Every finding on record at Albuquerque Heights Healthcare and Rehabilitation

Based on record review and interviews, the facility failed to ensure a resident had the right to communication with and access to persons and services inside the facility for 1 (R #80) of 1 (R #80) resident, when facility staff did not consistently communicate using the methods identified in R #80's care plan. If the facility does not provide residents with appropriate communicative services outlined in their plan of care, residents are likely to feel unimportant to facility staff. The findings are: A. Record review of R #80's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/08/26, revealed the following:R #80 was admitted on [DATE] with hearing loss, chronic kidney disease stage four (severe, advanced stage of chronic kidney disease where kidney function is critically reduced), and adult failure to thrive (progressive decline in weight, nutrition, physical function, and overall health). R #80's had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 13, cognitively intact. R #80 was discharged on 07/17/26. B. Record review of R #80's care plan, dated 07/02/26, revealed R #80 has impaired communication as evidenced by deafness and muteness (the condition of refraining from speech or of being temporarily speechless). Facility staff are to utilize electronic tablets for virtual interpreter services every hour and as needed, and they are to provide a sign language interpreter upon request or as needed. C. Record review of R #80's discharge MDS, dated [DATE], revealed a BIMS score of 0, indicating severe impairment due to R #80 rarely or never being understood. R #80's preferred language was documented as American Sign Language (ASL; uses hand shapes, movements, facial expressions, and body language to communicate), and R #80 preferred using an interpreter to communicate with healthcare staff. D. On 07/24/26 at 9:42 am, during an interview, the Social Services Director (SSD) stated he was unable to conduct the BIMS interview with R #80 because R #80 was nonverbal. The SSD stated the BIMS assessment is a verbal assessment, and since R #80 is nonverbal, the BIMS reflected this. He stated completing the assessment on a writing board or tablet would have defeated the purpose of the BIMS assessment. The SSD stated he would obtain an interpreter only for a resident who spoke a different language, and because R #80 was nonverbal, he did not use interpretive services. E. On 07/23/26 at 2:53 pm, during an interview, the Director of Nursing (DON) stated R #80's son wanted a certified interpreter for R #80, which the facility provided. She stated once the order for the interpreter was entered into R #80's medical record, the expectation would be to use the interpretive service. The DON stated she was unaware if facility staff utilized the interpretive services indicated in R #80's care plan.

Based on record review and interviews, the facility failed to implement a physician-ordered therapeutic diet for 1 (R #1) of 1 (R #1) resident, when the facility staff failed to: Provide a controlled carbohydrate (consistent or controlled; a meal plan designed to keep carbohydrate intake fairly equal at each meal and snack throughout the day and week to help stabilize blood sugar levels) diabetic diet as ordered by a physician for R #1. If physician-ordered therapeutic diets are not implemented as prescribed, then residents are likely to experience elevated blood sugars, difficulty chewing, inadequate nutritional intake, and an increased risk for further complications. The findings are: A. Record review of the facility's Food and Nutrition Policy, dated 05/01/2023, revealed diets are to be provided as ordered by the physician. B. Record review of R #1's face sheet revealed a re-admission date of 04/30/26 with the following diagnoses: Type II Diabetes (DM2; a disease in which the body cannot make or properly use insulin).Malnutrition (not consuming enough protein and calories).Pressure Ulcer (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin). C. Record review of R #1's hospital discharge orders, dated 04/30/2026, revealed R #1 was ordered to receive a diabetic diet. D. Record review of R #1's facility admission summary, dated [DATE], revealed R #1 was to receive a diabetic diet while in the facility. E. Record review of R #1's Nurse Practitioner (NP) #1 progress notes revealed the following: Dated 05/02/2026, R #1 is prescribed a controlled carbohydrate diet.Dated 05/07/2026, R #1 is prescribed a controlled carbohydrate diet. Dated 05/11/2026, R #1 is prescribed a controlled carbohydrate diet. F. On 05/18/2026 at 4:43 PM, during an interview, R #1's niece expressed concerns regarding the resident's nutrition. R #1's niece stated R #1 had diabetes and difficulty chewing due to not having teeth. R #1's niece stated during a care conference on 05/13/2026, she requested R #1's diet be changed to an easy chew diabetic diet. G. On 05/22/2026 at 2:33 PM, during an interview, the Registered Dietitian (RD) stated it is her expectation that residents diagnosed with diabetes receive a consistent carbohydrate diabetic diet, and residents without teeth receive an altered texture diet appropriate for chewing difficulties. The RD stated the resident diets must match the physician's diet orders from the hospital. The RD stated if a resident's diet does not match their diagnosis, chewing ability, or physician orders, then it could affect their blood sugar control, cause difficulty in chewing, discomfort, or result in poor nutrition. The RD stated R #1 should be receiving a controlled carbohydrate diabetic diet as ordered. H. On 05/22/2026 at 2:51 PM, during an interview, the Director of Nursing (DON) stated residents with diabetes or difficulty chewing due to poor oral health should receive diets appropriate to their needs. The DON stated if dietary needs were not properly assessed or followed, it can negatively impact the resident's nutrition and overall health. I. On 05/27/2026 at 11:07 AM, during an interview, the Nurse Practitioner (NP) #1 stated residents with hospital orders for a diabetic diet should receive the ordered therapeutic diet. The NP #1 stated if the diabetic diet order was not entered into the electronic health record, the resident could receive a regular diet, which could cause their blood sugars to increase.

Based on record review and interviews, the facility failed to ensure medications were administered as ordered for 1 (R #4) of 1 (R #4) resident, when the facility nursing staff: Failed to administer intravenous (IV; into the vein) antibiotics as ordered by a physician. If residents do not receive medications as prescribed, they may experience incomplete treatment, worsening infection, or failure to achieve the intended therapeutic effects.The findings are: A. Record review of the facility's Administration of IV Fluids and Medications, dated 10/2024, revealed the following: To correctly and aseptically (free from contamination caused by harmful bacteria, viruses, or other microorganisms; surgically sterile or sterilized) set up the primary IV bag and administration set. Close the IV clamp (a small, manual device attached to the tubing of an IV set that is used to control or stop the flow of fluids or medications into a patient's bloodstream) on the administration set. Spike the IV bag (the process of connecting an IV administration set to a fluid filled IV bag so that the solution can be delivered to a patient under sterile conditions) and hang the IV hook on the IV pole. Open and close the IV clamp. B. Record review of the facility's Medication Administration Policy, dated 01/2026, revealed the following: Medications are administered with written orders of the prescriber. Prior to administration, review and confirm medication orders for each resident.The timing of medication administration must align with manufacturer specifications. The person who prepares the dose for administration is the person who administers the dose. C. Record review of R #4's face sheet revealed an admission date of 05/01/2026 with the following diagnoses: Sepsis (a serious condition in which the body responds improperly to an infection). Endocarditis (a serious infection of the inner lining of the heart chambers and heart valves). D. Record review of R #4's physician orders, dated 05/02/2026, revealed an order for Ampicillin Sodium (antibiotic used to treat bacterial infections) 2 grams (G) to be administered intravenously every four hours until 05/31/2026. E. Record review of R #4's Change in Condition (CIC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) Assessment, dated 05/20/2026, revealed the following: R #4's IV antibiotic was not administered at the scheduled time because the IV tubing remained clamped (closed).R #4 received the IV antibiotic 2 hours and 30 minutes late. The physician was notified regarding the medication error. F. On 05/21/2026 at 2:42 PM, during an interview, Registered Nurse (RN) #1 stated R #4 was scheduled to receive IV Ampicillin at 6:00 AM, but the night nurse who connected the IV antibiotic to R #4, did not open the IV clamp as expected and R #4 did not receive the IV medication as ordered. RN #1 stated she identified the medication error when she was disconnecting R #4's IV antibiotic. RN #1 stated it is her expectation that residents receive medications as ordered, and if antibiotics are not administered as prescribed, then residents may experience incomplete treatment or worsening infection. G. On 05/21/2026 at 3:26 PM, during an interview, the Unit Manager (UM) stated a CIC was initiated for R #1 after the IV tubing was found clamped and the physician was notified, which required R #4's IV antibiotic administration times to be adjusted. The UM stated the night nurse did not release the IV clamp and R #4 did not receive the scheduled IV antibiotics as prescribed. The UM stated it is her expectation that all residents receive medications as ordered by a physician. H. On 05/22/2026 at 2:55 PM, during an interview, the Director of Nursing (DON) stated it is her expectation that all residents receive antibiotics and medications as ordered by a physician. The DON stated if a resident does not receive their antibiotic regimen as ordered, it could extend or alter the course of the antibiotic treatment. The DON stated R #4 should have received the IV antibiotic as ordered but did not.

Based on record review and interviews, the facility failed to notify the facility provider (Physician, Nurse Practitioner) for 1 (R #1) of 1 (R #1) resident, when staff failed to: Report R #1's follow-up blood pressure results to the Nurse Practitioner (NP) #1 as instructed.Document each time the NP #1 was notified after R #1's blood pressure was rechecked as ordered. If resident's experience a change in condition (CIC; a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) and the facility nursing staff does not notify the provider as ordered, then residents are at an increased risk for deterioration in condition, delayed medical intervention, hospitalization, or additional complications. The findings are: A. Record review of R #1's face sheet, dated 04/23/2026, revealed the following diagnoses: Type II Diabetes (DM2, a disease in which the body cannot make or properly use insulin). Acute Cystitis (Bladder infection).Hypertension (HTN; high blood pressure).Third Degree Burns (Severe burns that destroy the skin and damage deeper tissue). B. Record review of R #1's Change in Condition Assessment, dated 05/13/2026, revealed the following:R #1 experienced a change in condition related to abnormal vital signs (body temperature, pulse rate, respiration rate (rate of breathing), oxygen saturation (amount of oxygen in the blood), and blood pressure), including a low blood pressure reading. R #1's blood pressure was 88/51 (a normal blood pressure is 120/80) on 05/13/2026 at 7:56 AM. The facility provider recommended oral fluids be administered, R #1's blood pressure be rechecked, and the results reported back to the provider. C. Record review of R #1's nursing progress notes, dated 05/14/2026, revealed the following:R #1 attended a doctor's appointment and was later sent to the emergency room (ER) due to hypotension (low blood pressure). R #1's diastolic blood pressure (the lower number in a blood pressure reading; the pressure in your arteries when your heart rests between beats) was reportedly in the 50s upon arrival to the appointment, indicating significant low blood pressure. D. On 05/22/2026 at 10:14 AM, during an interview, the Director of Nursing (DON) stated R #1 experienced episodes of hypotension on 05/11/2026 and 05/13/2026. The DON stated the Nurse Practitioner (NP) #1 was notified of R #1's hypotension on 05/13/2026, but the notification for the 05/11/2026 hypotension episode was not documented. The DON stated that her expectation is that staff report abnormal vital signs, including hypotension, to the provider because failure to do so could result in deterioration or additional complications. E. On 05/22/2026 at 10:29 AM, during an interview, Registered Nurse (RN) #1 stated she notified the NP #1 about R #1's low blood pressure and was instructed to encourage oral fluids and recheck the resident's blood pressure. RN #1 stated she failed to follow up with NP #1 and document the repeat blood pressure after oral fluids were provided to R #1. F. On 05/27/2026 at 11:07 AM, during an interview, the NP #1 stated she was notified regarding R #1's low blood pressure on 05/13/2026 and instructed nursing staff to encourage oral fluid intake, recheck the resident's blood pressure, and call back if the resident did not improve. The NP #1 stated nursing staff did not call her back with an updated blood pressure reading for R #1, so she assumed R #1's blood pressure improved with oral hydration. The NP #1 stated R #1 later attended a doctor's appointment on 05/13/2026, where the resident's diastolic blood pressure reportedly dropped into the 50s and R #1 was sent to the hospital for an evaluation due to hypotension. The NP #1 stated she should have been contacted after R #1's blood pressure was rechecked, but she was not.

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment throughout the facility, as evidenced by failure to: Ensure bed footboards were maintained in safe working condition and free from damage. Ensure food remains was promptly cleaned from resident room floors. Ensure the 100-unit water dispenser area remained in good repair. Ensure laminate wooden floor slats were intact and not broken. Ensure the handrail in the 300 unit was free from damage. Ensure the 300 unit remained free from urine odors.These deficient practices exposed residents in the 100, 300, and 400 units to an unsafe and uncomfortable environment.The findings are:100 UnitA. On 02/02/26 at 9:45 a.m., during an observation of the 100-unit water dispenser area, observation revealed the water dispenser was positioned on a countertop with visible water damage to the surrounding surface. The countertop was darkened and discolored areas consistent with prolonged moisture exposure. The laminate surface broken and with water damage along the edges near the sink and water dispenser. The cabinet door beneath the countertop had a loose handle that was partially detached and hanging at an angle. Observation revealed multiple broken laminate wooden floor slats near the nursing station.300 UnitB. On 02/02/26 at 8:45 a.m., during an observation of the 300-unit, observation revealed a strong urine odor around rooms [ROOM NUMBER].C. On 02/02/26 at 1:34 p.m., during an observation of the 300-unit, observation revealed a strong urine odor upon entry into the unit, including the common area where residents were seated watching television.D. On 02/03/26 at 9:32 a.m., during an observation of the 300-unit, observation revealed a strong urine odor upon entry into the unit, including the common area where residents were seated watching television.E. On 02/03/26 at 8:16 a.m., during an observation of the hallway in the 300-unit, Section 3, outside Rooms 314-319 next to the linen closet, observation revealed the wall-mounted handrail was damaged. The lower protective cover beneath the handrail was cracked and partially broken, with a jagged section approximately ten inches long.400 UnitF. On 02/02/26 at 11:25 a.m., during an observation of room [ROOM NUMBER], observation revealed the resident occupying Bed B was sleeping in her bed. [NAME] leafy food and multiple plastic condiment cups were present on the floor underneath the bedside table located on the left side of the resident's bed. During the same observation, occupied Bed A was observed to have a broken footboard.G. On 02/02/26 at 1:45 p.m., during an interview with R #4, she stated she dropped her salad during dinner the previous evening 02/01/25 and no staff came to clean it up even after her request for assistance. She stated the food remaining on the floor made her feel bad and she stated by leaving food on the floor could attract cockroaches.H. On 02/03/26 at 10:15 a.m., during an interview with the Maintenance Director (MD), he stated it was his expectation that the 100-unit water dispenser area would remain in good repair. He stated flooring should be maintained in good condition because damaged flooring could create a tripping hazard for residents. He further stated the handrail in the 300 unit required repair and that the footboard of the bed in room [ROOM NUMBER]A should have been properly bolted to prevent potential injury.I. On 02/03/26 at 10:17 a.m., during an interview with the Administrator, she stated the 300 unit should not have heavy urine odors. She stated it was her expectation that Certified Nursing Assistants (CNAs) and housekeeping staff clean resident areas to prevent urine odors.J. On 02/03/26 at 10:32 a.m., during an interview with the District Manager of Housekeeping, she stated housekeeping cleans the facility daily. She stated she was present in the building for most of the previous day and did not identify urine odors related to bedding at that time. She stated if urine odors are repeatedly identified, housekeeping reports the concern through the Quality Control Inspection (QCI) process and checks the room for cleanliness. She stated housekeeping uses Rapid disinfectants when cleaning resident rooms and that urine odors can occur when bedding is not changed in a timely manner. She stated it was her expectation that hallways remain free of urine odors and that staff clean spills or soiled areas when observed.K. On 02/03/26 at 10:43 a.m., during an interview with the Director of Nursing (DON), she stated it was her expectation that if a resident drops food on the floor, a CNA or nursing staff clean the food when they see it. She further stated if a resident urinates in bed, CNAs are expected to change the resident and replace wet or soiled bedding.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 1 (R #1) of ( R #1) resident reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.The findings are:Record review of the facility's Pre-admission Screening for Mental Disorder and/or Intellectual Disability Patients policy, revised 02/16/24, revealed the Social Worker or designated staff will assure all patients with mental disorders and intellectual disability received appropriate pre-admission screenings according to Federal and State regulations. The policy stated if a PASARR was not completed or was incorrect, then Social Services would coordinate with the appropriate agency to conduct the evaluation, review PASARR results to determine care needs, and incorporate recommendations into the patient's assessment and care planning.Record review of R #1's facesheet revealed she was admitted to the facility on [DATE] and diagnosed on [DATE] with diagnosis of:Major DepressionGeneralized Anxiety Disorder. Record review of R #'s PASRR Level I Identification Screening, dated 12/10/25, revealed staff documented the resident did not have a diagnosis of or a suspected mental illness.On 02/03/26 at 9:00 am, during an interview with Social Worker (SW), she revealed the R #1 was diagnosed with Depression and Anxiety on 12/11/25 after her admission to the facility. She stated the PASRR should have revised to reflex the current diagnosis.On 02/03/26 at 11:00 am, during an interview with Administrator she stated it is her expectations the PASRR would have been revised with the new diagnosis.

Based on record review and interview, the facility failed to protect residents from the potential for accidents and hazards for 1 (R #20) of 4 (R #s 20, #21, #22 and #23) residents reviewed for falls by not preventing a resident from falling out of bed. This deficient practice could likely cause a resident to suffer health consequences such as a broken bone or a head injury. The findings are: A. Record review of R #20's face sheet revealed R #20 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (inability or difficulty communicating),Hemiplegia cerebral infarction affecting right dominant side (paralysis of the arm, leg, and trunk on the same side of the body),Contracture (a shortening of muscles around joints causing joint stiffness and immobility). B. Record review of R #20's Minimum Data Set assessment (MDS; a federally mandated assessment instrument completed by facility staff) revealed R #20 was dependent for all of his activities of daily living (ADL's include dressing, eating, moving in bed, toileting and bathing) and had impairment (substantially limits movement) on both lower extremities (both legs) and impairment one side with his upper extremity (arm). C. Record review of R #20's Kardex (electronic documentation system that enables nurses to write, organize, and easily reference key patient information that shapes their nursing care plan) dated 05/14/24 indicated nursing staff are to transfer R #20 via mechanical lift (two person) assist. D. Record review of R #20's care plan dated 10/29/25 revealed the following: Bed in low position, Ensure all equipment ready and in the room prior to patient care. E. Record review of R #20's nursing progress notes dated 10/28/25 at 10:50 am revealed the Certified Nursing Assistant #1 (CNA) attending to R #20, left the room to get the Hoyer lift (mechanical lift) and another staff member to assist with the Hoyer lift. CNA #1 did not lower the bed or move R #20 to the center of the bed before leaving the room. R #20 was left on the edge of the bed, and the bed was in high position. When CNA #1 returned to the room, R #20 was on the floor. The nurse was informed and did a head-to-toe assessment on R #20. R #20 was found to have an abrasion (scrape) to the left lateral knee (outer side of the knee joint). Neurological checks (an assessment to ensure there was no trauma to the brain) were initiated. F. Record review of R #20's nursing progress notes, change in condition dated 10/28/25 revealed provider recommendations to monitor for changes. Wound care order for the abrasion was put in place, triple antibiotic ointment cover with foam dressing. R #20 was stable, and nurse will continue to do neurological checks and monitor for pain. G. On 12/31/25 at 8:52 am, during an interview with the Unit Manager (UM)/Assistant Director of Nursing (ADON) #1, she stated she went into R #20's room right after he was found on the floor. She stated R #20 was dependent on staff for assistance, but he did not require two people assist with the exception of using the Hoyer lift. She stated when she spoke to CNA #1 about the incident (on 10/28/25), and CNA #1 told her she dressed R #20 and was able to get the Hoyer lift sling under him. She then left the room to find another staff member and the Hoyer lift. The UM #1 stated CNA #1 had left the room unattended with the bed in high position for several minutes, and left R #20 towards the edge of bed instead of in the middle of the bed. The UM/ADON #1 confirmed this was not the appropriate practice, and R #20's bed was still in a high position when she arrived in R #20's room after the fall. H. On 12/31/25 at 10:25 am, during an interview with Registered Nurse (RN) #1, she stated she spoke with CNA #1 and confirmed with the CNA what she did wrong. RN #1 stated CNA #1confirmed she should not have left the room with the bed in high position while R #20 was on the edge of the bed. RN #1 stated R #20 has spastic movements he is not able to control, which is why R #20 needed to be in the middle of the bed for his safety.

Based on record review and interviews, the facility failed to ensure the residents who require dialysis (a treatment that helps remove waste products and excess fluids from the blood when the kidneys are not functioning properly) receive such services, consistent with professional standards of practice and physician orders for 2 (R #1 and R #7) of 4 (R #1, R #7 R #9 and R #10) residents reviewed for dialysis, when:The facility failed to provide adequate transportation to ensure residents attended scheduled dialysis treatments. This deficient practice led to the hospitalization of R #1 and R #7. If the facility is unable to meet the appointment needs for residents receiving dialysis treatments, then residents are likely to receive inadequate care and experience health complications. The findings are: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease (ESRD; chronic irreversible kidney failure),Dependence on renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys cannot function properly),Type 2 diabetes mellitus with neuropathy (DM2; a disease in which the body cannot make or properly use insulin and can cause nerve damage). B. Record review of R #1's physician orders dated 04/04/25 revealed R #1 had dialysis treatments on Monday, Wednesday and Friday. C. Record review of R #1's nursing progress note dated 10/06/25 at 3:41 pm, indicated R #1 had dialysis on Monday, Wednesday, and Friday. R #1 did not go to dialysis on 10/06/25 due to the transportation company failing to arrive at the facility. R #1's most recent dialysis appointment occurred on 10/03/25. D. Record review of R #1's change in condition note dated 10/07/25 at 11:02 am, revealed R #1 had a complaint of distension (enlarged or swollen due to internal pressure) and fluid overload due to missed dialysis appointment on 10/06/25 because transportation was not available to take R #1 to dialysis. The note recommendation indicated R #1 should be transported to the hospital. E. Record review of R #1's hospital records dated 10/07/25 at 6:11 pm revealed the following: History and Physical: R #1 presents with missed dialysis due to arranged transport missing scheduled pick-up time. R #1 stated feeling of fullness to abdomen and shortness of breath due to volume overload. Review of Systems: indicated activity change and appetite change, shortness of breath, abdominal pain and nausea, with some dizziness.Physical exam: abdomen (stomach) indicated some distension (enlarged or swollen due to internal pressure) with abdominal tenderness.Labs: Potassium 7.4 high (normal range is 3.5-5.1), blood urea nitrogen (BUN test measures how much urea nitrogen is in your blood. It helps a healthcare provider determine if your kidneys are working as they should) 82 high (normal range is 6-27), Creatinine (key indicator of kidney function) 11.28 high (normal range is 0.55-1.02). Assessment and Plan: Hyperkalemia (high potassium levels in the blood) due to missed dialysis, urgent dialysis, and repeat potassium lab. F. Record review of R #1's provider an encounter progress note dated 10/19/25, revealed Hospital Course: R #1 is on dialysis due to end stage renal disease, presented to the hospital for volume overload from missed dialysis appointment due to arranged transport not picking up R #1. R #1 was taken to the hospital on [DATE] for fluid volume overload. R #7: G. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease (ESRD; chronic irreversible kidney failure),Dependence on renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly),Type 2 diabetes mellitus with neuropathy (DM2; a disease in which the body cannot make or properly use insulin and can cause nerve damage).Polyneuropathy (damage to multiple peripheral nerves, leading to symptoms such as pain, numbness, and weakness, often caused by systemic diseases like diabetes). H. Record review of R #7's nursing progress notes dated 10/01/25 through 12/06/25 revealed the following: 10/07/25 at 2:42 pm: R #7 did not go to dialysis on 10/07/25 due to transportation failing to arrive at the facility. Appointment was rescheduled to 10/08/25. 11/11/25 at 9:17 am: R #7 did not go to dialysis on 11/11/25 due to transportation failing to arrive at the facility. 11/12/25: R #7 was discharged to the hospital. 12/06/25 at 5:30 am: R #7 was waiting for dialysis transportation. Transportation services were called but they did not answer. R #7 remains at nursing home (missed appointment due to transportation failing to arrive at the facility). Appointment was rescheduled to 12/08/25. I. Record review of R #7's provider encounter notes dated 11/12/25 revealed the following: 1st call: R #7 with end-stage renal disease on dialysis and hypertension (high blood pressure) who presents with acute deterioration after missing his scheduled dialysis session on Tuesday (11/11/25). R #7 reports feeling cold, chills, shaking, and has a low-grade fever of 101 F (degrees Fahrenheit). He has not urinated in two days and has noticeable body swelling. 2nd call: called nursing facility for update on R #7 who was previously evaluated for fever, hypertension, and hypoxia (low oxygen levels) following a missed dialysis session. He has not noted any improvement since the prior evaluation.Nursing observations, evaluation, and recommendations are: R #7 noted with low grade fever and worsening confusion. Worthy of noting, R #7 missed dialysis on Tuesday 11/11/25. On-call provider gave order to send R #7 to the hospital. J. Record review of R #7's hospital Discharge summary dated [DATE] revealed the following: R #7 was presented to hospital with fever and chills. R #7 had emergent dialysis in the emergency room due to hyperkalemia (high potassium in the blood) from missed dialysis appointment due to transportation issues. admitted for acute metabolic encephalopathy (a change in how your brain works due to an underlying condition, causes confusion, memory loss and loss of consciousness) likely due to missed dialysis and sepsis (a life-threatening condition that occurs when the body's response to an infection causes injury to its own tissues and organs), most likely due to pneumonia (infection that causes inflammation in the lungs). K. On 12/11/25 at 11:26 am, during an interview with R #7, he stated he misses dialysis a lot because of transportation. R #7 stated that when he misses an appointment, sometimes he will go the next day and sometimes he must wait until the next appointment. R #7 also stated he went to the hospital in November 2025 after he missed a dialysis appointment. L. On 12/10/25 at 12:53 pm during an interview with Director of Nursing (DON), she stated the facility uses a resident's insurance to schedule transportation to appointments prior to utilizing the facility transport services. She stated the insurance company transportation is not dependable and they will often fail to show up for appointments or they won't notify the facility if they will be late picking up residents. M. On 12/10/25 at 12:59 pm, during an interview with Scheduler (SCH), she stated she sets up transportation for appointments, and she is required to utilize the resident's insurance transportation first before using the facilities transportation service. The SCH confirmed the outside transportation services are not dependable and have missed four medical appointments so far in December 2025. N. On 12/11/25 at 8:45 am, during an interview with the DON, she stated residents missing dialysis is a problem, because dialysis is essential for residents who require it. O. On 12/11/25 at 9:30 am during an interview with UM#1, she stated residents are often waiting in the front of the facility, ready to go to their appointments, and transportation will not arrive. P. On 12/11/25 at 1:30 pm, during an interview with Medical Doctor (MD)#1, he stated his expectation is a resident should not miss any appointment due to a lack of transportation. He confirmed dialysis appointments are sometimes missed due to a lack of transportation, and that should not happen. The MD #1 confirmed it was concerning that R #1 and R#7 were both hospitalized after missing dialysis treatments. Q. On 12/12/25 at 11:22 pm during an interview with DON, she stated her expectation for the dialysis residents would be to follow their plan of care which states they receive dialysis three times per week. She stated if a dialysis appointment is missed, it can cause the resident to become hemodynamically unstable (insufficient blood flow in the body symptoms can include high blood pressure or heart disease).

Based on observation, record review, and interview, the facility failed to meet professional standards of practice for 3 (R #1, #4, and #7) of 3 (R #1, #4, and #7) residents when: R #1 and R #7 were not administered medications per physician orders. Transportation was not consistently provided to R #1, R #4, and R #7 for appointments. If the facility is not adhering to professional standards for quality improvement, then residents are unlikely to get the highest quality of care. The findings are: Repeat DeficienciesMedication Administration: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease (ESRD; chronic irreversible kidney failure),Dependence on renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys cannot function properly),Type 2 diabetes mellitus with neuropathy (DM2; a disease in which the body cannot make or properly use insulin and can cause nerve damage). B. Record review of the physician orders for R #1 revealed the following: Gabapentin (anxiety medication) started on 11/24/25. Give two 100 mg (milligram) capsules three times per day for anxiety, crying and insomnia (inability to sleep). Atorvastatin (high cholesterol medication) started on 07/01/23. Give 40 mg at bedtime. Protonix (esophageal reflux medication) started on 08/25/25. Give 40 mg, 1 tablet by mouth at bedtime for esophageal reflux. C. Record review of R #1's Medication Administration Record (MAR) dated 12/01/25 revealed the following: Gabapentin,Atorvastatin,Protonix,All medications were scheduled to be administered to R #1 by 8:00 pm each night, but they were administered at midnight (12/02/25). D. Record review of R #1's summary to provider note dated 12/02/25 revealed R #1 informed the day shift nurse that the night nurse did not give her the 8:00 pm medications (due on 12/01/25) until midnight (12/02/25). E. On 12/11/25 at 9:30 am during an interview with Unit Manager (UM) #1, she stated R #1 informed her on 12/02/25 that she (R #1) did not get her medications until midnight (12/02/25), and she was supposed to get them at 8:00 pm on 12/01/25. The UM #1 confirmed R #1's medications should have been administered on time per physician orders and they were not. F. On 12/10/25 at 12:35 pm during an interview with Director of Nursing (DON), she stated R #1 did not get her Atorvastatin, Protonix, and Gabapentin on 12/01/25 as ordered and should have. R #7: G. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease.Dependence on renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly),Type 2 diabetes mellitus with neuropathy (DM2; a disease in which the body cannot make or properly use insulin and can cause nerve damage).Polyneuropathy (damage to multiple peripheral nerves, leading to symptoms such as pain, numbness, and weakness, often caused by systemic diseases like diabetes). H. Record review of R #7's physician orders dated 11/16/25 revealed the following: Gabapentin Oral Capsule for neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness), give 100 mg by mouth at bedtime.Remeron for depression and appetite, give 30 mg by mouth one time per day. Tylenol for pain, give 325 mg three times per day. I. Record review of R #7's Medication Administration Record (MAR) dated 12/01/25 revealed the following: Gabapentin,Remeron,Tylenol,All medications were scheduled to be administered to R #7 by 9:00 pm each night. These medications were documented as being administered at midnight on 12/02/25. J. Record review of R #7's summary to provider note dated 12/02/25 at 5:33 pm, revealed R #7 informed the day shift nurse that the night nurse did not give him the 9:00 pm medications (due on 12/01/25). K. Record review of R #7's care plan meeting notes dated 12/03/25 at 10:35 am, indicated during the care plan meeting, R #7 stated he was not administered his medications during the night of 12/01/25. L. On 12/11/25 at 9:30 am during an interview with UM #1, she stated she was told by R #7 that he did not receive any medications during the night of 12/01/25. UM #1 confirmed R #7 did not receive his night medications on 12/01/25 and should have. M. On 12/10/25 at 12:15 pm, during an interview with the Administrator (ADM), she stated she spoke to the night shift nurse who worked on 12/01/25, and that nurse confirmed the medications for R #7 were not administered, even though he marked on the MAR that they were. N. On 12/10/25 at 12:35 pm, during an interview with Director of Nursing (DON), she stated when they investigated the late and missing medications that occurred on 12/01/25, both R #1 and R #7 were the affected residents. The DON also stated the night shift nurse told her medications were documented as being administered, but not all the medications were administered to R #1 and R #7. The DON stated that R #1 got her medications late and R #7 did not receive his medications on the night of 12/01/25. Missed Appointments: R #1: O. Refer to F0698 for related findings.R #4: P. On 12/10/25 at 7:45 am, during an observation of the facility's front door, R #4 was waiting by the front door with a Certified Nursing Assistant (CNA) and UM #1 waiting for transportation to an appointment. Q. On 12/10/25 at 7:50 am, during an interview with UM #1, she stated R #4 had a follow-up appointment related to recent eye surgery, and the appointment was scheduled for 8:30 am (on 12/10/25). R. On 12/10/25 at 8:00 am, during an interview with UM #1, she confirmed R #4's follow-up appointment was canceled due to there being no transportation available to take R #4. R #7: S. Refer to F0698 for related findings. T. On 12/11/25 at 1:30 pm, during an interview with Medical Doctor (MD)#1, he stated his expectation is a resident should not miss any appointment due to a lack of transportation. He confirmed medical appointments are sometimes missed due to a lack of transportation, including dialysis appointments, and that should not be happening at the facility.

Based on observation, record review, and interview, the facility failed to ensure dental services were obtained to replace dentures (removable plate or frame holding one or more artificial teeth) for 1 (R #5) of 1 (R #5) resident reviewed for dental care and services. This deficient practice could likely result in the residents not receiving dental care and services to meet their needs. The findings are: A. Record review of the facility's dental service policy dated 09/15/25, indicated the facility is responsible for the loss or damage of dentures when the loss or damage is due to the facilities staff's misplacement, inadvertent disposal, and/or destruction of the dentures. B. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE] with the following diagnosis: Severe protein calorie malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). C. Record review of R #5's Brief Interview of mental Status (BIMS; a screening for cognitive impairment, scores range from 00 to 15 with 00 to 7 indicating severe impairment, 8 to 12 is moderately impaired, and 13 to 15 is cognitively intact) dated 11/09/25, revealed R #5 had a score of 13, which indicated R #5 was cognitively intact. D. Record review of R #5's personal effects inventory sheet dated 11/08/25 indicated she had upper and lower dentures upon admission into the facility. E. Record review of R #5's admission progress note (EENT- eyes, ears, nose, throat section) dated 11/08/25 revealed R #5 wore dentures. F. Record review of R #5's provider encounter progress note dated 11/10/25 indicated R #5 needed a dental referral for dentures. G. Record review of R #5's physician orders dated 11/10/25 revealed R #5 required a dental referral for denture replacements. H. On 12/10/25 at 12:56 pm, during an interview with the Scheduler (SCH), she stated she had not set up a denture replacement appointment for R #5 because she was told R #5 lost her dentures at the hospital. The SCH confirmed there was a denture replacement physician order in R #5's medical record. She stated a dental appointment should have been made for R #5 to replace her dentures, but that did not happen. I. On 12/11/25 at 8:45 am, during an observation and interview with R #5, R #5 sat on her bed and appeared to be edentulous (did not have teeth). R #5 stated she had her dentures for one or two days after she was admitted into the facility on [DATE], and they have been missing ever since (after being lost in the facility). R #5 stated she reported it to the facility staff, but the only thing she had heard about her missing dentures was the facility was working on it. She stated she feels embarrassed when she does not have her teeth in and she wants the facility to schedule an appointment to replace her lost dentures. J. On 12/11/25 at 12:35 pm, during an interview with Director of Nursing (DON), she stated she had not seen R #5 with dentures. She stated she was unaware until today (12/11/25) that R #5 had missing dentures. The DON confirmed R #5 had her dentures documented on the inventory sheet when she arrived on 11/08/25, and a dental referral should have been made for R #5 per the physician orders.

Based on observation and interview, the facility failed to maintain an environment that was clean and sanitary for 1 (R #4) of 1 (R #4) resident reviewed for a homelike environment by not maintaining and regularly cleaning a resident's room. If the facility fails to maintain a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. On 12/11/25 at 7:55 am during an observation of R #4's room, R #4's room was unclean with a large area of dried liquid on the floor. Dried footprints were present indicating someone had walked through the liquid, leaving footprints on the floor. There was a napkin stuck on the dry liquid, with other tissues and unidentified debris on the floor. The floor appeared as if it had not been cleaned for several days. B. On 12/11/25 at 7:58 am, during an interview with R #4, she stated she had not seen housekeeping in her room for several days and she wanted her floor cleaned. C. On 12/11/25 at 8:15 am during an observation of R #4's room, R #4's room was dirty with the same large, dried liquid area still present. Trash and debris were still present on the floor. D. On 12/12/25 at 10:05 am during an interview with the Housekeeping District Manager (HDM), she stated the resident rooms should be cleaned and mopped daily. She stated the Housekeeping Manager will check to make sure resident rooms are being cleaned properly and thoroughly. The HDM confirmed R #4's room was dirty and the floor should have been cleaned sooner. E. On 12/12/25 at 1:30 pm during an interview with HDM, she stated she spoke with the housekeeper responsible for R #4's room and she confirmed R #4's room was not cleaned on 12/11/2025 but should have been.

Based on observation and interviews, the facility failed to provide reasonable accommodation of needs for 1 (R #4) of 1 (R #4) resident reviewed by ensuring a call light was within reach. This deficient practice is likely to result in the residents not being able to call for help when needed. The findings are: A. On 12/11/25 at 7:55 am, during an observation and interview with R #4, R #4 was observed yelling from her room asking staff for help. R #4 stated she wanted a nurse because she was in pain and needed her pain medication. R #4's call light was under R #4's bed, stuck in between the bed wheels, and out of reach for R #4. R #4 confirmed she could not reach her call light, and she needed a nurse to administer pain medication. B. On 12/11/25 at 8:00 am, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed R #4's call light was not within reach for R #4. CNA #1 stated R #4's call light should be within reach at all times.

Based on record review and interview, the facility failed to develop a comprehensive care plan that included interventions for transfer assistance consistent with the resident's assessed needs and physician orders for 1 (R #4) of 1 (R #4) resident reviewed. If the facility fails to develop and implement a comprehensive care plan regarding a resident's transfer requirements, then staff may attempt unsafe transfer methods that increase the risk of falls, fractures, and other serious injuries. The findings are: A. Record review of the facility's Transfer and Lift policy, dated 03/01/24, stated residents requiring extensive or total assistance with transfers must be transferred using a mechanical lift with the assistance of two trained staff members. B. Record review of R #4's face sheet showed she was admitted to the facility on [DATE], diagnosis of muscle weakness. C. Record review of R #4's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/03/2025, revealed she was dependent for all activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating), including transfers, and required a mechanical lift with two staff members. D. Record review of R #4's physician orders, dated 07/03/2025, revealed an order for bed rest with every two hours with hourly turns every shift. The resident was permitted activity only as tolerated, with no independent transfers. E. Record review of R #4's care plan revealed the care plan did not contain documentation the resident required two staff members assistance or the use of a Hoyer/mechanical lift for transfers. F. On 08/14/2025 at 10:40 a.m., during an interview with the Administrator, she stated it was her expectation R #4's care plan should contain interventions addressing R #4's transfer needs, including two staff members assistance and mechanical lift use.

Based on record review and interview, the facility failed to ensure resident records were complete when staff did not document the evening meal percentages for 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) of 9 (R #1, #2, #3, #4, #5, #6, #7, #8 and #9) residents reviewed for meal intakes. This deficient practice could likely cause the Registered Dietician (RD) to not implement nutrition interventions if the meals were not documented for the RD's consideration during resident record reviews. The findings are: A. Record review of the meal intakes, dated 05/12/25 through 06/10/25 indicated staff did not document the evening meals for R #1, #2, #3, #4, #5, #6, #7, #8 and #9. B. On 06/10/25 at 7:21 am, during an interview, Registered Nurse #3 stated she was not sure which shift should document the dinner meal intakes. She stated the dinner meal trays were still coming out, and residents were still eating dinner during the staff shift change. She stated the dinner meal intake documentation should be done by the evening shift staff. C. On 06/10/25 at 7:28 am, during an interview, Registered Nurse #5 stated evening shift staff should document dinner meal intakes for the residents. D. On 06/10/25 at 7:36 am, during an interview, Certified Nursing Assistant (CNA) #1 stated her shift was from 6:00 am to 6:00 pm. CNA #1 stated staff usually served dinner trays between 5:15 pm to 6:00 pm. She stated residents were typically still eating when the night shift started working. CNA #1 stated night shift should document the evening meal percentages for the residents, since the residents were often still eating when shift change occurred. E. On 06/10/25 at 11:00 am, during an interview, the Registered Dietician (RD) stated she used information from all sources when she did the residents' quarterly nutrition assessment. She stated the residents' meal intakes percentages were a part of how she determined if residents should have an intervention in place. The RD stated she addressed staff not documenting the dinner meal intakes before, because the missing information could make it more challenging for her to do her resident nutritional assessments. F. On 06/10/25 at 11:20 am, during an interview, the Director of Nursing (DON) stated staff did not document the dinner meal percentages for the nine residents. The DON stated the dinner meal documentation was a compliance issue with the night CNAs. She stated the night shift should document the residents' dinner meal percentages.

Based on observation and interview, the facility failed to maintain a homelike environment when the facility did not have enough bath towels and face cloths for the residents. This deficient practice could cause residents to miss a shower if there are not enough towels available. The findings are: A. On 06/09/25 at 10:55 am, during an interview, Certified Nursing Assistants (CNA) #15 stated the facility was always short on linens, such as sheets and towels. She stated there were times when they opened the linen storage closet, and there were not any linens at all. She stated she went to other units to get what they needed, but the other units did not have much either. B. On 06/09/25 at 11:22 am, during an interview, Family Member (FM) #1 stated she will try to clean up R #1, but there was often not any towels or facecloth for her to use. She stated the facility frequently did not have enough clean linens available. C. On 06/09/25 at 12:15 pm, during an interview, the Housekeeping Director (HD) stated they did not have enough linens. She stated the management staff ordered new towels and linens every month. The HD stated even though management ordered new items there still was not enough towels and linens for the residents. The HD stated the facility did not do their own laundry at the facility. She stated the laundry went to another facility for cleaning. The HD stated she wondered if they received back the same amount of linens that they sent out to have washed. D. On 06/09/25 at 12:25 pm, observation of the new linens available for resident use and in the supply area revealed several bags of new towels and one large bag of washcloths. E. On 06/09/25 at 1:30 pm, during an interview, the Administrator stated linen and towels were an ongoing issue. The Administrator stated she was aware they ran short on linens, and they received complaints about not having enough towels and linens. She stated they placed orders every month for new linens. The Administrator stated she was not sure why the deficit continued to occur, because she ordered new towels, sheets, and facecloths every month. F. On 06/10/25 at 7:45 am, during an interview, R #11 stated there were times when there were not any towels available for showers. R #11 stated the newer CNAs told residents they could not have a shower when there were not any towels available, but the other CNAs got a blanket to use as a towel. G. On 06/10/25 at 8:30 am, during an interview, CNA #8 stated the facility was usually short on towels when she came to work on Monday mornings. CNA #8 stated she went to other units to get towels if she needed. She stated the laundry came in around midday. H. On 06/10/25 at 8:45 am, during an interview, R #12 stated the facility was always short on linens and towels. She stated she missed a shower in the past, because towels were not available. I. On 06/10/25 at 9:30 am, during an interview, CNA #13 stated there were issues with towels and facecloths not available everyday. CNA #13 stated she postponed or did not give the shower to residents at all if there were not any towels available for the resident.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #61) of 1 (R #61) resident reviewed for MDS assessments. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: Cognition A. Record review of R #61's face sheet revealed an admitted [DATE] and included the following diagnoses: - Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement.) - Other symptoms and signs involving cognitive function and awareness. This is not an all inclusive list. B. Record review of R #61's MDS, dated [DATE], revealed the following: - Brief Interview for Mental Status (BIMS; screening for cognitive impairment) was not completed due to resident was rarely or never understood. - Cognitive skills for daily decision making: Severely impaired decision making. - Evidence of an acute change in mental status from resident's baseline: No. - Hearing, speech, and vision: Usually understands and usually understood. C. Record review of R #61's MDS, dated [DATE], revealed the following: - BIMS was not completed due to resident was rarely or never understood. - Cognitive skills for daily decision making: Moderately impaired, decisions poor, cues/supervision required. - Evidence of an acute change in mental status from resident's baseline: No. - Hearing, speech, and vision: Rarely/never understands and rarely/never understood. D. Record review of R #61's MDS, dated [DATE], revealed the following: - BIMS score of 2, moderately impaired. - Cognitive skills for daily decision making: Staff did not complete. - Evidence of an acute change in mental status from resident's baseline: No. - Hearing, speech, and vision: Understands and understood. E. Record review of R #61's progress note, dated 01/31/25, and completed by the Physician Assistant, revealed the resident was unable to give any meaningful history or to answer appropriate questions during visit. General: Alert and awake. Oriented to self (knows who they are.) F. On 04/15/25 at 3:15 pm, during an interview, the MDS Coordinator stated R #61's MDS was coded incorrectly for making self-understood and understanding others. Behaviors G. Record review of R #61's annual MDS, dated [DATE], revealed the resident did not exhibit behaviors. H. Record Review R #61's Progress Notes revealed the following: -Dated 03/16/25, R #61 yelled and screamed at others. -Dated 03/19/25, R #61 yelled, cursed, and screamed. -Dated 04/02/25, R #61 yelled, cursed, and disrupted others. -Dated 04/03/25, R # 61 yelled and cursed. -Dated 04/03/25, R # 61 yelled and cursed. -Dated 04/03/25, R #61 yelled repetitively and cursed. -Dated 04/04/25, R #61 yelled loudly and said she wanted to go to bed. -Dated 04/08/25, R #61 yelled, cursed, and screamed. -Dated 04/08/25, R #61 yelled, cursed, and screamed. -Dated 04/08/25, R #61 yelled, cursed, and screamed. I. On 04/14/25 at 1:48 pm, during an interview with the Dementia Program Director, she stated R #61 had behaviors weekly. J. On 04/15/25 at 3:15 pm, during an interview with the MDS Coordinator, she stated R #61's MDS was coded incorrectly for behavioral symptoms. The MDS Coordinator stated R #61's MDS should indicate R #61 had behaviors. MDS Coordinator stated the resident's progress notes showed staff recorded R #61's behavior almost every other day. The MDS Coordinator stated she screened resident MDS's for accuracy. MDS Coordinator stated R #61's MDS appeared to contradict the information in the resident's record. MDS Coordinator stated the staff who completed the information in the MDS should follow-up on discrepancies for a more accurate representation of the resident. The MDS Coordinator reviewed R #61's record and stated she saw discrepancies.

Based on observation, interview, and record review, the facility failed to provide a light meal or a snack for 1 (R #177) of 1 (R #177) before the resident left the facility to go to dialysis (a medical treatment which filters waste and excess fluid from the blood.) This deficient practice could potentially cause prolonged recovery time for the resident after dialysis. The findings are: A. Record review of the facility's Dialysis Policy, last revised on 08/07/23, revealed nutritional/fluid management included the provision of meals before, during, and after hemodialysis (dialysis) and monitoring intake and output measurements as ordered. B. Record review of R #177's face sheet revealed the resident was admitted to the facility 03/19/25, with the following diagnoses: - Non-st elevation (NSTEMI) myocardial infarction (a heart attack that happens when a part of the heart is not getting enough oxygen), - Congestive heart failure (the heart cannot supply enough blood to meet the body's needs), - Ischemic cardiomyopathy (a type of heart failure caused by low blood flow to the heart muscle), - Type II diabetes (means that your body does not use insulin properly), - End stage renal disease (kidneys reach advanced state of loss of function), - Dependence on renal dialysis (a blood purifying treatment given when kidney function is not optimum.) C. On 04/07/25 at 9:36 am, during an interview with R #177, she stated she lived at the facility for awhile, and staff have not offered her anything to eat before dialysis. She stated she usually had to wait to eat until she came back sometime after lunch. She stated her lunch tray was always on her table when she came back from dialysis, and she ate that when she returned. D. On 04/07/25 at 9:45 am, during an interview with Certified Nursing Assistant (CNA) #8, she stated that she did not offer R #177 snacks or lunch, because R #177 left for dialysis right after breakfast. CNA #8 stated the resident would not need a snack or lunch. E. On 04/09/25 at 9:48 am, during an observation, staff propelled R #177 in her wheelchair to the transport van for dialysis. The resident did not have a snack or lunch with her. F. On 04/09/25 at 9:50 am, during an interview with R #177, she stated staff did not offer her a snack or a lunch before she left for dialysis. G. On 04/11/25 at 11:07 am, during an interview with CNA #9 she stated she did not offer a snack to the residents going to dialysis. H. On 04/11/25 at 11:09 am, during an interview with Nurse #10, she stated all staff were responsible to make sure dialysis residents received a snack or lunch before the resident left for dialysis. She stated if there was not something already prepared in the refrigerator for the dialysis residents, then someone should go down to the kitchen to get something. I. On 04/11/25 at 11:17 am, during an interview with the Dietary Manager (DM), he stated they had a list of residents who went to dialysis, and they made them sack lunches or snacks. He stated it depended on what time the resident went to dialysis whether they received breakfast and were back by lunch, or they left later in the morning and they needed a sack lunch. He stated they had five or six residents who were on dialysis. J. On 04/11/25 at 1:29 pm, during an interview with the Director of Nursing (DON), she stated it was expected for staff to offer all dialysis residents a snack or a lunch depending on their dialysis times. The DON stated she was unaware staff did not offer snacks or lunch to residents going to dialysis.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 2 (R #6 and #38) of 2 (R #6 and #38) residents sampled for ADLs when staff failed to: 1) Change R #6's soiled brief prior to assisting him to bed. 2) Clean and change R #38's ileostomy (a surgically made opening that connects your small intestine to your abdominal wall) bag. These deficient practices could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed and undignified. The findings are: R#6 A. Record review of R #6's face sheet, dated 07/23/24, revealed an initial admitted [DATE]. B. Record review of R #6's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/22/25, indicated R #6 required substantial staff assistance for toileting hygiene. C. Record review of R #6's care plan, dated 04/01/25, revealed the following: - Focus: R #6 required assistance from staff for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to limited mobility and weakness. - Goal: Resident's ADL care needs will be anticipated and met throughout the next review period. D. On 04/08/25 at 12:10 pm during an observation, R #6 appeared unclean and disheveled (untidy and disordered.) He lay in bed dressed in a hospital gown, his hair was greasy, and his beard had food crumbs throughout it. E. On 04/08/25 at 12:12 pm during an interview, R #6 stated he frequently went to bed with dirty brief. He stated he was not sure how often he went to bed with a dirty brief, but it happened a lot. R #38 F. Record review of R #38's face sheet, dated 01/22/25, revealed an initial admitted [DATE] with a diagnosis of colostomy (a surgically made opening that connects your small intestine to your abdominal wall.) G. Record review of R #38's MDS, dated [DATE], indicated R #38 required partial staff assistance for toileting hygiene or management of an ostomy (allows bodily waste to pass through an opening on the abdomen into a bag), to include wiping the opening. H. Record review of R #38's care plan, dated 04/01/25, revealed the following: - Focus: R #38 required assistance from staff for ADL care. - Goal: Resident's ADL care needs will be anticipated and met throughout the next review period. I. On 04/08/25 at 12:23 pm during an observation, R #38 was dressed in a soiled hospital gown with feces on it, and his ileostomy bag leaked at the base (where it connected at the abdomen). He stated his gown was soiled since last night. He stated staff come in to his room, tell him they will be right back to change him, and never return. R #38 stated his colostomy bag leaked at the base, and it took a long time for staff to answer the call light. He stated he waited to be changed since early in the morning. J. On 04/08/25 at 12:42 pm during an interview, an Anonymous Certified Nursing Aide (ACNA) stated often there were not enough Certified Nursing Aides (CNAs) working, and it sometimes took a while to get to residents who needed hygiene care. ACNA stated R #6 and R #38 required assistance with personal hygiene.

Based on interview and record review, the facility failed to promptly notify the ordering provider of critical laboratory results for 1 (R #180) of 1 (R #180) resident reviewed for change in condition. This deficient practice could cause a delay in treatment, creating a potential for harm or death to the resident. The findings are: A, Record review of R #180's face sheet revealed an admitted [DATE] with the following diagnoses: - Hepatitis C (inflammation of the liver), - Type II diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Angina pectoris (a type of chest pain caused by reduced blood flow to the heart) with presence of aortocornonary bypass graft (heart bypass surgery; a procedure to restore blood flow to areas of your heart), - Right foot amputation (loss of foot), - Stage 4 severe chronic kidney disease (severe loss of kidney function), - Staphylococcus (bacteria that causes infection) - Psoas muscle (located in the pelvic area) abscess (collection of puss due to an infection.) B. Record review of R #180's lab results, ordered and collected on 03/07/25, revealed the following: - On 03/08/25, some of the lab work came back as critical (Critical lab work results indicate a life-threatening condition and require immediate notification to the responsible healthcare provider for prompt action). - On 03/08/25 at 3:58 am, the lab called the facility, but staff did not answer. - On 03/08/25 at 4:34 am, the lab called the facility, but staff did not answer. - On 03/08/25 at 5:07 am, the lab called the facility, but staff did not answer. - A note, dated 03/08/25, directed staff to call the lab, Please call the lab regarding critical lab values. Unable to reach facility upon numerous attempts made. C. Record review of R #180's lab results, ordered and collected on 03/14/25, revealed the following: - On 03/15/25, some of the lab work that was completed came back as critical. - On 03/15/25 at 3:27 am, the lab called the facility, but staff did not answer. - On 03/15/25 at 4:11 am, the lab called the facility, but staff did not answer. - On 03/15/25 at 4:49 am, the lab called the facility, but staff did not answer. - A note dated, 03/15/25, on the lab work directed staff to call the lab, Please call the lab regarding critical lab values. Unable to reach facility upon numerous attempts made. D. Record review of R #180's medical record revealed staff did not document they called the lab back on 03/08/25 or 03/15/25. E. On 04/08/25 at 9:30 am during an interview with the Nurse #10, she stated when she came on shift on 03/15/25 at 6:00 am, she did not know labs were drawn the day before. She stated no one passed the information down to her when she came on shift. She stated the nurse that entered the order and called the lab should have passed down the information. She stated she found out about the labs because R #180's wife told her about them. Nurse #10 stated she went to R #180's medical chart and saw the resident's lab was critical and out of range. She stated she was relieved R #180's wife said something to her, because the resident needed to be go the hospital immediately. Nurse #10 stated the process for getting information like lab work was not very good. She stated she did not have the information she needed, because she did not receive the information from the night shift nurse during the shift change report. She stated the information should be passed down in report at shift change. She stated if the shift did not have the information, then they could not pass it down to the oncoming shift. She stated the night shift nurse would not have any information regarding lab work to report to her since they missed the lab's phone calls. E. On 04/11/25 at 8:58 am, during an interview with the Director of Nursing (DON), she stated the facility received a lot of complaints about family or providers unable to reach staff when they called the facility. She stated the facility did not have a message system, and callers were not able to leave a message. The DON stated the lab would immediately call the facility if a resident had critical lab results. The DON stated it was expected for staff to get critical labs to the provider as soon as possible, preferably the same day.

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment for resident rooms 205, 206, 207, 208, 211, and 213 when staff failed to: 1) Replace a broken plastic disposable glove holder in room [ROOM NUMBER] and 208. 2) Repair ripped flooring near a resident bed in room [ROOM NUMBER]. 3) Repair the hand rail end piece outside of room [ROOM NUMBER]. 4) Repair or replace a broken closet, a broken dresser, missing dresser drawer, broken blinds, and ripped flooring near the resident's bed in room [ROOM NUMBER]. 5) Maintain the shower in room [ROOM NUMBER] free of the storage of random items. 6) Replace broken blinds, cleaning a wall, and ensuring the room was free from a pungent (strong) urine odor in room [ROOM NUMBER]. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 04/08/25 at 11:20 am, observation of resident room [ROOM NUMBER] revealed a broken glove holder on the wall, a broken thermostat, and a broken dresser drawer. B. On 04/08/25 at 11:26 am, observation of resident room [ROOM NUMBER] revealed an wardrobe with a broken door and a missing bottom drawer, broken blinds, and ripped flooring. Further observations revealed large foam pads and cushions stored in shower. C. On 04/08/25 at 11:28 am, observation of resident room [ROOM NUMBER] revealed the hand rail, directly outside the resident entry door, was missing the end piece. Further observation revealed sharp edges exposed. D. On 04/08/25 at 11:31 am, observation of resident room [ROOM NUMBER] revealed ripped flooring by bed A. E. On 04/08/25 at 11:34 am, observation of resident #213 revealed broken blinds; a green gum-like substance on the wall in several spots by bed B, and a strong urine odor. F. On 04/09/25 at 9:53 am, observation of the Memory Care Unit revealed the following: - Ceiling vents throughout entire unit were filthy dust build-up. - Light covering in the hallway by resident room [ROOM NUMBER] was broken and missing a piece of plastic. - Ceiling tiles near the nurses station had brown spots splattered on them. - A gap around the sprinkler head on the ceiling near the exit door. G. On 04/11/25 at 3:25 pm during an interview, the Maintenance Director stated it was the responsibility of the Certified Nurse Aides (CNAs) and the nurses to submit work order requests through their electronic system. He stated he was currently the only maintenance person. H. On 04/14/25 at 2:23 pm during an interview, the Director of the Memory Unit verified the environmental and safety concerns and stated these concerns should be repaired.

Based on interview and record review, the facility failed to keep a resident free from abuse for 1 (R #2) of 3 (R #2) residents reviewed for abuse when Certified Nurse Aide (CNA) was verbally and physically abusive to R #2 when providing care. This deficient practice likely resulted in emotional distress and trauma for R #2. The findings are: A. Record review of the face sheet for R #2 revealed the following: - Schizophrenia (mental health disorder that affects an individual's ability to think, feel, and behave clearly), - Alzheimer's disease (a group of symptoms that affects memory, thinking and interferes with daily life), - Disruptive mood dysregulation disorder (causes chronic, intense irritability and frequent angry outbursts), - Cognitive communication deficit (communication difficulty), - Anxiety, - Depression, - Metabolic encephalopathy (change in how your brain works due to an underlying condition). - This is not an all inclusive list. - R #2 was initially admitted to the facility in 01/09/18. B. On 08/23/24 at 1:23 pm, during an interview with R #2, she stated she remembered CNA #5 yelled at her and pulled her hair. She stated she felt scared, like she was in trouble. She stated she felt fine now because no one was pulling her hair. C. Record review of the care plan for R #2, last revised on 03/11/22, indicated she had the potential to demonstrate verbal behaviors related to cognitive loss/dementia, schizophrenia, anxiety, history of verbal outbursts directed toward others, pseudobulbar affect (a neurological condition that causes people to have sudden, uncontrollable, and inappropriate episodes of abusive language, challenging or confrontational verbal behavior, hitting, scratching, resisting care.) D. On 08/21/24 at 3:42 pm, during an interview with CNA #6, she stated she was asked to work a few hours on the evening/night shift on 06/01/24 and she did. She stated CNA #5 asked her to assist with putting residents to bed during the evening/night shift. CNA #6 stated when they started to take R #2 to bed, the resident became upset and started to yell things like fuck you, bitch and whore. CNA #6 stated CNA #5 yelled back at R #2, and that made R #2's behaviors worse. CNA #6 stated when they got to R #2's room, she (CNA #6) went around to the far side of the resident's bed so she could control the bed. CNA #6 stated she heard a smack at one point and saw CNA #5 pulling away from R #2's knee. She stated she did not see CNA #5 hit R #2, but she saw CNA #5's hand pulling away and heard the noise of a smack. CNA #6 stated R #2 and CNA #5 continued to yell at each other, and she heard CNA #5 yell I hate you, too and Fuck you, too. CNA #6 stated she saw R #2 swing at CNA #5. CNA #6 stated she came around the bed to help with the resident, and she saw CNA #5 pulling R #2's hair. She stated CNA #5 had a fist full of the resident's hair and was pulling it straight up towards the ceiling. She said R #2 was screaming. CNA #6 stated she could not believe it. CNA #6 said she did not say anything to CNA #5 at this time, she felt like it would escalate the situation and just wanted to go and report it. CNA #6 stated she tried to make sure R #2 was safe in bed before she left the room. CNA #6 said she was going to leave the room, but CNA #5 told her to raise up the resident's bed. CNA #6 stated she turned around to grab the bed remote, and CNA #5 cussed at R #2. CNA #6 stated she witnessed CNA #5 put both hands on R #2's arms and pushed her down on the bed. She stated CNA #5 yelled, I fucking hate you. CNA #6 stated she immediately left the room, went and reported it to the nurse. She stated the nurse reported it to the weekend Unit Manger. She stated CNA #5 left the facility shortly after the incident. CNA #6 stated she went back to R #2's room, checked on the resident, and gave her some comfort. She stated R #2 seemed ok. F. On 08/22/24 at 12:11 pm, during an interview with Unit Manager #2, she stated she received a call from CNA #6 on 06/01/24. She stated CNA #6 told her she was helping to change R #2 when she saw CNA #5 abuse R #2. UM #2 stated CNA #6 told her in detail what she saw. UM #2 stated she called the nurse supervisor as soon as she got off the phone with CNA #6 and told him to suspend CNA #5 immediately. UM #2 stated the nurse supervisor suspended CNA #5. G. On 08/22/24 at 9:40 am, during an interview with the Administrator, he stated the UM #2 notified him of the incident and what happened. He stated CNA #5 was fired. He stated there was not a question about the incident and what happened, he believed CNA #6 and it was witnessed. He stated that he never spoke with CNA #5. CNA #5 was red lined in their system (she cannot be hired again by the corporation). The Administrator stated he never interviewed CNA #5 about the incident, but she was surprised when she was fired. He said CNA #5 did not have any previous allegations of abuse before the incident. He stated there were some complaints that she was rude sometimes and her attitude was not great.

Based on record review and interview, the facility failed to ensure that residents receive care consistent with professional standards to prevent pressure ulcers from developing for 5 (R #1-5) of 5 (R #1-5) residents who developed facility acquired pressure ulcers/sores (injury to the skin or tissue over a bony area) by: 1. The development and worsening of Stage 3 (deep skin ulcer evolved in crater like abrasion, through the second layer of skin into the fat tissue) and unstageable pressure sores (full thickness tissue loss but unable to determine the depth of the sore) for R #1-5. 2. Not starting treatment after identifying a pressure sore on 02/14/18 to 02/18/18, which resulted in a Stage 3 pressure sores identified on 02/19/18 for R #1. 2. Inaccurately assessing R #5 risk for developing pressure sore even after developing an unstageable pressure ulcer to her right buttock. 3. Conducting inaccurate Skin Check assessments for R #4 and R #5. 4. Not assessing R #4 for wheelchair use, which resulted in the development of Stage 3 pressure sores. 5. Changing R #2 from a wheelchair to Geri-chair (seat with large padded cushions that reclines) which resulted in the development of unstageable pressure sore to her sacrum. 6. Not implementing additional preventative measures for R #1-5 assessed at risk for pressure sore development. These deficient practice likely resulted in residents developing avoidable pressure ulcers, which likely resulted in pain and discomfort. The findings are: Findings for R #1: A. Record review of the Admission History and Physical dated 12/20/17 revealed that R #1 was admitted to the facility on [DATE] with Diagnosis: [REDACTED]. R #1 is fed via g tube (a medical tube that is inserted into the patient's digestive tract and delivers liquid nutrients and medicines to the body) and has a [MEDICAL CONDITION] (a surgical procedure in which an opening is formed by drawing the healthy end of the large intestine or colon through an incision in the abdominal wall which provides an alternative channel for feces to leave the body). B. On 06/28/18 at 10:00 am during interview with R #1's daughter, she stated that R #1 was never repositioned and was only put in his wheelchair for therapy. She stated that before he left for the hospital the last time (02/19/18), he had a bad pressure sore, the size of a baseball. She stated that while staff was changing her father on 02/19/18, both daughter and staff noticed the sore for the first time- It looked awful. C. Record review of R #1's care plan dated 02/16/18 and initiated by Licensed Practical Nurse (LPN) #2 stated Resident is at risk for skin breakdown as evidenced by limited mobility. D. Record review of facility Skin Check document dated 02/14/18 identified a new a pressure wound located on the right and left buttocks. Interventions for wound care treatment indicated: Apply barrier cream (cream to protect skin from dampness) with each cleansing and assist resident in turning and reposition every ____ (blank) hrs. This document was signed by Licensed Practical Nurse (LPN) #1. The skin check did not include measurements or wound staging (degree of injury). No skin check documents completed before 02/14/18 indicated any skin breakdown. E. Record review of facility progress notes revealed: 1. 02/14/18 at 1:46 am: a note completed by LPN #1 which stated a skin check was performed. The following New skin injury/wound(s) were identified: Pressure Area(s): location(s): right and left buttocks. 2. 02/15/18: no note regarding skin assessment, skin care or skin breakdown. No note indicated any breakdown of skin on the buttocks area or any treatment of [REDACTED]. 3. 02/16/18: no note regarding skin assessment, skin care or skin breakdown. No note indicated any breakdown of skin on the buttocks area or any treatment of [REDACTED]. 4. 02/16/18 at 7:05 pm: a Post Admission Family conference. The note is signed by LPN #2. There is no indication during the care conference that R #1 has any skin breakdown, has been assessed for any skin breakdown or is being treated for [REDACTED]. 5. 02/17/18: no note regarding skin assessment, skin care or skin breakdown. No note indicated any breakdown of skin on the buttocks area or any treatment of [REDACTED]. 6. 02/18/18 at 7:18 pm: CNA (certified nurses aide) reported an open sore on the resident's bottom. Upon assessment, it looks similar to a Kennedy ulcer (an open, rapidly developing, wound of irregular shape associated with end of life) vs (versus) pressure ulcer. Provider called and orders received for wound care. Provider asked for attending to assess resident tomorrow (02/19/18). 7. 02/19/18 at 4:12 am: Per day shift RN (Registered Nurse), new wound to sacral (triangle bone at bottom of spine) area. Assessed wound, appears to be a bruise with shearing, not actively bleeding. Will report to day shift nurse for MD (medical doctor) assessment in a.m. (morning) Wound not previously noted. 8. 02/19/18 at 1:50 pm: Family stated that he (R #1) had received a wound while at facility. Upon inspection of skin UM (unit manager) (name of unit manager) Registered Nurse (RN) #3 observed a purple butterfly shaped area to coccyx (buttocks) area with dressing in place. The progress note also indicated R #1 was sent to (name of local hospital) at the request of the family due to R #1 appeared to be slow to respond. F. Record review of the Treatment Record dated (MONTH) (YEAR) did not identify any wound care treatment. G. Record review of the Physician orders [REDACTED]. 1. Pressure ulcer- shallow cleanse wound- location buttocks with DermKlenz (a liquid applied to a wound area to clean the wound) and apply stingfree skin prep to periwound (skin and tissue surrounding a wound) skin and adhesive contact. Apply [MEDICATION NAME] Hydrogel (an gelatin [MEDICATION NAME] with vitamin E and applied to a wound area to promote healing and maintain moistuere) and cover with Dermadress (a sterile, multi-layered composite wound covering similar to a large bandaid) composite. 2. Pressure distribution cushion to chair 3. Pressure redistribution mattress to bed H. Record review of (name of local hospital) Emergency Department notes dated 02/19/18 at 2:19 pm revealed a skin assessment completed by the emergency room provider indicating a stage 3, 6x4 cm (centimeter) decubitus ulcers (alternate name for pressure ulcer) on bilateral (both) sacrum (buttock) area. I. On 06/28/18 at 11:00 am during interview with the Wound Care Nurse (WCN) regarding wound care of residents, she stated that she is the designated and trained wound care nurse for the facility. WCN stated that a pressure ulcer could begin to show signs such as redness and if left untreated could develop into a stage 3 pressure ulcer within a couple days. She also stated that she did not recall assessing or treating R #1 and she checked her treatment book and confirmed she had no record of having been informed or R #1's pressure sore or of assessing and treating it. Findings for R #4: J. Record review of the Admission Record for R #4 revealed that she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. K. Record review of the Lift Transfer Reposition assessment for R #4 dated 04/03/18 revealed patient able to transfer independently or with supervision without using a device. L. Record review of the Braden Scale for predicting Pressure Sore Risk revealed the following scores (score of 16 or less is considered risk for developing pressure ulcers): 1. 04/10/18: 14 2. 04/24/18: 13 M. Record review of Progress Notes for R #4 revealed: 1. 04/03/18 Arrived by wheelchair van and w (with) wheelchair. 2. 04/04/18 Resident utilized w/c (wheelchair) for motivating (sic) around unit. It has been reported that she was ambulatory (related to or adapted to walking) at her last facility. She has made no attempt to ambulate since her arrival. resident confused and slightly agitated at times. She will require some time to adjust to new surroundings. 3. 04/12/18 Referral to PT (physical therapy) has been put in on 4/4/2018. Haven't been able to get a hold of family for consents. 4. 04/14/18 Resident W/C (wheelchair) bound. She requires assistance to transfer. Apparently, she was ambulatory prior to transfer to this facility. Speech is impaired. She is able to make her basic needs known and follow instructions. 5. 04/22/18 PT eval remains pending. 6. 04/29/18 No therapies at this time. 7. 05/03/18 Our staff reported that she had an open wound. Checked skin:: lf (left) buttock, open area, 2x2 cm, two small spots, complained pain. Cleaned with wound cleanser, applied TAO (triple antibiotic ointment) and proveil dressing (sterile wound contact surface with is air and water permeable). Reported to (Name of WCN). N. Record review of the Skin Integrity Report for R #4 revealed: 1. 05/04/18: left gluteal fold (fold of the buttocks) lateral (side), stage 3, 1.1 cm length by 1.3 cm width with less than 0.2 cm depth, 100% granulation (new connective tissue). 2. 05/04/18: left gluteal fold medial (middle), stage 3: 0.7 cm length by 0.9 cm width and less than 0.2 cm depth with 100% granulation. 3. 05/04/18: Right buttock gluteal fold, stage 3: 1.2 cm length by 1.3 cm width with 100% granulation 4. 05/11/18: Both left gluteal wounds merged into 1 wound. 5. 06/05/18: Left gluteal fold, 0.5 cm length by 0/5 cm width with 100% granulation. 6. 06/11/18: Right buttock gluteal fold, resolved. 7. 06/15/18, 06/22/18, 06/26/18: left buttock fold: 0.3 cm length by 0.3 cm width with 100% [MEDICATION NAME] (formers outer layer of skin) O. Record review of the Skin Check assessments for R #4 revealed: 1. 04/04/18, 04/11/18, 04/18/18, 04/25/18, revealed no skin injuries/wounds. 2. 05/03/18, 05/10/18, 05/17/18 revealed pressure wound to buttocks 3. 05/24/18, 05/31/18, 06/05/18: No skin wounds identified 4. 06/12/18 revealed pressure sore on buttocks 5. 06/19/18: No skin wounds identified 6. 06/26/18: 06/28/18: pressure wound on buttocks P. On 06/28/18 at 10:59 am during interview with the WCN she confirmed that R #4 has a facility acquired pressure ulcer. She stated She came to us from another facility and apparently at that facility she was mobile and ambulatory. She was placed in a wheelchair when she came with us. Not sure why. She developed (2) stage 3 ulcer's on each buttock. One has healed and we have her in therapy and she is ambulating with a walker now. The other ulcer is improving, decrease in size granulation to [MEDICATION NAME]. Q. On 06/28/18 at 1:05 pm during observation and interview, R #4 is sitting in a chair in the dining room. Her walker is next to her. She states that she is cold but unable to answer any questions regarding sores or pain. R. On 06/29/18 at 1:36 pm during interview with the Director of Nursing (DON) regarding R #4, she stated that she is very familiar with R #4 because she used to work at the nursing facility that R #4 was transferred from. DON stated She was there for several years and she started exit seeking a lot more, she had a wander guard (bracelet that alerts staff when a resident is trying to leave the building) but was trying to go to front door. They were looking at it being a risk for her safety. She was transferred here for the locked unit. She does really well. She isn't constantly looking for her way out. Regarding the wheelchair use, she stated When she first came in, we wanted to get an eval (evaluation) that it was safe to use a walker. It seemed like she was just sitting in a wheelchair. Very much like she is now sitting in her regular chair. DON confirmed that R #4 uses a walker now and needs only supervision assistance for transfers. S. On 06/29/18 at 2:38 pm during interview with the Resident Care Coordinator (RCC) when asked how R #4 was when she arrived, she stated Pretty much how she is now. She has always been pretty quiet. Didn't move around very much. She didn't want to lay down and she wasn't walking. She confirmed she came in with a wheelchair. When asked if she could get up from her wheelchair, she stated I didn't see her make any attempts to get up. I do know that she refuses to lay down. I know the CNAs would try and lay her down before meals. Nothing has really changed. She will be compliant with most things and then she will refuse. She (R #4) states that she doesn't like it here. When asked if R #4 needs assistance, RCC stated that she is independent and gets up when she wants to, uses her walker, If she wants to move, she can get up. Regarding being referred to therapy, RCC stated that there was a delay in getting her to therapy because the email address (between staff and therapy) was wrong. T. On 06/29/18 at 3:10 pm during interview with Unit Manager (UM) #1, she stated that when R #4 was admitted she just sat, We couldn't get her to move around much or participate in activities. She seemed very upset to be here. She came to us in a wheelchair. UM #1 confirmed that R #4 was not assessed for use of a wheelchair. She stated that she was not aware that she was previously ambulatory, They said at the previous facility she was walking with a walker. If she can walk, I want her to walk. She was pretty confused. She was mad. We had a hard time getting her in the shower. UM #1 confirmed that on 05/04/18, R #4 had (2) unstageable pressure ulcers. I was surprised to see the development at this level. UM #1 confirmed that R #4 just had a regular soft cushion in her wheelchair. UM #1 also stated that all residents admitted to the facility are on standard pressure ulcer precautions (regardless of their Braden Scores) which include repositioning every 2 hours and barrier cream, and that only when a pressure ulcer actually develops are additional interventions implemented for those residents. U. On 06/29/18 at 3:42 pm during interview with the Former Therapy Director (FTD), he confirmed that R #4's therapy evaluation was not completed until 05/04/18. He stated that he had met with R #4 on 04/06/18 to talk about therapy and she was confused and agitated, She was telling me that this isn't where she is suppose to be. She got a little angry. He also confirmed that they were also waiting on payor verification (who will pay for services) before starting therapy. FTD stated that he was unsure why R #4 was put into a wheelchair when she was admitted especially since she was using a walker at her former facility. FTD stated that nursing should be assessing residents before they are just moved into a wheelchair. Findings for R #5: V. Record review of the Admission Record revealed that R #5 was admitted to the facility on [DATE]. W. Record review of the physician progress notes [REDACTED].#5 was diagnosed with [REDACTED]. X. Record review of the Braden Scale for Predicting Pressure Sore Risk for R #5 revealed the following scores: 1. 01/16/18: 21 2. 01/23/18: 21 3. 01/30/18: 21 4. 02/28/18: 22 5. 03/07/18: 21 6. 03/14/18: 20 7. 05/15/18: 20 8. 05/22/18: 20 9. 05/29/18: 20 Y. Record review of the Skin Integrity Report for R #5 right buttock revealed: 1. 03/19/18: Skin Tear 1.4 by 1.4 centimeter (cm) with 100% granulation. Note identifying changed to pressure dated 03/29/18 2. 03/29/18: 1.6 cm length by 1.7 cm width with less than 0.2 cm depth with 50% slough (yellow [MEDICATION NAME] tissue) and 50% granulation 3. 04/05/18: Stage 3 pressure ulcer, 1.6 cm length by 1.7 cm width with less than 0.2 cm depth with 50% slough and 50% granulation 4. 04/12/18: Stage 3 pressure ulcer, 1.6 cm length by 1.7 cm width with less than 0.2 cm depth with 25% slough and 75% granulation. 5. 04/19/18: Stage 3 pressure ulcer, 0.8 cm length by 0.9 cm width with less than 0.2 cm depth with 25% slough and 75% granulation 6: 04/26/18: Unstageable pressure ulcer, 1.8 cm length by 1.7 cm width with 100% slough 7. 05/03/18: Unstageable pressure ulcer, 3.5 cm length by 3.2 cm width with 100% slough 8. 05/10/18: Unstageable pressure ulcer, 3.0 cm length by 3.2 cm width with 80% slough and 20% granulation 9. 05/17/18: Stage 3 pressure ulcer, 3.0 cm length by 3.2 cm width with 10% slough and 90% granulation 10: 05/24/18: Stage 3 pressure ulcer, 4.0 cm length by 3.2 cm width with 50% slough and 50% granulation 11: 06/07/18: Stage 3 pressure ulcer, 3.5 cm length by 3.0 cm width with 25% slough and 75% granulation 12. 06/21/18: Stage 3 pressure ulcer, 2.9 cm length by 2.8 cm width with 100% granulation Z. Record review of the physician progress notes [REDACTED].>1. 04/04/18: No mention of any pressure injuries 2. 04/16/18: No mention of any pressure injuries 3. 05/02/18: Nursing staff informs me that pt (patient) wound is healing well and in no (sic) the size of a quarter. They report pt receives wound care 2x (times)/day. AA. Record review of Skin Checks Assesments for R #5 revealed: 1. 03/22/18, 03/26/18 and 03/29/18 identified scab to right upper thigh 2. 04/05/18: No skin injury/wounds identified 3. 04/09/18 to 05/09/18: Identified wound to right upper thigh/buttock BB. Record review of the Care Plan for R #5 dated 03/19/18 revealed (Name of R #5) has actual skin breakdown related to moisture/excessive perspiration, shear/friction risks, incontinence (having no or minimal voluntary control over urination), limited mobility, impaired sensation, frequent refusal of turning/repositioning, frequent refusal of brief change. CC. Record review of Wound Care Nurse note revealed: 1. 04/05/18: new scabbed area noted to R (right) buttock, which upon assessment, has been noted to be caused from a shearing force/skin tear. New orders received to clean and cover daily. R buttock pressure ulcer stage III has had no change; Will continue daily Santyl (enzyme helps break up and remove dead skin) treatment. 2. 04/16/18: Patient's R buttock wounds have declined, AEB necrosis development, increase in size .New treatment orders received to cleanse site with wound cleaner, pat dry, skin prep peri-wound (tissue surrounding wound), apply [MEDICATION NAME] (wound care dressing) to wound bed, cover with foam dressing qd (every day) and PRN (as needed). Assessed wheelchair to ensure roho (contoured foam base) cushion in place as patient prefers to stay up in wheelchair all day long. No cushion. 3. 04/19/18: R (right) proximal (near the center) buttock wound has had a decline AEB (as evidenced by) increase in size, development of necrosis (cell injury resulting in premature cell death) to wound bed .PA (Physician Assistant) notified of wound decline, new order received to insert foley catheter (thin tube inserted into the bladder to drain urine) to control moisture to wound as patient is incontinent until wound resolve. LAL (low air loss: circulate a constant air flow) mattress also ordered to aid in wound management. 4. 05/03/18: Wounds to R buttock have enlarged and turned into one single wound, wound bed 100% slough .Patient spends majority of day in wheelchair, as she declines to lay in bed in order to relieve pressure to buttocks. Mental disabilities may impair patients ability to understand education given on benefits of offloading pressure to her buttocks, although she verbalizes understanding. DD. On 06/28/18 at 10:59 am during interview with Wound Care Nurse, she stated that R #5 developed 4 small wounds on her right buttock and they merged into one large wound since she has been admitted to the facility. She stated I was notified when they were 4 small wounds. They were unstageable. All I can say is that when they (staff) tell me (about the wound) I look at the wound that day. WCN confirmed that staff may not be informing her immediately when a wound is observed. She stated, For a wound to turn that severe that quickly, the resident is probably not being repositioned. EE. On 06/28/18 at 12:45 pm during observation and interview, R #5 is sitting in her wheelchair in the dining room. She confirms that she has sores on her a** but that they are healing. R #5 denies any pain. FF. On 06/28/18 at 12:49 pm during interview with Licensed Practical Nurse (LPN) #3 regarding R #5, she states She usually lays down for short periods of time but then wants to get up. She needs assistance getting in and out of bed. She can stand a bit and (staff) have her stand up and then sit her back in the chair (to reposition her). LPN #3 states that when the wounds were first noticed they were small less than dime size. She states that residents' skin is checked twice weekly during showers by the Aides and during peri-care (washing the genitals and anal area) and then once weekly by the nurse. She stated that if a wound is noted, the nurse puts it in the 24 hour progress notes to be reviewed the following day in the daily meeting. GG. On 06/29/18 at 1:06 pm during observation, R #5 is in the dining room, sitting in her wheelchair in the middle of the room, trying to use her feet to scoot the wheelchair forward. the foot rests are flipped upwards. R #5 seems to be struggling to move herself, and scoots herself forward in the chair to get a better foot grip. HH. On 06/29/18 at 3:10 pm during interview with the Unit Manager (UM) #1 regarding R #5, she stated It was probably the third skin check that we noticed little bubbles on her bottom, Unstageable blisters. She was having behaviors of eating off other peoples plates and eating snacks. It was hard to get her out of the chair and she was a heavy wetter. She wouldn't let us take her to the restroom. She did have behaviors at one point. She would take her clothes off at the end of the bed and roll around in her bm (bowel movement). We tried toiletting for BMs. Because she would sneak food from everyone we could never know when she needed to BM. Her focus is food. Anything that tiers her away from food is not going to work for her. Findings for R #2: II. Record review of Admission Record revealed that R #2 was admitted to the facility on [DATE], with the following Diagnosis: [REDACTED]. JJ. Record review of the Skin Integrity Report for R #3 dated 06/25/18 revealed unstageable pressure sore to her sacrum (triangular bone at the base of the spine) 1 cm length by 1 cm width and 100% slough. KK. Record review of Progress Notes dated 06/25/18 revealed Wound appears to be caused by pressure, unstageable. PT/OT eval (evaluation) pending for appropriate chair per Unit Manager .Patient to be turned and repositioned Q (every) 2 hours. LL. Record review of Care Plan for R #2 initiated 01/11/16 and revised 04/22/18 revealed (Name of R #2) is at risk for skin breakdown as evidenced by incontinence and decreased mobility. MM. On 06/28/18 at 10:59 am during interview with WCN, she confirmed that R #2 developed an unstageable pressure ulcer on her sacrum while at the facility. She stated They just recently switched her to a geri-chair from a wheelchair. We were not able to put any cushions (in the geri chair) and she broke down on her sacrum and now has an unstageable (wound). I was not made aware of any signs of breakdown until she had an open wound and I staged it unstageable. We put a PT/OT referral to decide the most appropriate chair. She is being turned and repositioned. She is fine with turning just needs reminding. I am seeing her in bed more often (now since the wound developed). I have never had issues (wounds) in the wheelchair until she was switched to geri-chair. I was not made aware that happened (chair switch) until the wound was present. NN. On 06/28/18 during an interview with UM #1, she stated that R #2 had been in a regular wheelchair and then staff decided to move her to a geri-chair because she appeared to be more comfortable and was able to stretch and move around more on the geri-chair. Now that she is moving around more in her chair is when UM #1 thinks she got the wound on her sacrum. OO. On 06/28/18 and 06/29/18 during several observations R #2 was observed in a geri-chair surrounded with pillows in the TV (television) room. R #2 was also observed being repositioned by staff. Findings for R #3: PP. Record review of the Admission Record revealed that R #3 was admitted to the facility on [DATE]. QQ. Record review of Progress Notes for R #3 revealed: 1. 06/08/18 Resident admitted .arrived by wheelchair van w/ wheelchair. Reason for admission is post trauma and/or accident Rehabilitation. A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: Bruise(s): description: RUE (right upper extremity) other wound(s): Location(s): Burn areas on UEs (upper extremity), ABD (Abdomen) and chest. Donor site (portion of the body where skin was transplanted) on thighs and back. 2. 06/21/18 Last week patient had notable poor appetite, decreased intake, per dietician report. Supplements ordered. Patient reports she needs side rails in order to turn and reposition properly, but reports willingness and understanding of benefits. Management notified of patient's need for siderails. 3. 06/22/18: Due to sacral unstageable pressure ulcer and skin graft (skin transplant) donor sited bilateral thighs, which are frequently noted to be urine-soaked, PA (Physician Assistant) (Name of PA #1) order for foley catheter insertion until wounds stabilize for wound management aid Patient now has bed enablers to aid in turning/repositioning which patient does herself, with reminders by staff. RR. Record review of the Braden Scale for Predicting Pressure Sore revealed the following scores: 1. 06/08/18: 20 2. 06/12/18: 18 3. 06/15/18: 16 4. 06/26/18: 14 SS. Record review of the Skin Integrity Report for R #3 revealed that on 06/18/18 and 06/25/18, R #3 has an unstageable pressure sore to her sacrum measuring 4.5 cm length by 6 cm width at 100% slough. TT. Record review of Care Plan for R #3 revealed: 1. 06/20/18 resident/patient requires assistance/is dependent for ADLs care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfers, locomotion, toileting related to: Limited mobility. 2. 06/08/18 (Name of R #3) is at risk for alterations in comfort related to acute pain, burns. 3. 06/20/18 Resident is at risk for skin breakdown as evidenced by limited mobility. UU. On 06/28/18 at 10:59 am during interview with the WCN, she stated that R #3 acquired an unstageable pressure sore since admission to the facility. She stated She came in [MEDICAL CONDITION] 30 % of her body and it was grafted. When she first came in her appetite was poor and intake and hydration was very poor. She has an Unstageable on her sacrum. I did look at the skin assessment (prior to development of the sore) and it stated no new changes. I think there probably were signs (of a pressure sore before it became unstageable). The standard of care is turning and repositioning. As soon as we noted appetite was poor and her pain wasn't being management, we gave her IV bolus (large amount of fluid delivered at a fast rate) and pain is better now too. It (sore) is still unstageable. I also asked to have a foley catheter inserted, it (urine) was soaking her dressing. Patient was in agreement. Low airloss mattress. PT/OT (Occupational Therapist) is helping with mobility which helps with repositioning. She is now able to transfer herself to bed. RD (Registered Dietician) is following too. VV. On 06/28/18 at 12:50 during interview with R #3 she stated that she has a wound on her back end and that the nurse here believes that she got it from sitting in a wet diaper. She stated that the wound is not part of the grafts or burns. R #3 stated I think it (sore) started shortly after I got here. R #3 stated she did not recall what had happened (treatment/care) when she first arrived because she was in a lot of pain and was unable to contribute to any part of her care.

The facility failed to ensure that residents were free from accidents by failing to address water leaking from the ceiling and pooling on the floor of Resident #76's room. A night shift CNA (Certified Nursing Aide) placed a towel over the water but failed to notify maintenance of the issue. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, being identified at the facility on 06/09/15 at 1:10 pm. The facility administrator was notified at this time. The facility took corrective action by providing an acceptable Plan of Removal on 06/09/15 at 2:25 pm. Based on the Plan of Removal, interventions included: 1. Immediate rounds made to all resident rooms for ceiling leaks and correct immediately, 2. Weekly Maintenance rounds to monitor for ceiling leaks and correct immediately if identified, 3. Current staff will be in-serviced regarding immediate notification of maintenance of any water leaks in areas of resident access and to provide safe environment for residents in area by restricting access until corrected and 4. Maintenance will complete monthly preventative maintenance on air conditioning drain plugs. On 06/10/2015 at 2:45 pm during observation, Resident #76's room revealed that there was no longer a towel on the floor and the metal plate was no longer dripping water. Based on the Plan of Removal and observation, the IJ was lifted on 06/09/15 at 2:25 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of D. Based on observation, interview and record review, the facility failed to address an ongoing problem of a leak in the ceiling of one (R #76's) of four (R #s 14, 76, 150 and 243) residents reviewed for accident/hazards. This deficient practice was an immediate jeopardy situation to the resident due to the possibility of slipping and falling. The findings are: Findings for Resident #76 A. On 06/10/15 at 8:33 am, during an observation of R #76's room (Room 208) (the secured dementia unit), it was observed that there was a towel on the floor collecting water that was dripping from the ceiling. The water was coming from a metal plate in the ceiling. The metal plate in the ceiling was rusty in some areas. B. On 06/10/15 at 8:33 am, during interview with R #76. He indicated that he stepped in it (pointing at the wet towel) that morning when he had gotten up to go to the bathroom. C. On 06/10/15 at 9:25 am, during observation of R #76's room, he was observed to be up and out of bed going towards the bathroom. D. On 06/10/15 at 9:25 am, during observation of R #76's room (Room 208), the towel was still on the floor and was very wet when touched. The metal plate in the ceiling was still dripping water onto the towel. E. On 06/10/2015 at 9:28 am, during an interview with CNA #3, she stated that the reason for the towel placed on the floor of room 208 was due to the rain from the previous night when it was noticed (by a night shift CNA) that the roof was leaking. CNA #3 stated that the night shift CNA placed the towel on the floor and told the day shift staff that this was due to the ceiling leaking. F. On 06/10/15 at 9:32 am, during an interview with LPN (Licensed Practical Nurse) #1, she stated that Resident #76 is ambulatory and is able to get in and out of bed on his own with the assistance of his walker. LPN #3 stated that she was unaware of the towel on the floor and stated that this has happened before when it has rained heavily. LPN #3 stated, I didn't think it rained that hard. G. On 06/10/15 at 9:55 am, during interview with CNA #4 she stated that the night shift CNAs informed her that the roof was leaking and that they put the towel there so the resident didn't slip. CNA #4 stated that she did not know if anyone notified the Maintenance Director. CNA #4 stated that if the staff notice maintenance issues, they fill out a work order and place them in a slot at the nurses station and the maintenance department picks them up each day. CNA #4 stated that she is not sure if an order had been placed and/or picked up. H. On 06/10/15 at 10:01 am, during interview with the Maintenance Director, he stated that he was not aware that the roof in Resident #76's room was currently leaking but stated that, It's probably the air conditioner. I'll go check it now. The Maintenance Director stated that the air conditioner, Sweats and leaks into a pan in the ceiling and when it gets backed up, it leaks into the room and I have to get a ladder to fix it. The Maintenance Director stated that he would expect that a work order would be filled out when the issue was identified by the staff, but confirmed that a work order for the leaking roof had not been placed in the maintenance Log Box by staff. I. Record review of the maintenance log book from 01/2015 to 06/2015 revealed that no work order had been made. J. On 06/10/15 1:00 pm, during interview with the Administrator, she stated that if there was a leak in the roof somewhere in the building, staff should complete a work order and notify maintenance right away and that this should take place (during business hours) no longer than one hour of identifying the leak. The Administrator stated that some of the safety measures that should take place are to block off the area, put up a sign to notify of the wet floor and place a bucket under the leak.

Based on observation, record review, and interview, the facility failed to promote care for 2 (R #51 and #224) of 2 (R #51 and #224) sampled residents in which Resident #51 was left on a bed pan (an object used for toileting of a bedridden patient) for forty two minutes, which caused him pain. Residents #51 was also left wet and cold when his bedding hadn't been changed after using a urinal (a device that allows people to urinate while they are in bed). Resident #224 was observed calling out for help, and could be heard calling out for help at the nurses station for twenty four minutes and no staff attended to the resident. This deficient practice has the potential to cause embarrassment and harm to residents who are dependent on facility staff for assistance. The findings are: Resident #51 A. Review of the Facility Grievance Reports revealed the following: 1. On 07/23/14 Resident #51 reported to therapy staff, "That yesterday after dinner, he was left on the bedpan for 42 min (minutes), at which time Certified Nursing Assistant (CNA) returned to clean pt (patient). Pt. (patient) reports he was in pain and very upset." 2. On 07/30/14 Resident #51 reported to a Physical Therapist (identified as PT #1), "He (the resident) woke up at 3:00 am, to use urinal and had a spill. That his (CNA) (identified as CNA #1) came in and gave him (the resident) a sheet and blanket and left the room...(Name of Resident #51) stated he fell asleep waiting for the CNA (identified as CNA #1) to return, woke again at 5:30 am, wet and cold. (Name of Resident #51) says CNA (identified as CNA #1) returned and said he was getting off his shift at 6:00 am and the next CNA could help change his sheets. The floor was still wet and sticky with urine...Pt. (patient) extremely upset..." B. On 08/05/14 at 8:50 am, observation of Resident #51 revealed the resident to be laying in bed. The resident (Resident #51) was also observed to have no lower legs and was having to use his upper body to move around. He was also observed to be dependent on staff for activities of daily living (ADLs). C. On 08/05/14 at 8:51 am, during interview when Resident #51 was asked if the staff treat him with respect and dignity, he stated, "Some do and some don't. Some are really snotty. If it wasn't for the patients here, they (referring to the staff) wouldn't have a job. Once, a staff member left me here (referring to laying in bed)for forty two minutes on the bed pan and when she finally came in, I told her I could feel the rings around my butt from the bed pan and it hurt. She could have at least come and checked on me or say, I will come back to check on you, but she did not. It was painful for me. Then another time, another staff was snotty to me. He was just rude to me. I push the button (referring to the call light) because I was told by the staff to push the light when I need help, so I do, but they don't come. I even filed a grievance about it." D. Review of the Medical Record for Resident #51 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. History and Physical dated 07/03/14 indicated [DIAGNOSES REDACTED]. It further indicated that Resident #51 is alert, oriented to name, month, and answers questions in context and follows commands. 3. Care Plan initiated 07/11/14 indicated that Resident #51 has Impaired Physical Mobility as manifested by requiring extensive to total assistance from staff for bed mobility, transfers, and toileting. The Care Plan further indicated that Resident #51 has Impaired Functional Mobility and requires extensive assistance from staff for dressing, personal hygiene and bathing. The Care Plan further indicated Resident #51 has urinary incontinence and uses briefs for [DIAGNOSES REDACTED]. 4. Admission Minimum Data Set ((MDS) dated [DATE] indicated that Resident #51 is able to make himself understood, has clear speech, and has no short or long term memory problems. It further indicated that Resident #51 requires extensive assistance from staff for toileting, personal hygiene, and is occasionally incontinent (loss of bladder control) of urine. E. On 08/05/14 at 8:10 pm, observation was made of Resident #51 laying in bed. At this time, he was unable to reach a urinal that had been placed on the bathroom sink for him to use. F. On 08/05/14 at 8:11 pm, during interview Resident #51 stated, "The bed pan issue happened to me in the evening time like right about now. I knew forty two minutes had gone by because I looked at the clock on my wall (resident was observed pointing to a clock located on the wall where the resident could see it). That is how I knew forty two minutes had gone by. Another time, one staff person left me here laying in bed wet. I peeded in my urinal and then he came and removed it. He then put it to where I couldn't reach it anymore. I went to pee again and I got the sheet wet. I rang the bell and he didn't come back to my room until 4:30 am. He finally came back and I told him you left me wet. I told him that I was ringing the bell and he didn't come help me. I know my sheets were wet because I was getting cold. I was only given a sheet, but I wanted another cover to stay warm. That person was very snotty to me. I was so upset that I told my Physical Therapist (PT) about it that next morning." G. On 08/07/14 at 7:30 am, during interview CNA #2 stated that she had worked with Resident #51 before and that "He does use a urinal as well as a bed pan." CNA #2 further stated, "He (the resident) did tell me once that he was very upset with the staff. About two weeks ago, I came on my shift in the morning at 6:00 am, and his (Resident #51) call light was on. I went in his (Resident #51's) room and he was upset because the urinal had spilt and his bottom pad was very wet and the top sheet was also wet. He (Resident #51) was complaining that he (the resident) had asked the night shift CNA to change his sheet on the bottom, but he did not. So, when I came on my shift, I found him (Resident #51) really wet. The whole pad underneath him (the resident) was pretty saturated, and the blanket on top of him was wet as well." H. On 08/07/14 at 7:45 am, during interview Licensed Practical Nurse (LPN) #1 stated, "There was one time he (Resident #51) was very upset that he was left on the bed pan. He (the resident) said that one CNA left him on the bed pan for awhile and was upset. I guess, the CNA was with another resident and it took the CNA awhile to get him (Resident #51) off the bed pan." I. On 08/07/14 at 8:43 am, during interview PT #1 stated, "Due to his [MEDICAL CONDITION] , he uses a urinal. He is aware of when he needs to go to the bathroom. I did file a grievance for him 2-3 weeks ago. He (Resident #51) said he was put on the bed pan by staff. He then told me that he had his call light on and forty (40) minutes had gone by and no-one came back to check on him. He pays attention to the clock on the wall and he told me it was forty minutes. I did work with him the following morning and he said that his back side was hurting and he was very upset and uncomfortable with what happened during the night. He did complain to me the next morning. I also filed another grievance for him another morning he was very upset. He said that he had wet the bed and the urine from the urinal had spilled. He pressed the call light and said a CNA came in and only put a cover over him. He said he thought they were going to come back but they didn't. Then in the early morning around 5:30 am or so, he was cold and wet." J. On 08/07/14 at 9:00 am, during interview regarding Resident #51 being left wet after using the urinal, CNA #1 stated that he recalled assisting Resident #51 with his sheet then earlier in the morning, he was getting ready to get off his shift and would let the oncoming day shift CNA know. K. On 08/07/14 at 3:15 pm, during interview the Assistant Director of Nursing (ADON) for the 100 unit stated, regarding the issue with the urinal, it came to my attention on 07/30/14. I went to talk with him (Resident #51) and he told me the night CNA wouldn't change his bed, and the bed stayed wet until the morning. I assured him I wouldn't have the same CNA work with him anymore because I noticed they had certain issues working together. The issue with the bed pan, (name of Resident #51) had wanted to go to the bathroom and the CNA went to put him on the bed pan and another light was going off in another room. When I talked to him, he (Resident #51) said the CNA was gone for 40 minutes and it took her that long to help him off the bed pan." L. On 08/07/14 at 3:18 pm, during interview regarding Resident #51 being left on the bed pan, CNA #3 stated, "That was my first time working with him. He used the call light and had to go to the bathroom so I put him on the bed pan. I then gave him the call light to call when he was finished. At that time, I walked out of his room to help another resident who's call light was going off and I took a little slower time to get back to help him. He waited a little too long, to be taken off the bed pan. It was around twenty (20) minutes I would say that he was waiting. I got pulled away to help someone else. I just got busy." Resident #224 M. On 08/05/14 at 10:15 am, observation of Resident #224 revealed her to be sitting in a wheelchair with a very large purple and blue bruise over her entire right eye. Her right eyelid and cheek bone also had a very large laceration above her right eyebrow. The bruise was seen extending from the whole eyelid, and cheekbone. N. On 08/06/14 from 8:00 am to 8:24 am, (twenty four minutes) observation of Resident #224 was made of the resident calling out 'Help, Help' on the 100 unit. At this time, (Resident #224) could be heard at the nurses station from her room calling out for help. Twenty four minutes had gone by and no staff had gone in Resident #224's room to help her. Staff were observed walking by Resident #224's room and she (the Resident) could still be heard calling out 'Hello, Help, Help' and nobody would help her. O. On 08/07/14 at 7:30 am, during interview CNA #2 stated, "She (Resident #224) goes through periods of confusion and really isn't able to use the call light. I know she had a bad fall a while ago, and sometimes she can't recall things that happened a few hours before. She is really confused." P. On 08/07/14 at 4:10 pm, during interview Registered Nurse (RN) #1 stated, "She (Resident #224) is very confused. She calls out at times and at times will scream out." Q. On 08/08/14 at 10:43 am, observation of Resident #224 was made. She was observed sitting in the 100 day room with her right eye black and blue, bruises to the left forearm, and laceration above the right eye. R. On 08/08/14 at 12:38 pm, Resident #224 was again heard calling out for help. She could be heard at the nurses station calling out, 'Hello' and 'Help' from her room. Ten (10) minutes had gone by before staff entered her room to assist her. S. Review of the Medical Record for Resident #224 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. History and Physical dated 07/22/14 indicated Resident #224 also has a Percutaneous Endoscopic Gastrostomy (PEG tube), (a flexible feeding tube that is placed through the abdominal wall and into the stomach). It further indicated that Resident #224 has cognitive deficits, oriented to name only, and has poor memory. 3. Admission MDS dated [DATE] indicated Resident #224 required extensive assistance from staff for bed mobility, and transfers. 4. Care Plan (no date) indicated that Resident #224 is at risk for falls. Staff are to answer call lights in a timely manner, and encourage to call for assistance. 5. Departmental Notes dated 08/02/14 indicated, "Pt (patient) has been calling and yelling out from her room very frequently the past few days according to staff." Based on observation, record review and interviews, the facility failed to ensure 6 (R #2, 10, 35, 101, 130, and 172) of 6 (R's #2, 10, 35, 101, 130, and 172) sampled residents were cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Resident's indicated they waited a long time for staff to answer call lights which resulted in them soiling themselves, having to call out for help from staff, and staff being rude or harsh when answering call lights. This deficient practice has the potential to cause embarrassment and harm to residents who are dependent on facility staff for assistance. The findings are: A. On 08/05/14 at 9:20 am, during interview Resident #2 stated, "They need more staff to help the three people (referring to staff on the 300 unit). Sometime's I have to wait and wait. Seems like it's throughout the day." B. On 08/05/14 at 3:58 pm, during interview Resident #10 was asked if she has to wait a long time for staff to assist her, she stated, "Sometimes I have to wait a long time for assistance. We get help eventually, but sometimes it takes a while. In the evening and at night." C. On 08/06/14 at 8:29 pm, during interview when Resident #35 was asked how do the staff treat her, she stated, "There was one incident with a CNA. She said I spoke sharply to her. She got mad, and threw the diaper on the bed and said 'here you can get someone else to help you'...The other night, my CNA, kind of chewed me out for putting a new pink mat on my chair instead of on the bed. She was just mad, because I used the new mat that was for the bed on the chair to sit on." When asked if she (Resident #35) feels afraid to make a complaint for fear of retaliation, she stated, "They say that we won't but I don't know." D. On 08/08/14 at 8:08 am during observation, at the nurses station on the 300 unit, Resident #101 was in room [ROOM NUMBER] calling out, "Please, sombody help me. Please, somebody help me." No staff other than the Certified Medication Aide (CMA) was on the unit. The call light went on at 8:10 am. At 8:15 am, Resident #101 was yelling out "Nurse, Nurse." At 8:18 am, the Maintaince Director went into the residents room. He told Resident #101 he would go find somebody to help get him up. The call light went on again at 8:21 am, the Staffing Coordinator went in. Resident #101 told them he wanted to get up because he had a doctor's appointment at ten. CNA #9 went in at 8:22 am, stated "I'll be back" and came back out. At 8:24 am, CNA #7 went in with the lift (a device used to get residents out of bed) and stated that she needed to wait for her partner. At 8:35 am, CNA #9 came in to help CNA #7. From 8:10 am to 8:35 am, Resident #101 was observed calling out for help. E. On 08/06/14 at 8:46 pm, during interview, Resident #130 stated, "I would tell the staff that I have to go to the restroom and she (staff) would tell me just to go in my brief, and I said I can't do that. She said just to do it, and I will clean it. But I can't do that." F. On 08/04/14 at 1:04 pm, during observation of lunch service in the main dining room, Resident #172 was sitting in a high back wheelchair, his left arm was in a splint, and both feet were on the foot rest. He told CNA #10 that he wanted to leave the dinning room, he asked her if she could help him. CNA #10 told him one minute and instead took another resident a meal tray to their room. Resident #172 is unable to ambulate his wheelchair on his own, so he was observed waiting in his wheelchair next to the table. A staff member came and removed Resident #172 from the main dining room at 1:16 pm. Resident #172 was waiting for twelve minutes. G. On 08/04/14 at 3:48 pm, during interview Resident #172 stated, "When I ask for something, like to go to bed, they (referring to staff) say no, that I don't have to or they come up with and excuse. It happens quite often." When asked if it's a particular shift, he stated, "It's anytime. Half the time I'm hollering for the nurse, because they don't see the call light, then they come in and yell at me and tell me I'm disturbing the other residents. They tell me they can't take me to my room until everybody else finishes dinner." Resident #172 stated, that he has asked to go to the bathroom and they don't come back and he's dirtied his briefs and they just clean him up with a bed bath or sometimes a shower, "It's a horrible feeling." H. On 08/04/14 at 4:15 pm, during interview Resident #172 pushed his call light for help because he was having pain in his left arm. CNA #6 came in at 4:32 pm, he (the resident) told her that he needed to use the restroom. She (CNA#6) said ok, she'll go get the lift. As of 4:38 pm she (CNA #6) had not returned to take Resident #172 to the restoom. After leaving his room, no CNAs were visible on the 300 unit. (Call light was observed going off for twenty five minutes without staff assisting the resident) I. On 08/07/14 at 11:37 am, during interview Resident # 172 stated that he did recall pushing his call light for the staff on 08/04/14. When Resident #172 was asked about the times he has soiled his briefs, he stated, "Yes, that was terrible. It's happened about five or six times in the last two months." When the resident was asked how long does he have to wait for the CNAs, he stated, "Quite awhile. Sometimes about half an hour, sometimes it's longer than half an hour. When I ask them, how come you didn't come by, they tell me '"I have other people to take care of."' Resident #172 stated, "They (staff) are a little bit perturbed." I tell quite a few people. They (referring to staff) tell me to calm down. They tell me to be patient, I tell them I lost all my patients with the service they give me." When Resident #172 was asked if he has filed a complaint, he stated "No." I don't want to get anybody in trouble. When I push the button that turns the light on, sometimes it takes hours before they come. When I ask them, did you see my light, they say 'yeah but we're working with someone else'. I told them I'm a patient just like them, why don't you help me. They (the staff) say they (referring to other residents) needed them more than I did. They have so many excuses. At this time, Resident #172 was observed to becoming upset. Sometimes I'm in pain or my back is bothering me and I ask them to take me to my room and they tell me that I have to wait till everybody else is done eating." Resident #172 stated, "That's why I yell, "Nurse, nurse", and five or six of them (staff) won't even answer me or check to see if I need anything." J. On 08/08/14 at 10:39 am, during interview CNA #8, stated, "He (referring to Resident #172) is a two person transfer." When asked about his toileting needs, CNA #8 stated, "Two people. Sometimes he will let us know (referring to toileting), when we check him he's already wet. If he lets us know in time, we take him to the shower room to use the lift." When CNA #8 was asked if Resident #172 is incontinent, the CNA responded, "Yeah, more often now. I check on him when I have time. I try to make everybody close to two hours, or I will check if they holler or the call lights are on." K. Review of the Medical Record for Resident #172 revealed the following: 1. Face Sheet dated 07/29/14, indicated Resident #172 has [DIAGNOSES REDACTED]. 2. MDS (minimum data set) dated 06/16/14, indicated Resident #172 has, "Clear speech, is able to express ideas and wants, and understands verbal content...ADL Self-Performance: bed mobility, transfer, and toilet use... needs extensive assistance with one person physical assist...Balance During Transitions and Walking: Moving from seated to standing position and moving on and off toilet resident was not steady, only able to stabilize with staff assistance...and is always incontinent of bowel and bladder" 3. physician progress notes [REDACTED]. He states he had a bad day yesterday. When told about the Nursing homes concern, he states he is doing well and that his agitation is normal under the circumstances... I (referring to individual who filled out form) tried to contact the nurse in the NH (nursing home) but after waiting several minutes on the phone, nobody would pick up the line." 4. Care Plan reviewed on 07/18/14 indicated, Resident #172 has "Incontinence: Bladder and Bowel; which can cause increased risk for skin breakdown, soiled clothing, and discomfort... Interventions are to provide incontinence products, encourage participant to toilet every two hours, hands on assistance with toileting and incontinence product management." 5. Care Plan reviewed on 07/18/14 inidcated, "Participant requires assist with transfers wheelchair propulsion. 6. ADL Flow Record (no date) indicated, resident is total dependence with bed mobility, transfers, and toilet use and requires one to two persons assist.

Based on observation, record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 (R #51) of 1 (R #51) sampled residents reviewed who was left on a bed pan (an object used for toileting of a bedridden patient) for forty two minutes which caused him pain. The resident was also left wet and cold when his bedding hadn't been changed after using a urinal (a device that allows people to urinate while they are in bed). This deficient practice likely caused the resident to remain in pain from being left on the bed pan with no relief, and embarrassment from being left wet in soiled linen. The findings are: A. Review of the Facility Grievance Reports revealed the following: 1. On 07/23/14 Resident #51 reported to therapy staff, "That yesterday after dinner, he was left on the bedpan for 42 min (minutes), at which time Certified Nursing Assistant (CNA) returned to clean pt (patient). Pt. (patient) reports he was in pain and very upset." 2. On 07/30/14 Resident #51 reported to a Physical Therapist (identified as PT #1), "He (the resident) woke up at 3:00 am, to use urinal and had a spill. That his CNA (identified as CNA #1) came in and gave him (the resident) a sheet and blanket and left the room...(Name of Resident #51) stated he fell asleep waiting for the CNA (identified as CNA #1) to return, woke again at 5:30 am, wet and cold. (Name of Resident #51) says CNA (identified as CNA #1) returned and said he was getting off his shift at 6:00 am and the next CNA could help change his sheets. The floor was still wet and sticky with urine...Pt. (patient) extremely upset..." B. On 08/05/14 at 8:50 am, observation of Resident #51 revealed the resident to be laying in bed. The resident (Resident #51) was also observed to have no lower legs and was having to use his upper body to move around. He was also observed to be dependent on staff for activities of daily living (ADLs). C. On 08/05/14 at 8:51 am, during interview Resident #51 stated, "Once, a staff member left me here (referring to laying in bed) for forty two minutes on the bed pan and when she (staff) finally came in, I told her I could feel the rings around my butt from the bed pan and it hurt. She could have at least come and checked on me or say, I will come back to check on you, but she did not. It was painful for me." D. Review of the Medical Record for Resident #51 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. History and Physical dated 07/03/14 indicated [DIAGNOSES REDACTED]. It further indicated that Resident #51 is alert, oriented to name, month, and answers questions in context and follows commands. 3. Care Plan initiated 07/11/14 indicated that Resident #51 has Impaired Physical Mobility as manifested by requiring extensive to total assistance from staff for bed mobility, transfers, and toileting. The Care Plan further indicated that Resident #51 has Impaired Functional Mobility and requires extensive assistance from staff for dressing, personal hygiene and bathing. The Care Plan further indicated Resident #51 has urinary incontinence and uses briefs for [DIAGNOSES REDACTED]. 4. Admission Minimum Data Set ((MDS) dated [DATE] indicated that Resident #51 is able to make himself understood, has clear speech, and has no short or long term memory problems. It further indicated that Resident #51 requires extensive assistance from staff for toileting, personal hygiene, and is occasionally incontinent (loss of bladder control) of urine. E. On 08/05/14 at 8:10 pm, observation was made of Resident #51 laying in bed. At this time, he was unable to reach a urinal that had been placed on the bathroom sink for him to use. F. On 08/05/14 at 8:11 pm, during interview Resident #51 stated, "The bed pan issue happened to me in the evening time like right about now. I knew forty two minutes had gone by because I looked at the clock on my wall (resident was observed pointing to a clock located on the wall where the resident could see it). That is how I knew forty two minutes had gone by. Another time, one staff person left me here laying in bed wet. I peeded in my urinal and then he came and removed it. He then put it to where I couldn't reach it anymore. I went to pee again and I got the sheet wet. I rang the bell and he didn't come back to my room until 4:30 am. He finally came back and I told him you left me wet. I told him that I was ringing the bell and he didn't come help me. I know my sheets were wet because I was getting cold. I was only given a sheet, but I wanted another cover to stay warm. That person was very snotty to me. I was so upset that I told my Physical Therapist (PT) about it that next morning." G. On 08/07/14 at 7:30 am, during interview CNA #2 stated that she had worked with Resident #51 before and that "He does use a urinal as well as a bed pan." CNA #2 further stated, "He (the resident) did tell me once that he was very upset with the staff. About two weeks ago, I came on my shift in the morning at 6:00 am, and his (Resident #51) call light was on. I went in his (Resident #51's) room and he was upset because the urinal had spilt and his bottom pad was very wet and the top sheet was also wet. He (Resident #51) was complaining that he (the resident) had asked the night shift CNA to change his sheet on the bottom, but he did not. So, when I came on my shift, I found him (Resident #51) really wet. The whole pad underneath him (the resident) was pretty saturated, and the blanket on top of him was wet as well." H. On 08/07/14 at 7:45 am, during interview Licensed Practical Nurse (LPN) #1 stated, "There was one time he (Resident #51) was very upset that he was left on the bed pan. He (the resident) said that one CNA left him on the bed pan for awhile and was upset. I guess, the CNA was with another resident and it took the CNA awhile to get him (Resident #51) off the bed pan." I. On 08/07/14 at 8:43 am, during interview Physical Therapist #1 stated, "Due to his [MEDICAL CONDITIONS], he uses a urinal. He is aware of when he needs to go to the bathroom. I did file a grievance for him 2-3 weeks ago. He (Resident #51) said he was put on the bed pan by staff. He then told me that he had his call light on and forty (40) minutes had gone by and no-one came back to check on him. He pays attention to the clock on the wall and he told me it was forty minutes. I did work with him the following morning and he said that his back side was hurting and he was very upset and uncomfortable with what happened during the night. He did complain to me the next morning. I also filed another grievance for him another morning he was very upset. He said that he had wet the bed and the urine from the urinal had spilled. He pressed the call light and said a CNA came in and only put a cover over him. He said he thought they were going to come back but they didn't. Then in the early morning around 5:30 am or so, he was cold and wet." J. On 08/07/14 at 9:00 am, during interview regarding Resident #51 being left wet after using the urinal, CNA #1 stated that he recalled assisting Resident #51 with his sheet then earlier in the morning, he was getting ready to get off his shift and would let the oncoming day shift CNA know. K. On 08/07/14 at 3:15 pm, during interview the Assistant Director of Nursing (ADON) for unit 100 stated, regarding the issue with the urinal, it came to my attention on 07/30/14. I went to talk with him (Resident #51) and he told me the night CNA wouldn't change his bed, and the bed stayed wet until the morning. I assured him I wouldn't have the same CNA work with him anymore because I noticed they had certain issues working together. The issue with the bed pan, (name of Resident #51) had wanted to go to the bathroom and the CNA went to put him on the bed pan and another light was gong off in another room. When I talked to him, he (Resident #51) said the CNA was gone for 40 minutes and it took her that long to help him off the bed pan." L. On 08/07/14 at 3:18 pm, during interview regarding Resident #51 being left on the bed pan, CNA #3 stated, "That was my first time working with him. He used the call light and had to go to the bathroom so I put him on the bed pan. I then gave him the call light to call when he was finished. At that time, I walked out of his room to help another resident who's call light was going off and I took a little slower time to get back to help him. He waited a little to long to be taken off the bed pan. It was around twenty (20) minutes I would say that he was waiting. I got pulled away to help someone else. I just got busy."

Based on record review and interview the facility failed to ensure that 1 (R #4) of 8 (R #'s 1, 4, 5, 6, 7, 8, 9, 10) sampled residents identified for pain management was free from pain by not administering pain medication as needed. This failure resulted in R #4 who had just undergone a status [REDACTED]. This failed practice caused one resident's pain to be mismanaged. The findings are: A. Record review and interviews for R #4 revealed the following: 1. Medical Record review identified: a. "Physician Telephone Orders" dated [DATE] indicated the resident requires skilled nursing services for a [DIAGNOSES REDACTED]. b. "Long Term Care admission orders [REDACTED]. The orders also indicated the resident does not have decisional making capacity. Long Term Care admission orders [REDACTED]. Orders also indicated other prn medications to include: [MEDICATION NAME]/[MEDICATION NAME] ,[DATE] mg po ,[DATE] tabs (tablets) every 4 hours prn for pain, and [MEDICATION NAME] ,[DATE] mg ,[DATE] tabs po q 4 hours prn. c. "Admission Resident Data Set" dated [DATE] indicated the residents level of consciousness was lethargic...and required extensive assistance for bed mobility, transfers, and toileting..."Patient arrived [DATE] at 7:00 pm via ambulance. Complete assessment was not done by nursing staff until [DATE] at 12:00 noon. Pt. (patient) unable to provide any verbal information d/t (due to) dementia and confusion"...At 12:00 noon on [DATE], "Pt. shows signs of pain (grimacing) when left leg is moved." d. "history and physical examination ORIF (Open reduction internal fixation) R (right) hip surgery." The history and physical indicated the general appearance of the resident to be somnolent (sleepy; drowsy), but agitated with stimulation and confused. It further indicated current medications available for administration included Tylenol, and [MEDICATION NAME]. e. "Physical Therapy Evaluation & Plan of Treatment" dated [DATE] indicated, "Pain assessment revealed that during the course of being evaluated by physical therapy, the resident was having occasional labored breathing, short periods of hyperventilation, occasional moaning or groaning, low level of speech with a negative disapproving quality. The residents body language demonstrated rigid, fists clenched, knees pulled up, pulling away, striking out and facial grimacing. Pain intensity: ,[DATE] constant; location to right hip. The therapy evaluation indicated that the pain limits the patients functional activities." f. "Occupational Therapy Evaluation & Plan of Treatment" dated [DATE] indicated, "Pt. has inability to bear weight. Found to have a pelvic fracture and had a right hemiarthroplasty." It further indicated, the pain assessment method that was used to assess pain was using a "faces" pain rating scale. It indicated an intensity of pain of ,[DATE]. "Pt. unable to describe/rate." g. "Comprehensive Care Plan for Comfort" dated [DATE] indicated, "Pain to the right hip. Assess for non-verbal signs of pain...Medicate prior to PT/OT (physical therapy/occupational therapy)...and Monitor response to medication." h. Physical Therapy Discharge Summary" dated [DATE]-[DATE] indicated, "Patient was in so much pain during therapy but can't rate. Nurse informed. Discharge reason: Patient is medically unstable. i. "PRN Medication Administration Record" dated [DATE] indicated no documentation that [MEDICATION NAME] ,[DATE] mg or Tylenol 325 mg was administered to the resident as per physician orders. The resident was experiencing pain with facial grimacing; Intensity ,[DATE] constant; location was to the right hip on [DATE] during a Physical Therapy Evaluation. The resident was also showing signs of pain (grimacing) on [DATE] when the left leg was moved. j. "Emergency Kit Narcotic Count Sheet" (no specific date) indicated there was no sign out of [MEDICATION NAME] from [DATE] through [DATE]. This Narcotic Count sheet indicated that the [MEDICATION NAME] was available, but was not administered to the resident. k. "Physician Telephone Orders" dated [DATE] indicated "[MEDICATION NAME] (a potent narcotic used to treat pain) Patch...Change patch every 72 hours." This was a routine scheduled medication that was ordered by the physician. l. "Routine Medication Administration Record" dated November 2012 indicated that the only documented time the resident was ever administered pain medication was on [DATE]. B. Interviews identified: a. On [DATE] at 4:05 pm, during interview, Family Member #1 stated, "My father had advanced dementia. He was not eating and he had no strength. When he got to the nursing facility on [DATE] he was in horrible pain. He was getting sicker and sicker and one morning, he was in tears. He can't talk due to his dementia. He went onto Hospice and when he was discharged from the nursing facility, he died two days later. I kept telling the staff to look at him. He was in such pain that he couldn't do anything. For three days while at the nursing facility, he was in much pain. He was moaning and groaning.'' b. On [DATE] at 9:45 am, during interview, Staff #2 (Licensed Practical Nurse - LPN) stated, "The first night I recall, he was in a lot of pain. When he came in to the facility, the orders were for [MEDICATION NAME], and Tylenol as needed for pain. We do have the [MEDICATION NAME] available in the e-kit. All his prn meds would have been there and available for him. He came in the evening of [DATE] and if we didn't have enough medications to cover him for pain for the night, I believe the doctor should have been called. It was hard to even assess his pain level because he was non- verbal. In the morning of [DATE], he was very restless. The family had said, 'This is not normal for him.' We thought the restlessness was related to his hip injury that he just had surgery for [REDACTED]. c. On [DATE] at 10:55 am, during interview, the Occupational Therapist (OT) stated, "I did my evaluation on the resident on [DATE]. This was the next morning after he was admitted . My evaluation consisted of determining his baseline bed mobility, dressing ability, toileting, grooming, balance and basic ADL (activities of daily living) functioning. He was very confused and unable to understand and follow one step directions. He was non verbal. His prior level of functioning according to the family was, mid assist with grooming/bathing and supervision with toileting. When I saw him, he was requiring maximum assistance from the caregivers to perform tasks. He needed maximum assistance for feeding, and toileting. For the pain assessment, I used the 'faces' scale based on his behaviors. He was ,[DATE] for pain, meaning, he was unable to state his pain. Staff was notified. I was told that he had scheduled meds available. He was only seen for therapy evaluation on [DATE] then he was also discharged on [DATE] because he was medically unstable. When I saw him he was not able to rate his pain. When I used the faces scale, I put him at a ,[DATE] for pain which meant severe pain (Pain that interferes with concentration). It would have meant he had a wrinkled nose, had a raised upper lip and rapid breathing. This is what I physically saw with him when I did my evaluation on [DATE]." d. On [DATE] at 12:40 pm, during interview, Staff #4 (Registered Nurse - RN) stated, "I did the initial assessment on [DATE]. Sometimes, if the staff doesn't get the assessments done, it will get passed down to the night shift then if the night shift nurse can't do it, then it would get passed onto the next day. That is what looks like happened in this case. That is not how it should be. I remember he was grimacing when his leg was moved. He was sitting up in the wheelchair and when I put his legs on the foot rests he was grimacing. It seemed like he was in pain when moving his leg. I believe he had pain meds ordered. By the second day he was here, he would have had all his meds already in and available to administer. When I came in on [DATE], I could see that the assessment was never done." The nurse did not confirm that the medication had been administered to the resident. e. On [DATE] at 12:45 pm, during interview, Staff #5 (LPN) stated, "From what I remember, the resident came in the evening of [DATE]. The night nurse told me, if I could get the orders and if I would write the MAR/TAR (Medication Administration/Treatment Administration Record) he would do the rest as far as the assessment went. I knew we didn't have [MEDICATION NAME] in the e-kit. We could have given him the [MEDICATION NAME] if he was having pain. It would have been in the e-kit and available to use until the [MEDICATION NAME] came in." The nurse did not confirm that the medication had been administered to the resident. f. On [DATE] at 2:35 pm, during interview, Staff #6 (LPN) stated, "The admission nurse does the assessment and it was supposed to be done by the admission nurse. That is one of the first things to be done when a patient is admitted . The resident data summary is also supposed to be filled out by the admission nurse such as skin assessments, and pain management. That is the priority. In the MAR, if he were in any pain, it would have been documented in the narcotic flow sheet if any meds were administered." The nurse did not confirm that the medication had been administered to the resident. g. On [DATE] at 9:00 am, during interview, the Consultant Pharmacist stated, "The [MEDICATION NAME] would not have been available in the e-kit to administer because we don't put category two controlled drugs in the e-kit. The [MEDICATION NAME] ,[DATE] (though) is available in the e-kit. As far as the Tylenol, they have it on hand and they could use that because that is a house stocked medication. The [MEDICATION NAME] ,[DATE] would be available, but the only way to dispense it would be to get the hard copy to us in pharmacy which we don't have a record of the hard copy ever being submitted. The staff are supposed to fill out a log slip whenever one (a narcotic from the e-kit) is used. We went through the e-kit and we did not find that [MEDICATION NAME] medication was noted and/or ever signed out. What happens is that the [MEDICATION NAME] would be available very quickly once the staff fax over a hard copy to get the authorization to take it out of the e-kit. The [MEDICATION NAME] ,[DATE] would be available within 2 hours if it were a stat (immediately) order. That didn't happen in this case. So, if he (the resident) were in pain, there would have been pain medication available to administer to the resident such as the Tylenol 325 or the [MEDICATION NAME] ,[DATE]." h. On [DATE] at 8:15 am, during interview, the Physical Therapist (PT) stated, "I did his initial PT evaluation on [DATE]. From what I recall when I did my evaluation on him, the pain assessment revealed his breathing was occasionally labored breathing, short periods of hyperventilation, occasional moan, or groan. He was "consolable", meaning with distraction, or he was reassured by voice or touch. His body language was rigid, fists clenched, knees pulled up, pulled away. He also had facial grimacing. The pain intensity was ,[DATE] to the right hip. The pain was limiting his functional activities. From what I recall, I asked the nurse if he was premedicated prior to therapy, which is our standard protocol, and I was informed he had been. He was in so much pain but couldn't rate it even with premedication. Nurse was informed. Pain intensity prior to treatment was ,[DATE]. Pain intensity post-op (afterwards) was ,[DATE]. Location was pain to the right hip." B. Review of the facilities "Pain Management" Policy and Procedure dated [DATE] indicated, The licensed nurse will screen the resident upon admission for signs and symptoms of pain, using a standard pain rating scale...The Licensed nurse will complete a comprehensive pain assessment. An example of components that may be included in the assessment: description of pain, location, intensity, quality, frequency/onset, and duration...If the resident cannot verbally indicate the intensity and/or severity of pain using a verbal pain scale, the licensed nurse shall screen/assess the resident using non-verbal cues, i.e. grimacing, moaning, etc...The licensed nurse will notify the physician of pain assessment findings and obtain order(s) for pharmacological interventions...The licensed nurse shall administer pain medication as ordered and document on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" C. Review of the facilities "Admission of Resident" Policy and Procedure dated ,[DATE] indicated, "The licensed nurse will initiate the admission process within the shift of admission...Take temperature, pulse, respiration, blood pressure...and record appropriately"

Based on record review and interview, the facility failed to provide 1 (R #1) of 1 (R #1) residents with the correct amount of Insulin to help control his blood sugar. This failure resulted in the resident receiving 20 units of regular insulin instead of 2 units that was ordered by the physician. This deficient practice is likely to have caused the resident to experience an adverse outcome in which he was found unresponsive, was cold and clammy, having blood sugars as low as 29, experiencing respiratory distress, and having to be admitted to the Hospital Intensive care unit. The findings are: A. Review of the medical record for R #1 revealed the following: 1. Long Term Care admission orders [REDACTED] a. [DIAGNOSES REDACTED]. b. CBG's (Capillary Blood Glucose) levels to be checked ac/hs (before meals and at bedtime). Notify doctor if <60 or >400. c. The resident was to be receiving [MEDICATION NAME] Regular Insulin per sliding scale which indicated the following units to be administered: 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, greater than 400 call the doctor. 2. Integrated Care Plan for Diabetes Mellitus dated 01/06/12 indicated, "Monitor for...change in level of consciousness, excessive perspiration, Report to MD promptly. Meds as ordered, monitor effect of meds." 3. Diabetic Monitoring Flow Sheet dated 12/25/11 at 11:00 am revealed the residents blood sugar was 310. There was no documentation on the Diabetic Monitoring Flow sheet indicating 8 units of Insulin was administered per physician orders. On 12/25/11 at 4:00 pm, the residents blood sugar was 210. There was no documentation on the flow sheet indicating 4 units of Insulin was administered per physicians order. a. Diabetic Monitoring Flow Sheet dated 12/26/11 revealed at 8:30 pm the residents blood sugar was 200. The flow sheet further revealed "20 units" of Insulin was administered to the resident instead of "2 units" that was ordered by the physician. The flow sheet was checked "no" indicating the physician was not notified of the error at this time. 4. Licensed Nurses Notes dated 12/26/11 revealed, "At 4:00 am CNA (certified nursing assistant) (Name of Staff #1) informed RN (registered nurse) (Name of Staff #2) that (name of R #1) was not looking right. Upon entering room, the resident was having labored breathing, unresponsive, and cold skin. Asked CNA to get a set of vitals." a. At 4:05 am, the nurses notes revealed that Staff #2 had to get assistance from LPN (Licensed Practical Nurse) Staff #3, who told Staff #2 to obtain a blood sugar which was 39. b. At 4:40 am, the nurses notes indicated "Sugars were approximately mid 50's." c. At 5:30 am, the nurses notes indicated "Blood sugars were still low- mid 50's." The nurses notes revealed at this time oxygen was now having to be administered to the resident at 5 liters to assist in breathing. d. At 6:30 am, the nurses notes indicated "After change of shift, morning nurse (who was identified as LPN, Staff #4) asked me (Staff #2) to check on resident because he didn't look right. Glucose level was 29 and resident was again unresponsive...Secretions were suctioned with a Yanker catheter to assist in breathing." 5. Departmental Notes dated 12/26/11 by Staff #4 indicated, "During report at start of shift I was informed by nurse that the resident was given 20 units of Insulin instead of 2 units during the bedtime Insulin administration. CNA reported while during her shift change, he (the resident) was foaming at the mouth. When I entered the room I observed red tinged sputum coming out of the residents mouth, crackles were audible in lower lobes bilaterally, respirations were at 30, respirations were labored. I tried two different pulse ox's and could not get a reading on his 02 (oxygen) saturation. He was disoriented. The blood sugar was 29 at this time (7:00 am). Paramedics arrived at 7:30 am." B. Review of the Monthly record of vital signs/weights and pain assessment (no date indicated) revealed no documentation of any vital signs that were being recorded when the resident was experiencing a change in condition. C. Review of a Report of Alleged Incident/Accident report dated 12/25/11 at 8:30 pm revealed the residents vital signs at the time of the incident were: Blood pressure 156/89, Pulse 110, oxygen saturation was 82% and the blood sugar was 44. "Resident given 20 units of Insulin instead of 2 units (per sliding scale). Wrong dose of Insulin. Condition of resident prior to incident was alert and oriented." D. Review of the Incident/Accident Investigation Interview Witness Statement dated 12/26/11 from Staff #2 (who administered the wrong dose of Insulin) revealed, "At approximately 8:30 pm on 12/25/11 I administered 20 units of [MEDICATION NAME]. The sliding scale called for 2 units for a glucose reading of 200. I was unaware of the situation until 4:00 am when the CNA informed me that the resident did not appear well...Blood sugar was 42. He was lethargic...He was put on oxygen and performed suctioning to maintain airway as he was spitting up pink frothy sputum...After an hour to 1 1/2 he again slipped to unresponsive." E. Review of a written statement dated 12/26/11 documented by Staff #3 revealed, "At 4:00 am, RN on unit 400 came to ask me to look at his resident who was unresponsive. I instructed him to check the CBG. It was 39...Initially his 02 sat was 83...I looked in the MAR (Medication Administration Record) as Staff #2 told me he had given 20 units Insulin at bedtime and saw no order for 20 units of any Insulin." F. Review of the Ambulance Patient Care Report dated 12/26/11 indicated the chief complaint was "Altered Mentation-Decreased Level of response." Assessment revealed, productive cough-pink frothy. At 7:24 am the resident was placed on a partial non-rebreather oxygen device at 15 lpm (liters per minute). Vital signs at 7:26 am revealed pulse was 74, oxygen was 71%. Lung sounds: left and right lungs rales were heard. At 7:46 am vital signs were blood pressure 161/106, pulse was 76. "Upon arrival pt. (patient) found laying in bed...Pt has pink frothy sputum coming from nose and mouth. Nursing home staff have no knowledge of pt's medical history. Staff state they gave 20 units of Insulin instead of 2 units by mistake." G. Review of the Admitting Hospitals Emergency Department Chart dated 12/26/11 revealed the following: 1. Vitals at time of arrival were Temperature: 95.2, Pulse 113, Respirations 36, Blood pressure 161/106. Triaged as critical. Appears disoriented and confused. Patient with pink frothy sputum noted. Pt. verbal but unable to understand. Only understands "I am cold." Arrived with blood sputum in face mask. Pale skin. Feels cold to the touch. Respiratory distress. Tachypneic (Abnormal rapidity of respiration). 2. Admitting Hospital Discharge Summary dated 12/30/11 indicated the admission [DIAGNOSES REDACTED]. He required high liter flow oxygen initially. He was placed on bilevel ventilation. Admit to the Intensive Care Unit. H. The following interviews were conducted: 1. On 01/18/12 at 1:00 pm, during interview, a family member to R #1 stated, "My concern is that we believe the way they were giving him his medications, especially the Insulin affected his mental state. He needs total assistance for everything from getting into his bed and bathing. He could not make his needs known to anyone. 2. On 01/19/12 at 10:50 am, during interview, Staff #3 stated, "He (referring to Staff #2) was new to the building. I asked him to check the blood sugar of the resident and when he did it was low. I also recall the resident had a bunch of sputum in his mouth. When we looked at the MAR indicated [REDACTED]. 3. On 01/19/12 at 11:00 am, during interview, Staff #2 stated, "That was my first night working on that unit. I wasn't sure what to do. I was panicking. Around 8 or 9:00 pm the night before, I remember having to give him Insulin. I drew it up by myself. I didn't ask another nurse to check it with me. I told him I would return, then I left the room. It wasn't until all this happened when I thought I gave him too much Insulin. I remember he was coughing up pink frothy sputum and he was having a hard time breathing." 4. On 01/19/12 at 11:55 am, during interview, Staff #4 stated, "As I was coming in on the morning shift 12/26/12, as (name of Staff #2) and I entered the residents room he was foaming at the mouth. I saw him in bed gurgling and that's when (name of Staff #2) told me he had given the resident 20 units of Insulin instead of 2 units the night before. To me he looked like a Hospice patient who was going to die. I couldn't even get an 02 sat (saturation) on him." 5. On 01/19/12 at 12:35 pm, during interview, when asked about the blood sugars that were taken on 12/25, (with no documentation of Insulin being administered per physician orders [REDACTED]. per the orders." The Director of Nursing (DON) stated,"They should have been documenting as to why the Insulin was not administered." The Administrator then stated, "We were unable to determine what happened without the documentation why it was not administered." 6. On 01/19/12 at 2:00 pm, during interview, the DON stated, "I don't think he (staff #2 who administered the 20 units of Insulin) became aware of anything until the CNA came and got him at 4:00 am. 7. On 01/19/12 at 2:55 pm, during interview, Physician #1 stated, "The sliding scale Insulin only called for 2 units to be administered, but the nurse misread the order for 20 units and that's what was given. Subsequently over the night, he (referring to R #1) could not be controlled anymore and we had to transport him out. I think the nurse gave the 20 units of Insulin because that was what he thought the sliding scale required but that was incorrect. I would have expected the nurse to notify me the evening prior on 12/25 when it was realized that the incorrect dosage of Insulin was given." 8. On 01/19/12 at 4:30 pm, during interview, Staff #1 stated, "When I went to check on him at 4:00 am I noticed his breathing was different. I asked him if he was ok and he was not responding. I remember his vitals were low. Before I left on my shift, I saw that he was breathing bad again and I had to go and get the nurse because he was not looking good." I. Review of the facilities Policy and Procedure for [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (no date indicated) revealed, Standard: "Appropriate nursing care are provided to residents with diabetes mellitus who require Insulin...to minimize the risk and ensure prompt recognition of hyper/[DIAGNOSES REDACTED]." Procedures: "All diabetic residents receive insulin...according to physician's orders [REDACTED]. J. Review of the facilities Policy and Procedure for Administration of Medication revised 1/03 indicated, Standard: "All medications are administered safely and appropriately..." Policy: "Responsibility of the nursing professional is to be aware of the correct dosage and side effects of a medication before administration."

Based on record review and interview, the facility failed to follow Physician order [REDACTED].#1) of 1 (R #1) residents. This resulted in the resident receiving 20 units of regular insulin instead of 2 units that was ordered by the physician. This deficient practice is likely to have caused the resident to experience an adverse outcome in which he was found unresponsive, was cold and clammy, having blood sugars as low as 29, experiencing respiratory distress, and having to be admitted to the Hospital Intensive care unit. The findings are: A. Review of the medical record for R #1 revealed the following: 1. Long Term Care admission orders [REDACTED] a. [DIAGNOSES REDACTED]. b. CBG's (Capillary Blood Glucose) levels to be checked ac/hs (before meals and at bedtime). Notify doctor if <60 or >400. c. The resident was to be receiving [MEDICATION NAME] Regular Insulin per sliding scale which indicated the following units to be administered: 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, greater than 400 call the doctor. 2. Integrated Care Plan for Diabetes Mellitus dated 01/06/12 indicated, "Monitor for...change in level of consciousness, excessive perspiration, Report to MD promptly. Meds as ordered, monitor effect of meds." 3. Diabetic Monitoring Flow Sheet dated 12/25/11 at 11:00 am revealed the residents blood sugar was 310. There was no documentation on the Diabetic Monitoring Flow sheet indicating 8 units of Insulin was administered per physician orders. On 12/25/11 at 4:00 pm, the residents blood sugar was 210. There was no documentation on the flow sheet indicating 4 units of Insulin was administered per physicians order. a. Diabetic Monitoring Flow Sheet dated 12/26/11 revealed at 8:30 pm the residents blood sugar was 200. The flow sheet further revealed "20 units" of Insulin was administered to the resident instead of "2 units" that was ordered by the physician. The flow sheet was checked "no" indicating the physician was not notified of the error at this time. 4. Licensed Nurses Notes dated 12/26/11 revealed, "At 4:00 am CNA (certified nursing assistant) (Name of Staff #1) informed RN (registered nurse) (Name of Staff #2) that (name of R #1) was not looking right. Upon entering room, the resident was having labored breathing, unresponsive, and cold skin. Asked CNA to get a set of vitals." a. At 4:05 am, the nurses notes revealed that Staff #2 had to get assistance from LPN (Licensed Practical Nurse) Staff #3, who told Staff #2 to obtain a blood sugar which was 39. b. At 4:40 am, the nurses notes indicated "Sugars were approximately mid 50's." c. At 5:30 am, the nurses notes indicated "Blood sugars were still low- mid 50's." The nurses notes revealed at this time oxygen was now having to be administered to the resident at 5 liters to assist in breathing. d. At 6:30 am, the nurses notes indicated "After change of shift, morning nurse (who was identified as LPN, Staff #4) asked me (Staff #2) to check on resident because he didn't look right. Glucose level was 29 and resident was again unresponsive...Secretions were suctioned with a Yanker catheter to assist in breathing." 5. Departmental Notes dated 12/26/11 by Staff #4 indicated, "During report at start of shift I was informed by nurse that the resident was given 20 units of Insulin instead of 2 units during the bedtime Insulin administration. CNA reported while during her shift change, he (the resident) was foaming at the mouth. When I entered the room I observed red tinged sputum coming out of the residents mouth, crackles were audible in lower lobes bilaterally, respirations were at 30, respirations were labored. I tried two different pulse ox's and could not get a reading on his 02 (oxygen) saturation. He was disoriented. The blood sugar was 29 at this time (7:00 am). Paramedics arrived at 7:30 am." B. Review of the Monthly record of vital signs/weights and pain assessment (no date indicated) revealed no documentation of any vital signs that were being recorded when the resident was experiencing a change in condition. C. Review of a Report of Alleged Incident/Accident report dated 12/25/11 at 8:30 pm revealed the residents vital signs at the time of the incident were: Blood pressure 156/89, Pulse 110, oxygen saturation was 82% and the blood sugar was 44. "Resident given 20 units of Insulin instead of 2 units (per sliding scale). Wrong dose of Insulin. Condition of resident prior to incident was alert and oriented." D. Review of the Incident/Accident Investigation Interview Witness Statement dated 12/26/11 from Staff #2 (who administered the wrong dose of Insulin) revealed, "At approximately 8:30 pm on 12/25/11 I administered 20 units of [MEDICATION NAME]. The sliding scale called for 2 units for a glucose reading of 200. I was unaware of the situation until 4:00 am when the CNA informed me that the resident did not appear well...Blood sugar was 42. He was lethargic...He was put on oxygen and performed suctioning to maintain airway as he was spitting up pink frothy sputum...After an hour to 1 1/2 he again slipped to unresponsive." E. Review of a written statement dated 12/26/11 documented by Staff #3 revealed, "At 4:00 am, RN on unit 400 came to ask me to look at his resident who was unresponsive. I instructed him to check the CBG. It was 39...Initially his 02 sat was 83...I looked in the MAR (Medication Administration Record) as Staff #2 told me he had given 20 units Insulin at bedtime and saw no order for 20 units of any Insulin." F. Review of the Ambulance Patient Care Report dated 12/26/11 indicated the chief complaint was "Altered Mentation-Decreased Level of response." Assessment revealed, productive cough-pink frothy. At 7:24 am the resident was placed on a partial non-rebreather oxygen device at 15 lpm (liters per minute). Vital signs at 7:26 am revealed pulse was 74, oxygen was 71%. Lung sounds: left and right lungs rales were heard. At 7:46 am vital signs were blood pressure 161/106, pulse was 76. "Upon arrival pt. (patient) found laying in bed...Pt has pink frothy sputum coming from nose and mouth. Nursing home staff have no knowledge of pt's medical history. Staff state they gave 20 units of Insulin instead of 2 units by mistake." G. Review of the Admitting Hospitals Emergency Department Chart dated 12/26/11 revealed the following: 1. Vitals at time of arrival were Temperature: 95.2, Pulse 113, Respirations 36, Blood pressure 161/106. Triaged as critical. Appears disoriented and confused. Patient with pink frothy sputum noted. Pt. verbal but unable to understand. Only understands "I am cold." Arrived with blood sputum in face mask. Pale skin. Feels cold to the touch. Respiratory distress. Tachypneic (Abnormal rapidity of respiration). 2. Admitting Hospital Discharge Summary dated 12/30/11 indicated the admission [DIAGNOSES REDACTED]. He required high liter flow oxygen initially. He was placed on bilevel ventilation. Admit to the Intensive Care Unit. H. The following interviews were conducted: 1. On 01/18/12 at 1:00 pm, during interview, a family member to R #1 stated, "My concern is that we believe the way they were giving him his medications, especially the Insulin affected his mental state. He needs total assistance for everything from getting into his bed and bathing. He could not make his needs known to anyone. 2. On 01/19/12 at 10:50 am, during interview, Staff #3 stated, "He (referring to Staff #2) was new to the building. I asked him to check the blood sugar of the resident and when he did it was low. I also recall the resident had a bunch of sputum in his mouth. When we looked at the MAR indicated [REDACTED]. 3. On 01/19/12 at 11:00 am, during interview, Staff #2 stated, "That was my first night working on that unit. I wasn't sure what to do. I was panicking. Around 8 or 9:00 pm the night before, I remember having to give him Insulin. I drew it up by myself. I didn't ask another nurse to check it with me. I told him I would return, then I left the room. It wasn't until all this happened when I thought I gave him too much Insulin. I remember he was coughing up pink frothy sputum and he was having a hard time breathing." 4. On 01/19/12 at 11:55 am, during interview, Staff #4 stated, "As I was coming in on the morning shift 12/26/12, as (name of Staff #2) and I entered the residents room he was foaming at the mouth. I saw him in bed gurgling and that's when (name of Staff #2) told me he had given the resident 20 units of Insulin instead of 2 units the night before. To me he looked like a Hospice patient who was going to die. I couldn't even get an 02 sat (saturation) on him." 5. On 01/19/12 at 12:35 pm, during interview, when asked about the blood sugars that were taken on 12/25, (with no documentation of Insulin being administered per physician orders [REDACTED]. per the orders." The Director of Nursing (DON) stated,"They should have been documenting as to why the Insulin was not administered." The Administrator then stated, "We were unable to determine what happened without the documentation why it was not administered." 6. On 01/19/12 at 2:00 pm, during interview, the DON stated, "I don't think he (staff #2 who administered the 20 units of Insulin) became aware of anything until the CNA came and got him at 4:00 am. 7. On 01/19/12 at 2:55 pm, during interview, Physician #1 stated, "The sliding scale Insulin only called for 2 units to be administered, but the nurse misread the order for 20 units and that's what was given. Subsequently over the night, he (referring to R #1) could not be controlled anymore and we had to transport him out. I think the nurse gave the 20 units of Insulin because that was what he thought the sliding scale required but that was incorrect. I would have expected the nurse to notify me the evening prior on 12/25 when it was realized that the incorrect dosage of Insulin was given." 8. On 01/19/12 at 4:30 pm, during interview, Staff #1 stated, "When I went to check on him at 4:00 am I noticed his breathing was different. I asked him if he was ok and he was not responding. I remember his vitals were low. Before I left on my shift, I saw that he was breathing bad again and I had to go and get the nurse because he was not looking good." I. Review of the facilities Policy and Procedure for [MEDICAL CONDITION] and [DIAGNOSES REDACTED] (no date indicated) revealed, Standard: "Appropriate nursing care are provided to residents with diabetes mellitus who require Insulin...to minimize the risk and ensure prompt recognition of hyper/[DIAGNOSES REDACTED]." Procedures: "All diabetic residents receive insulin...according to physician's orders [REDACTED]. J. Review of the facilities Policy and Procedure for Administration of Medication revised 1/03 indicated, Standard: "All medications are administered safely and appropriately..." Policy: "Responsibility of the nursing professional is to be aware of the correct dosage and side effects of a medication before administration."

Based on interview, observation and record review, the facility failed to maintain a resident's highest practicable well-being by not providing post surgical pain management during a wound care dressing change for 1 (#151) of 45 residents. The findings are: A. On 05/18/11 at 3:07 pm, Resident #151 stated, "When I was first admitted on the 100 unit from the hospital, I was in pain after surgery. I got here at 3:00 pm but was not able to get pain medication until after 2:00 am. They told me they did not have any back-up medication to give me. The staff did not offer me any pain relief, no massage, no breathing techniques, nothing." B. On 05/23/11 at 9:43 am, during interview Registered Nurse (RN) #14 stated, "If we have an order before 5:00 pm it (medications) comes in from (Name of the Facilities Contracted Pharmacy) at 9:00 pm or we can stat (request immediately) the order and it will take 1-2 hours for them to deliver the medication. We can also look in the emergency kit (E-kit) for the medication. We can call the doctor and get an order for [REDACTED]. C. On 05/23/11 at 10:00 am, during interview the Director of Nursing (DON) stated, "It should take no longer than 3 hours to get pain medication. We can call stat for pain medication or get it out of the E-kit. Then the patient can get their medication right away. I would not expect a patient to have to wait more than 3 hours for pain medication." D. On 05/23/11 at 9:50 am, during observation of the E-kit, RN #14 was able to identify 3 different pain medications which could have been substituted for pain relief. E. Review of the Medical Record for Resident #151 revealed the following: 1. Face sheet indicated resident was readmitted on [DATE]. [DIAGNOSES REDACTED]. 2. December Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] a. On 12/05/10 the medication "[MEDICATION NAME] 5/325 milligrams (mg) 1-2 tabs po (orally) q (every) 4 hours prn (as needed) for pain and [MEDICATION NAME] 800 mg q 8 hours prn for mild pain." b. On 12/05/10 at 10:40 pm "[MEDICATION NAME] was administered." c. On 12/06/10 at 2:05 am "[MEDICATION NAME] was administered." (11 hours after admission.) 3. Nursing notes identified: a. 12/05/10 at 10:00 pm, "Pt (patient) arrived on unit at 7:45 pm by ambulance... Incision to midline of abdomen... Pt. rated pain 7 to 8 out of 10 (10 indicates the worst pain)... [MEDICATION NAME] not effective. Medications ([MEDICATION NAME]) pending pharmacy." b. 12/06/10 at 03:45 am, "pt. swinging arms in bed, and yelling due to pain... Pt was shaking head, swinging arms and yelling, "'I need pain medication now. I can't stand this anymore..."' Pt pain 10 out of 10. c. There was no documentation to indicate that the physician was called to request a different pain medication. 4. Pain Management Policy and Procedure revised 08/31/09 identified: a. "Provide around the clock dosing." b. "The licensed nurse will notify the physician of pain assessment findings and obtain order(s) for pharmacological interventions, if indicated." c. "If pain is of new onset, changed in nature, not relieved with current medication, etc. (etcetera), the nurse will notify the physician for a review of the medication and pain management plan."