by the resident if the resident chose to sit with legs dangling from the side of the bed facing the window. The administrator and director of nursing were notified of the concern during a summary meeting on 10/10/19 at 3:45 PM. 6. For Resident #97 facility staff failed to ensure the resident received adequate supervision to prevent accidents by ensuring the non-ambulatory resident did not have access to stairs. Resident #97 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, contractures of hips and knees, repeated falls, attention and concentration deficits and spatial neglect following subarachnoid hemorrhage dysphagia, Alzheimer's disease, hypertension, major depression, and psychosis. On the quarterly Minimum Data Set assessment with assessment reference date 8/21/19, the resident was assessed with short and long term memory deficits and severely impaired cognitive skills for daily decision making and as without signs of delirium, psychosis, or behaviors affecting care. The resident was assessed as requiring extensive assistance of 2 or more persons for transfer, supervision for locomotion on the nursing unit in a wheelchair, and extensive assistance of one person for locomotion in a wheelchair off the unit. A Facility Reported Incident (FRI) dated 4/14/19 reported Resident #97 was found on the floor at the bottom of the stairwell near the laundry area. The resident was assessed in Emergency Department and returned to the facility. Prior to the fall, the resident was ambulatory with wheelchair, wandering, and seeking exit. After the fall, the resident was moved to a ground level floor and a wanderguard was placed. During the tour on 10/8/19, the surveyor observed that the stairwell doors were locked with a numbered keypad. Staff members interviewed by the surveyor were unable to say how a wheelchair dependent resident might gain access to the stairwell. The surveyor interviewed the director of nursing (DON) about the incident and the DON was unable to offer an explanation. The DON explained that the resident now resided on the lower level of the facility and was not at risk for falling down stairs. The resident was unable to answer questions about the incident. The administrator and DON were notified of the concern during a summary meeting on 10/10/19. 7. Facility staff failed to ensure the environment remained free of accident hazards by when partially depleted oxygen storage tanks were stored free-standing in the oxygen storage room creating a potential fire hazard. In 10/08/19 at 4:56 PM, the surveyor inspected the oxygen storage room. The room contained 6 empty oxygen tanks standing loose in the floor. There were open spaces in the empty tank rack and empty portable carriers. The CNA with the surveyor moved the empty tanks to the storage rack while the surveyor was present. On 10/10/19 at 3:45 PM during a summary meeting, the administrator and director of nursing were notified of the safety concern. No oxygen tanks were observed to be improperly stored for the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, clinical record review, staff interview, family interview, and over the course of a complaint investigation, the facility staff failed to ensure that 3 of 45 Residents in the survey sample received adequate supervision and assistance to prevent accidents, Resident # 85, Resident # 82, and Resident # 101. The findings included: The facility staff failed to transfer Resident # 85 using the Hoyer Lift as determined necessary by the comprehensive plan of care, during a transfer from the wheelchair to the bed, resulting in the resident sustaining a 14 inch laceration to the lateral left leg which required that she be transferred to the emergency room where she received sutures, a Penrose drain, and required antibiotic therapy. A facility reported incident was sent into the Office of Licensure and Certification on 11/9/17. The Office of Licensure and Certification converted this facility reported incident into a complaint, which was investigated during an unannounced Medicare/Medicaid recertification survey that took place on site at the facility on 5/29/18 through 6/4/18. Resident # 85 was originally admitted to the facility on [DATE] with a readmission date of 5/31/11. Diagnoses included but were not limited to: hypothyroidism, heart failure, hypertension, and chronic pain. The clinical record for Resident # 85 was reviewed on 5/31/18 at 9:35 am. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 5/2/18. Section C assesses cognitive patterns. In section C1000, the facility staff coded that Resident # 85's cognitive status as severely impaired. Section G assesses functional status. In Section G0110, the facility staff documented that Resident # 85 totally dependent requiring assistance of 2 or more persons for transfers. The current plan of care for Resident #85 was reviewed and revised on 5/9/18. The focus area for At risk for falls related to: Use of medication, assistance with mobility, has interventions that included but were not limited to Transfer using the Hoyer lift with staff assistance. On 5/31/18 at 9:42 am, the surveyor observed a progress note in the clinical record written on 11/4/17 at 2:57 pm. The progress note stated, This nurse along with coworker was sitting at the nurses station and heard someone calling out for the nurse. Upon going down the hall observed patients left lower extremity bleeding with large approx. 10x10 cm (centimeter) gash. Skin flap was intact and adipose tissue exposed. Recovered gash with skin flap, applied pressure, contacted 911 for transport to ED (emergency department) elevated patient leg while applying pressure. Resident transported to ED via ambulance at 1425 (2:25 pm), resident RP (responsible party) notified at 1432 (2:32 pm) of incident and that patient was at ED. Will contact ED for update on the resident. On 5/31/18 at 9:46 am, the surveyor observed a progress note in the clinical record written on 11/4/17 at 5:57 pm. The progress note stated Returned from ER (emergency room) with orders to not get patient up to leave in bed, left leg wrapped in Coban with Penrose drain in place, return to ER on Monday to remove drainage bag, and return in 2 weeks for suture removal, 1 gram vancomycin given in hospital, started on Doxycycline 100 mg (milligram) BID (twice daily) for 10 days. On 5/31/18 10:20 am, the surveyor spoke with the DON (director of nursing) about Resident # 85 sustaining an injury to her left leg on 11/4/17. The DON stated to the surveyor that the CNA (certified nursing assistant) in this situation did not use the lift and transferred the resident improperly. On 5/31/18 11:25 am, the surveyor interviewed LPN # 3(licensed practical nurse) in the presence of the survey team. The surveyor asked LPN # 3 what happened during the incident on 11/4/17 in which Resident # 85 sustained an injury to her left leg. LPN # 3 stated that she heard CNA calling for help. LPN # 3 and another nurse rushed down there and saw the extent of the wound. LPN # 3 stated that she put the skin back and applied pressure. The surveyor asked LPN # 3 to describe the wound to Resident # 85's left leg. LPN #3 stated that the wound was Very long and deep and I knew it needed medical attention that I couldn't give. LPN # # stated that she contacted the physician and got Resident # 85 sent to the ER. LPN # 3 stated that she educated the CNA because she transferred the resident improperly. LPN # 3 stated that the CNA was using a stand and pivot technique when transferring Resident # 85 and stated that Resident # 85 was assisting with standing during the transfer and then Resident # 85 stated My leg, my leg, and the CNA looked down and saw the blood and called for the nurses. On 5/31/18 at 11:55 am, the surveyor interviewed CNA # 1 in the presence of the survey team. The surveyor asked CNA # 1 to tell what happened on 11/4/17 when Resident # 85 sustained an injury to her left leg. CNA #1 stated That day I was in a hurry because I was behind. I usually use the stand up and the lift wasn't available. I think someone else was using it. I transferred her using stand and pivot. CNA # 1 stated that Resident # 85 stood and did fine and when I sat her on the bed she said oh my leg I looked down and saw the blood. CNA # 1 stated that she put Resident # 85's legs on the bed and called for the nurse. CNA # 1 stated, I am assuming that she hit it on the bed rail that was on the bed at the time. CNA # 1 stated that she had worked with Resident # 85 before and was familiar with her plan of care and knew that she was supposed to use the lift. CNA # 1 stated again that she was behind and this is the reason she transferred incorrectly. CNA # 1 stated that she was placed on suspension and when she returned she was educated on the use of the lift with the residents. On 5/31/18 at 1:43 pm, the surveyor reviewed the MDS assessment that was completed for Resident # 85 prior to the incident on 11/4/17. The MDS assessment was a quarterly assessment with an ARD of 10/4/17. In Section G 0110, the facility staff documented that Resident # 85 was totally dependent with transfers requiring the assistance of two or more persons. On 5/31/18, the administrative staff was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 6/4/18. *** This is a complaint deficiency*** 2. The facility staff failed to maintain an accident free environment for Resident #82 in regards to a fall. Resident #82 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, UTI, Parkinson's disease, anxiety disorder, depression, Psychotic Disorder and Schizophrenia. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/1/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #82 was also coded as being totally dependent on 2 or more staff members for bed mobility, transfer and bathing. Then being totally dependent on 1 staff member for dressing and personal hygiene. The surveyor performed a review on Resident #82's clinical record on 5/31 and 6/1/18. It was noted that the following documentation was made in the nurses' notes dated and timed for 3/9/18 at 1607 (4:07 pm): Called to room by CNA. Upon entering room resident lying in floor on back, blood noted to head and floor. Approximately 2 in (inch) laceration noted to left eyebrow. Resident assessed. Pressure applied to laceration for approx. (approximately) 15 mins with bleeding controlled. Resident was not moved d/t (due to) fall with head injury .Resident stated he was trying to hold on but is not used to not having side rails and could not hold on .MD (medical doctor) notified new order to send to ER for evaluation . Then on 3/9/18 at 2334 (11:34 pm) the nurses' notes read in part .Resident returned to facility @ 9 pm via stretcher transported by EMS accompanied by father .Laceration to left eye with 6 stitches above eyebrow. L (left) eye swollen and purple. Sm (small) bump on right side of forehead. Abrasion to right knee. L (left) knee cap swollen and purple. Ice pack applied .Father very verbally upset that rails were removed from bed and demanded that they be put back .Supervisor talked to father about new policy concerning rails. Father stated he would be talking to Administration . The surveyor reviewed the MDS with ARD of 2/1/18, in which the resident was coded as being totally dependent on 2 or more staff members for bed mobility, transfer and bathing. The comprehensive care plan was also reviewed by the surveyor. Under the Focus section of the care plan it read in part .Mobility impairment . with the following interventions listed on the care plan: Assist to turn and reposition frequently. Assistive device: w/c (wheelchair) Call bell within reach Encourage choices with care Inspect skin with care. Report reddened areas, rashes bruising or open areas to charge nurse Nail care PRN (as needed) -refer to the Podiatrist PRN. Observe and report changes in physical functioning ability Observe and report changes in ROM (range of motion) ability Praise effort at participation Provide all needed assistance w/ADL's (activities of daily living) & mobility. Provide all needed assistance w/toileting-provide incontinence care PRN. Resident to have left hand orthotic placed in AM, removed at night, and worn no more than 12 hours per order. Therapy per order. The surveyor interviewed the director of nursing (DON) on 6/1/18 at 8:50 am in the conference room. The surveyor asked how the resident obtained a laceration above his left eyebrow on 3/9/18. The DON stated, He got the laceration by sliding off the edge of the bed when the CNA was changing him. The doctor was called and he told us to send the resident to the ER for evaluation. The surveyor asked the DON if the side rails were present on the bed at the time of the accident. The DON stated, No, they were not. The surveyor asked the DON what was the date that the side rails were removed from the resident's bed. The DON stated, I don't know the exact date but I know we looked at the most ambulatory residents first and removed those first and then we worked our way through the rest of the residents. I know we began this around the 29th of January and ended taking the side rails off the beds the middle of March. The surveyor interviewed CNA #2 at 9:05 am in the conference room. The surveyor asked CNA #2 to tell the events leading up to and surrounding _______ (name of resident) fall from his bed on 3/9/18. CNA #2 stated, I was changing him and used the draw sheet to turn him towards the window which was away from the side of the bed that I was standing on. He began to start falling and I could see him grabbing at the sheet but he fell anyways. The surveyor asked CNA #2 if the side rails were on or off the bed at the time of this fall. CNA #2 stated, I don't remember when the side rails were taken off but they were not on there when he fell out of the bed. The surveyor asked CNA #2 how many staff members were needed to turn this resident and how would you know about this information to care for the resident. CNA #2 stated, In the past he could use the side rails to hold on if he felt like he was falling. We did only use 1 aide to turn him but since the accident we are required to have 2. There is a [NAME] on each unit that tells you how many aides are needed to do certain things with the resident and then we also get a report from the charge nurse. This surveyor and the team leader for the survey went into Resident #82's room at 9:25 am to interview the resident about the above documented fall on 3/9/18. The surveyors spoke to the resident but the resident was attempting to speak but the surveyors were unable to understand what he was saying. The father was sitting at the bedside of the resident and this surveyor asked if he could remember what the staff told him about the fall that occurred on 3/9/18. The father stated, they took his side rails off the bed that morning and by that afternoon, the aide was in here changing him and he slid off the bed, hit his head on the table over there and had to get 6 stitches above his left eye. I don't understand why they took the side rails off the bed. The surveyor asked what exactly was he told regarding the removal of the side rails from the bed. The father stated, They said it was against state law to have side rails on the bed. The surveyor again interviewed the DON at 11:05 am in the conference room. The surveyor requested a copy of the bed rail assessments that were performed prior to the removal of the side rails from the bed. The DON stated, I don't think that we have an assessment immediately prior to the removal of the side rails but I could be wrong. I have only been the DON here since about March and this was started prior to me accepting this position. At 1:38 pm, the surveyor interviewed LPN #2 by phone and asked if she could remember _____ (name of resident) falling off the side of the bed on 3/9/18. LPN #2 stated, The CNA called me to come into the resident's room and told me that she was changing him and he rolled off the side of the bed. I know she told me that she had been standing on the right side of the bed and turned him towards the window and that's when he fell. The surveyor asked if she could recall if there were side rails present on the bed at the time of the fall and she replied, No. The surveyor asked how many aides are needed to turn the resident in bed. LPN #2 stated, At that time we only used 1 aide but now after the fall we are required to have 2 staff in there so this does not happen again. The surveyor notified the administrative team on 6/4/18 at 4 pm of the above documented findings. The surveyor asked the administrative team if there was any other information that they would like for the survey team to consider in regards to the fall. The administrator stated, I believe you have everything that we could give you at this point. No further information was provided to the surveyor prior to the exit conference on 6/4/18. 3. The facility staff failed to maintain a hazard free environment for Resident #101 in regards to the bedside table. Resident #101 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to anemia, coronary artery disease, heart failure, high blood pressure, Peripheral Vascular Disease, End Stage Renal Disease, diabetes and depression. On the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/26/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident # 101 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and being totally dependent on 2 staff members for bathing. On 5/30/18 at 3:30 pm, the surveyor went into Resident #101's room. During the resident interview, the surveyor observed the bedside table had worn edges that had sharp edge. The resident stated, It will cut you if you are not watching. The surveyor notified LPN #2 at 3:50 pm of the above documented findings concerning the sharp edges that were present on the bedside table. PN #2 and the surveyor retuned to the resident's room and stated, I'll go and get another one. That is worn out and the edges are sharp and you could get a splinter because the wood is showing. The nurse went and found another bedside table and replaced the one in the room. LPN #2 stated that she had notified the maintenance director and the nurse manager of the condition of the bedside table in the resident's room. The surveyor notified the administrative team of the above documented findings on 5/31/18 at 4 pm. No further information was provided to the surveyor prior to the exit conference on 6/4/18.