Every finding on record at Avante Villa at Jacksonville Beach Inc

Based on observations, interviews, record reviews, and a review of the facility's policies and procedures, the facility failed to provide transfer/discharge notification to the Long-Term Care (LTC) Ombudsman's office prior to or as soon as was practicable for five (Residents #22, #90, #148, #156, and #16) of five residents reviewed for transfer/discharge. Appropriate notification of the LTC Ombudsman's office provides added protection for residents from being inappropriately transferred or discharged , provides residents with access to an advocate who can inform them of their options and rights, and ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include: On 05/28/2026 at 11:53 AM, Social Services Director (SSD) G provided a list of resident transfers/discharges from 03/01/2026 through 05/26/2026. 1.A review of Resident #22's medical record revealed an admission date of 05/05/2026 and a discharge date of 05/07/2026. A review of the Transfer/Discharge Report dated 05/07/2026 revealed a planned discharge to another skilled nursing facility (SNF). There was no evidence in the resident's medical record of a Nursing Home Transfer/Discharge Form (CMS (Centers for Medicare and Medicaid Services) Form 3120) or notification of the LTC Ombudsman's office of the discharge. 2.A review of Resident #90's medical record revealed an admission date of 04/27/2026 and a discharge date of 05/26/2026. A review of the discharge order provided by SSD G revealed a physician's order dated 05/22/2026 for the resident to discharge home on [DATE] with skilled home care services. There was no evidence in the resident's medical record of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office of the discharge. 3.A review of Resident #148's medical record revealed an admission date of 02/25/2026 and a discharge date of 03/22/2026. The Nursing Home Transfer/Discharge Form (CMS Form 3120) for Resident #148 was provided by SSD G. A review of the form revealed that the resident was transferred to the hospital on [DATE]. The form was incomplete and revealed no explanation for the transfer, nor did it indicate when the LTC Ombudsman's office was notified of the transfer. There was no evidence in the resident's record verifying that the LTC Ombudsman's office was notified or received a copy of the transfer/discharge form. 4.A review of Resident #156's medical record revealed an admission date of 01/20/2026 and a discharge date of 02/03/2026. A progress note on 02/02/2026, provided by SSD G, revealed that Resident #156 was to be transferred to another SNF on 02/03/2026. The note was completed by SSD G, and it read, Call to wife, no answer, left message with information. No answer. There was no evidence in the resident's medical record of a Nursing Home Transfer/Discharge Form (CMS Form 3120) or notification of the LTC Ombudsman's office of the discharge. On 05/29/2026 at 12:42 PM, an interview was conducted with SSD G, who stated the LTC Ombudsman's office was notified of planned discharges as they occurred. She stated at the end of the month, the LTC Ombudsman's office received a report/log listing that included hospital transfers and unplanned discharges. On 05/29/2026 at 12:55 PM, a follow-up interview was conducted with SSD G, who stated there was a Performance Improvement Plan (PIP) related to LTC Ombudsman's office transfer/discharge notifications. She stated she monitored the process monthly. SSD G stated the facility was following the regulations regarding notification of the LTC Ombudsman; however, no evidence was provided that a PIP specific to notification of the LTC Ombudsman's office of transfers/discharges had been implemented. A review of the facility's PIP list did not identify a PIP addressing LTC Ombudsman's office notification of transfers/discharges. 5.A review of Resident #16's medical record revealed that the resident was admitted to the facility 2/18/2026. A review of the Discharge, Return Anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/7/2026, revealed that the resident experienced an unplanned transfer to an acute care hospital on 5/7/2026. A review of the Nursing Home Transfer/Discharge Form (CMS Form 3120) revealed that the resident was transferred to an acute care hospital for evaluation on 5/7/2026. The resident's medical record contained no evidence indicating that the Long-Term Care (LTC) Ombudsman's office was notified of the resident's transfer or received a copy of the transfer/discharge form. On 05/29/2026 at 12:45 PM, an interview was conducted with SSD G. She confirmed that the facility's process for notification of the LTC Ombudsman's office was to fax a monthly report/log listing for residents who were transferred to the hospital. On 05/29/2026 at 12:48 PM, an email was received from the LTC Ombudsman who confirmed that no transfer notification had been received for Resident #16. A review of the facility's policy and procedure titled Notice Requirements Before Transfer/Discharge (issued: 3/2/19, revised: 3/2/19), revealed: Procedure: c. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Written Notice: 2.A copy of the notice must be placed in the resident's clinical record, and a copy must be transmitted to the resident's legal guardian or representative and the local ombudsman council within 5 business days after signature by the resident or resident designee.

Based on observations, interviews, record reviews, and a review of facility policies and procedures, the facility failed to provide adequate fingernail care for four (Residents #57, #72, #118 and #140) of 57 sampled residents. A failure to provide basic nail hygiene can contribute to painful, ingrown nails, skin infections, other injuries and/or a loss of dignity. The findings include:1.On 05/26/2026 at 11:57 AM, Resident #57 was observed resting in bed. The fingernails on his right hand were elongated with brown matter underneath them. The fingernails on his left hand were not visible. He confirmed that he had not received fingernail care, he desired fingernail care, and he would not refuse fingernail care if offered. (Photographic evidence obtained)On 05/26/2026 at 2:27 PM, Resident #57 was observed resting in bed. He confirmed that he had eaten his lunch and fed himself. The fingernails on his right hand were elongated with brown matter underneath the nails as observed earlier this day at 11:57 AM. The fingernails on his left hand were not visible. (Photographic evidence obtained)A review of Resident #57's medical record revealed an admission date of 04/29/2026 with diagnoses including palliative care, End-Stage Renal Disease (ESRD) and epilepsy. A review of the resident's active physician's orders revealed he was receiving hospice services (ordered 05/11/2026).A review of the admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/05/2026, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 possible points, indicating moderate cognitive impairment. No behaviors were documented. The resident required substantial/maximal staff assistance with personal hygiene tasks. No refusals of care were identified.A review of the resident's active care plan revealed:Focus Area: Activities of Daily Living (ADL)/Self-Care Performance Deficit related to activity Intolerance, hemiplegia (weakness/paralysis on one side of the body), and health status at risk for further decline in ADLs related to hospice care. Date Initiated: 04/30/2026. Revision: 04/30/2026.Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 04/30/2026. The resident's care plan did not include/address behaviors or refusal of/resisting ADL care. 2.On 05/26/2026 at 12:08 PM, Resident #72 was observed lying in bed. His fingernails on both hands were elongated. (Photographic evidence obtained) He was interviewed and confirmed that he had not received fingernail care, that he wanted his fingernails trimmed, and would not refuse care if offered. On 05/26/2026 at 2:29 PM, Resident #72 was observed lying in bed. His fingernails remained elongated as they were observed earlier in the day at 12:08 PM. (Photographic evidence obtained) He confirmed that he had not received any fingernail care yet during this shift (7:00 AM - 3:00 PM).A review of Resident #72's medical record revealed an admission date of 04/30/2020 with diagnoses including traumatic brain injury. No refusals of care were documented.A review of the Annual MDS assessment with an ARD of 05/10/2026, revealed a BIMS score of 03/15, indicating severe cognitive impairment. No psychosis or behaviors were documented. The resident was dependent on staff for personal hygiene. A review of the resident's active care plan revealed:Focus Area: Resident has ADL/Self-Care Performance Deficit related to his health status. Date Initiated: 05/11/2020, Revision: 05/03/2021.Intervention: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 05/11/2020. The resident's care plan did not include/address behaviors or refusal of/resisting ADL care. 3.On 05/26/2026 at 12:17 PM, Resident #118 was observed with elongated fingernails with brown matter under them. (Photographic evidence obtained)On 05/26/2026 at 2:29 PM, Resident #118 was again observed with elongated fingernails with brown matter under them. He confirmed he had not received fingernail care during this shift (7:00 AM - 3:00 PM).A review of Resident #118's medical record revealed an admission date of 01/13/2026 with diagnoses including seizures and generalized muscle weakness. The resident had no documented behavior of refusing care.A review of the resident's Quarterly MDS assessment with an ARD of 04/21/2026, revealed a BIMS score of 06/15, indicating severe cognitive impairment. No psychosis or behaviors were indicated.A review of the active care plan revealed:Focus Area: ADL/Self-Care Performance Deficit related to health status. Date Initiated: 01/14/2026, Revision on 01/14/2026.Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 01/14/2026. The resident's care plan did not indicate/address refusal of or resisting ADL care. 4.On 05/26/2026 at 3:01 PM, Resident #140 was observed resting in bed. Her fingernails had jagged edges with brown matter under them on both hands. (Photographic evidence obtained) A review of the resident's medical record revealed an admission date of 04/01/2026 with diagnoses including schizophrenia, bipolar disorder, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of an admission MDS assessment with an ARD of 04/07/2026, revealed a BIMS score of 13/15, indicating intact cognition. No behaviors were documented. The resident required substantial/maximal assistance with personal hygiene tasks. The resident had no documented behavior of refusing care.A review of the care plan revealed:Focus Area: ADL/Self-Care Performance Deficit related to activity intolerance, weakness, dementia, pain, health status. Date Initiated: 04/02/2026, Revision on 04/02/2026.Interventions: Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 04/02/2026. The resident's care plan did not indicate/address refusal of or resisting ADL care. On 05/26/2026 at 2:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) H who was asked if she had received education on ADL care. She stated she had not received any classroom-type education on ADL care, but that her orientation consisted of shadowing another CNA for three days and observing ADL care being provided. She was asked how often fingernail care was provided to the residents. She stated fingernail care was provided weekly. She confirmed that fingernail care was provided by the CNAs. She stated the Activities Department provided some fingernail care and nail polishing; however, she did not know how frequently it was provided. She stated the CNAs were ultimately responsible for the residents' fingernail care. CNA H was accompanied to the bedsides of Residents #57, #72, #118, and #140. She confirmed that these residents required fingernail care. On 05/26/2026 at 12:38 PM, an interview was conducted with Licensed Practical Nurse (LPN) C who confirmed that the licensed nurses and CNAs were responsible for the residents' fingernail care. She stated the Activities Department also provided nail care. When she was asked how often the residents were provided fingernail care, she replied that fingernail care was provided to the residents every 15 days and daily for residents who got food under their nails when they fed themselves.A review of the facility's policy and procedure titled Activities of Daily Living (ADLS) Maintain Abilities (Issued: 03/02/2019, Revised: 03/02/2019), revealed:Policy: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident: and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs,Procedure:3. The facility will provide care and services for the following activities of daily living:a. Hygiene-bathing, dressing, grooming, and oral care.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal/oral hygiene .

Based on record reviews, observations and staff interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for two (Resident #89 and #103) of three residents reviewed for safety/accidents, from a total survey sample of 28 residents. The facility failed to properly store and dispose of razors and hair shears used by Resident #89 who shared a room with Resident #103. Resident #103 was severely cognitively impaired and independently mobile. This placed both residents and any other resident who could access this room at risk for accidents with injury. The findings include:1.A review of Resident #89's Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/24/26, revealed a brief interview for mental status (BIMS) score of 12 out of 15 possible points, indicating moderate cognitive impairment. Resident #89 had no impairments to his upper or lower extremities, used a walker and was independent with all self-care.2.A review of Resident #103's medical record revealed an admission date of 3/6/26 with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of the resident's Quarterly MDS assessment with an ARD of 4/3/2026, revealed a BIMS score of 3 out of 15 possible points, indicating severe cognitive impairment.Resident #103 was care planned on 4/22/2026 with a review date of 6/30/2026 for Elopement Risk/Wandering related to disorientation in a new environment. The resident had a history of impaired safety awareness. On 5/26/2026 at 11:40 AM, upon entering Resident #89's and #103's room, Resident #89 was observed in bed with his eyes closed. He did not respond when greeted. Resident #103 was sitting in a chair next to his bed. A razor and hair shears were observed in the residents' shared bathroom in a lidless bin next to the sink. (Photographic evidence obtained)On 5/27/2026 at 10:34 AM, upon entering Resident #89's and #103's room, a razor was observed in the residents' shared bathroom inside a lidless bin next to the sink. (Photographic evidence obtained)On 5/27/2026 at 1:41 PM, the Director of Nursing (DON) was asked to provide the facility's policy for storage and disposal of sharps used for personal care. No policy was received on 5/27/20 26.On 5/28/2026 at 1:45 PM, upon entering Resident #89's and #103's room, a razor was observed in the residents' shared bathroom inside a lidless bin next to the sink. (Photographic evidence obtained)On 5/28/2026 at 1:58 PM, Licensed Practical Nurse (LPN) C was interviewed. She stated independent residents could have combs and brushes in their rooms but not fingernail clippers or personal razors because they could be used as weapons. She stated one of her residents had family members who visited and shaved the resident's beard, but they took the supplies with them when they left. Knives or any type of sharp items could not be kept in resident rooms. For residents who required assistance with grooming, staff kept the razors and shaving items in the locked supply closet.On 5/28/2026 at 2:05 PM, Certified Nursing Assistant (CNA) B was interviewed. When he was asked where he stored personal care and grooming supplies, he stated they were kept in the supply closet on the East Wing next to the nurses' station. He said the supply closet stored deodorant, toothpaste, nail files, nail clippers, briefs, and regular razors. For residents who required assistance with ADL (activities of daily living) care or grooming, he provided care, and hazardous supplies like razors were returned to the supply closet and labeled for that resident or were disposed of. Independent residents were allowed to keep razors or nail clippers in their rooms in the personal area but not in the bathroom if they had roommates.On 5/28/2026 at 2:15 PM, CNA B was accompanied to Resident #89's and #103's room. Two razors were observed in the bathroom shared by the two residents inside a lidless bin next to the sink. CNA B stated, This is a problem. He further stated the razors should not be in the residents' bathroom because only one of them was permitted to use personal razors with little supervision.On 5/28/2026 at 2:48 PM, the DON was asked to provide any policy the facility had for the storage and disposal of sharps used for personal care (specifically razors). No policy was received on 5/28/2026.On 5/29/2026 at 10:25 AM, the DON was interviewed. She was asked if residents who were independent could store razors or any type of sharps in their rooms. She stated, No, this is not permitted under any circumstances. She was asked if the facility had a policy stating residents were prohibited from keeping sharps in their rooms. She stated the facility did not have a specific policy addressing how the facility should handle and store razors/sharps for independent residents who did their own grooming.

Based on observations, interviews, record reviews, and a review of facility policies and procedures, the facility failed to ensure its medication error rate was not 5.0% or greater. There were 26 opportunities for error with three identified medication errors resulting in an error rate of 11.0% and involving Residents #59 and #135, two of nine residents observed during medication administration. The findings include:On 5/28/2026 at 9:44 AM, Licensed Practical Nurse (LPN) K was observed preparing Divalproex Sodium 500 milligrams (mg), 1 tablet, to administer to Resident #59. She was asked if she had prepared all medications that were to be administered to the resident at that time. She reviewed the electronic Medication Administration Record (eMAR) and confirmed that she had prepared all medications and treatments that were due to the resident at that time. LPN K administered the above medication to the resident at bedside. After administration, the resident's active physician's orders were reviewed with LPN K in the eMAR. LPN K confirmed that according to the physician's orders, Resident #59 should have received two tablets of Divalproex Sodium 500 mg to equal 1000 mg as well as Voltaren External Gel 1% (to be applied topically BID - twice a day). LPN K acknowledged responsibility for assuring the right residents received the right medications at the right time, at the right frequency, at the right dose and via the right route. On 5/28/2026 at 4:25 PM, LPN I was observed preparing Trazadone Hydrochloride (HCL) 50 mg, 1 tablet, to administer to Resident #135. LPN I was then observed administering the above medication to the resident at bedside. The resident's active physician's orders were reviewed with LPN I in the eMAR, and she confirmed that according to the physician's orders, the resident should have received two tablets of Trazadone HCL to equal 100 mg. LPN I acknowledged responsibility for assuring the right residents received the right medications at the right time, at the right frequency, at the right dose and via the right route. On 05/28/2026 at 5:30 PM, an interview was conducted with the Director of Nursing who stated her expectation for nursing staff when administering medication was that they ensure they were administering medications to the right person at the right time via the right route, at the right frequency and for the right medication and dosage. A review of the facility's LTC (Long-Term Care) Pharmacy Services and Procedures Manual under 6.0 General Dose Preparation and Medication Administration (Effective Date: 12/01/07, Revision Date: 01/01/22), revealed:4. Prior to administration of medications, facility staff should take all measures required by Facility Policy and Applicable Law, including, but not limited to the following:4.1.1Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct date, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule.

Based on observations, interviews, and record review, the facility failed to ensure that professional standards of practice were adhered to regarding the changing and dating of enteral feeding equipment for five (Residents #1, #15, #17, #18 and #19) of eight residents reviewed for enteral tube feeding (TF). This could result in the residents not receiving appropriate care and/or clinical complications.1. On 12/22/2025 at 10:00 am, Resident #1 was observed lying in bed with the head of the bed elevated at approximately 30 degrees. Nutren 1.5 enteral feeding was noted to be infusing via g-tube at 60 milliliters (ml)/hour (hr.). The water flush bag was dated on 12/20/2025 at 6:00 am and the enteral feeding bag was undated. (Photographic evidence obtained)Review of Resident #1's medical record revealed an admission date of 5/26/2025. Her diagnoses included Hemiplegia and Hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, Neuromuscular Dysfunction of Bladder, Unspecified Atrial Fibrillation, and Gastrostomy Status.Review of Resident #1's physician's orders revealed free water 180ml/4h to provide 1080 ml of free water with formula and flushes (6/13/2025) and enteral feed two times a day Nutren 1.5ml @ 60ml/hr. x 20 hr. (off 12 am, on 4 am) + 180 ml free water flow q4hr (6/1/2025).2. On 12/22/2025 at 11:30 am, Resident #15 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for his enteral tubing was undated. (Photographic evidence obtained)Review of Resident #15's medical record revealed an admission date of 10/16/2025. His diagnoses included gastrostomy status, amyotrophic lateral sclerosis, dysphasia, oropharyngeal phase, functional quadriplegia, and major depressive disorder. Review of Resident #15's physician's orders revealed enteral feed order every shift Osmolite 1.5 70 ml/hr. continuous 150 milliliter flush every three hours while pump is on and enteral feed order every shift Osmolite 1.5 start feeding at 0600 infuse at 80 milliliters an hour continuous until 1280 milliliters has been infused flush with 120 milliliters water every two hours while pump is on flushed by syringe 120 milliliters before and after each feed cycle period.3. On 12/22/2025 at 11:40 am, Resident #17 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for her enteral tubing was undated. (Photographic evidence obtained)Review of Resident #17's medical record revealed an admission date of 5/24/2024. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction, dysphagia, oropharyngeal phase, aphasia, other specified anemias, unspecified severe protein calorie malnutrition, bipolar disorder, other seizures, gastrostomy status, neuromuscular dysfunction of bladder, and gastroesophageal reflux disease.Review of Resident #17's physician's orders revealed enteral feed order two times a day Isosource 1.5 at 55 ml/hr. for 20 hours, flush with 200 milliliters of water every four hours.4. On 12/22/2025 at 11:45 am, Resident #18 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's water bag for her enteral tubing was undated. (Photographic evidence obtained)Review of Resident #18's medical record revealed an admission date of 9/8/2023. Her diagnoses included other Cerebral Infarction due to Occlusion or Stenosis of Small Artery and Anoxic Brain Damage. Review of Resident #18's physician's orders revealed Isosource 1.5 at 60ml/hr. for 20 hours off 10:00 am to 2:00 pm for Activities of Daily Living with/200 milliliters of Free Water Flush every 6 hours.5. On 12/22/2025 at 11:55 am, Resident #19 was observed to be lying in bed with the head of the bed elevated at approximately 30 degrees. The resident's enteral feeding bag was undated. (Photographic evidence obtained)Review of Resident #19's medical record showed to read an admission date of 4/8/2022. The resident's diagnoses included malignant carcinoid tumor of the small intestine, gastrostomy status, hemiplegia and hemiparesis following cerebral infarction, dysphagia, oropharyngeal phase, and gastroesophageal reflux disease. Review of Resident #19's physician's orders revealed enteral feed order every four hours flush with 150 milliliters of water, Enteral feed to order flush G tube with 10 CC's of water before and after bolus feeds, and Enteral feed order two times a day Isosource 1.5 at 50 ml/hr. for 20 hours plus 150 milliliters of free water flow every four hours-on at 2:00 PM off at 10 AM period.During an interview on 12/22/2025 at 10:50 am, Staff A, Licensed Practical Nurse (LPN), stated, The night shift changes out all of the tube feedings, bags and syringes. When asked why there were several tube feedings that were either undated or outdated, LPN stated, Night shift changes those.During an interview on 12/22/2025 at 1:30 pm, Staff B, Registered Nurse (RN), stated, The bags and everything are changed out on the midnight shift.During an interview on 12/22/2025 at 2:15 pm, the DON stated, All the tube feedings, water bags and syringes are changed out by the midnight shift. It should be dated when it is placed.

Based on observation, interviews, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one (Resident #2) of three residents reviewed for accident hazards. A bottle of Zyrtec (over the counter allergy medication) and [NAME] nasal spray were found on Resident #2's bedside table. Resident's son brought over-the-counter medications to the resident on 4/7/25 at approximately 1:00 pm, and facility staff did not remove the medication until after 9:45 am on 4/8/25. During this time, approximately 21 hours and three shifts later, other residents had access to the medication at Resident #2's bedside. The findings include: On 4/8/25 at 9:41 am, Resident #2's room was observed. A bottle of Zyrtec and [NAME] nasal spray were observed sitting on top of the bedside table. (Photographic evidence obtained) When the resident was asked how she got the medications. She stated, My son brought them to me around 1 pm yesterday, I know that I'm not supposed to have them. I'll probably just put them away or give them to my son when he comes. When asked if she had spoken to anyone in the facility about getting orders for these medications. She stated, They have nasal spray, but I used this brand at home, so I asked my son to bring it for me. I'll let him take it home with him when he comes, he visits every day at 1:00 pm and he takes me outside for fresh air. A review of Resident #2's medical record revealed she had a BIMS (brief interview for mental status) score of 15/15, indicating intact cognition. The record review revealed no physician orders for [NAME] nasal spray. No physician orders to self-medicate was found in the record. No assessment for self-administration of medications was found in the record. A review of Resident #2 care plan revealed she was not care planned for self-administration of medications. On 4/8/25 at 2:38 pm, an interview was conducted with Employee A LPN (Licensed Practical Nurse). She was asked about the facility's process for residents who self-administer medication. She stated, Well first it has to be approved by the doctor and then the resident must be assessed by the nurse to determine if they are able to self-medicate. Then some patient teaching is done and then we get an order to self-medicate. It is also added to the care plan. She was asked to explain the facility process for observing unauthorized medications at the resident's bedside. We confiscate it, educate the resident and family members to why they shouldn't have it. If the resident insists on self-medicating we can assess if they can self-medicate, if not we explain why they can't. On 4/8/25 at 2:43 pm, an interview was conducted with Employee B LPN, the nurse who cared for Resident #2. She was asked to explain the facility's process for residents who desire to self- medicate. She stated, Go to the doctor first and get an order, then the DON or a nurse has to assess if the patient is capable to self-administer medications. The nurse was asked to go to the room of Resident #2. The surveyor explained the resident had the over-the-counter medications at the bedside earlier. The nurse stated, We discovered she had medications at the bedside, and we removed them and locked them in the medication room until her son came. He took them home and we asked him to please not bring them anymore. The resident has nasal spray on the medication cart that was ordered by the doctor and also Zyrtec, so I'm not sure why she asked him to bring it. The resident and the son have been educated previously not to bring medications into the facility for safety reasons.

Based upon observations, interview and record review, the facility failed to ensure respiratory services were administered according to a physician's order for five residents receiving respiratory care from 40 sampled residents (#96, 106, 59, 105, and 90). The findings include: 1. Observations made during the tour on 09/16/24 at 11:35 AM, revealed that Resident #96's oxygen concentrator flow was set at 2 Liters per minute (L/min.) (photographic evidence obtained). During an interview on 09/16/24 at 11:35 AM, the resident reported she was unsure what the oxygen flow rate should be set at and noted that she did not manipulate her concentrator's oxygen flow rate. A second observation on 09/17/24 at 9:50 AM, revealed that the resident's oxygen concentrator flow rate was set at 2 L/min. (photographic evidence obtained). Review of the electronic medical record for Resident #96 documented the resident is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, mild intermittent asthma, uncomplicated, muscle weakness (generalized) chronic systolic (congestive) heart failure, diabetes mellitus type II, unspecified atrial fibrillation and major depressive disorder. Review of the electric medical record for Resident #96's physician orders revealed a lack of documentation of a current order for oxygen. 2. Observations made during the tour on 09/16/24 at 11:48 AM, revealed that Resident #106's oxygen concentrator flow rate was set at 2.5 Liters per minute (L/min.) (photographic evidence obtained). The resident was not capable of responding to interview questions. A second observation on 09/17/24 at 9:49 AM, revealed that the resident's oxygen concentrator flow rate was set at 2.5 L/min. (photographic evidence obtained). Review of the electronic medical record for Resident #106 documented a [AGE] year old female admitted to the facility on [DATE] with diagnoses including other cerebral infarction due to occlusion or stenosis of small artery, muscle weakness (generalized), cognitive communication deficit, anoxic brain damage, not elsewhere classified, acute respiratory failure with hypoxia, tracheotomy status, gastronomy status, dysphasia following cerebral infarction, major depressive disorder, dependence on supplemental oxygen. Review of the electronic medical record of Resident #106 documented re Tracheotomy (trach) - Encourage and assist resident with use of humidified oxygen 6.5%/2 liters via trach collar. Order started on 09/08/23. Review of the medication administration record (MAR) for Resident #106 documented oxygen was administered per physician order at 2 liters via trach collar. 3. Observations made during the tour on 09/16/24 at 11:48 AM, revealed that Resident #59's oxygen concentrator flow rate was set at 2.5 Liters per minute (L/min.) (photographic evidence obtained). During an interview on 09/16/24 at 11:48 AM, the resident reported that she was unsure what the oxygen flow should be set at and noted that she did not manipulate her concentrator's oxygen flow rate. On 09/17/24 at 9:55 AM, the resident was observed sitting in a wheelchair in her room waiting to leave for a dialysis appointment. The resident was wearing a nasal cannula attached to a portable oxygen tank adhered at the back of her wheelchair. Review of Resident #59's electronic medical record documented a [AGE] year old female admitted to the facility on [DATE] with diagnoses including end stage renal disease, muscle weakness (generalized), chronic obstructive pulmonary disease, diabetes mellitus type II, paroxysmal atrial fibrillation, heart failure, unspecified, cardiac arrest due to other underlying condition, anemia in chronic kidney disease, hypertension disorder, sclerotic heart disease of native coronary artery without angina pectoris, long term (current) us of anticoagulant, dependence on renal dialysis. Review of the minimum data set (MDS) for Resident #59 dated 08/24/24 documented that the resident had minimal difficulty with hearing, clear speech, made self understood, understood others and had adequate vision. The resident's brief interview for mental status (BIMS) score was 15, which suggested the resident was cognitively intact. Review of the care plan for Resident #59 documented a focus of altered respiratory status/difficulty breathing related to shortness of breath, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and dry nose. The goal for the resident noted that the resident would maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions included oxygen settings: oxygen care and settings according to medical doctor (MD) order. Intervention created on 06/10/24. Review of the electronic medical record for Resident #59 lacked documented evidence of a current physician order for oxygen (O2). Review of discontinued physician orders documented oxygen saturations (Sat) every shift and as needed. Call medical doctor if Sat is over 90. Every shift for oxygen saturations for shortness of breath (SOB). Order started on 06/27/24 at 22:50 and ended 08/26/24. Change O2 humidifier bottle every night shift every Saturday. Order start on 06/27/24 at 22:50 and ended 08/26/24. Change O2 set up and bag weekly and as needed. Every night shift every Saturday. Place in labeled O2 bag and tie to handle of O2 concentrator. Order started on 06/27/24 at 22:50 and ended 08/26/24. O2 at 2 liters/minute (L/min.) via nasal cannula for SOB and as needed. Order started on 06/28/24 at 22:50 and ended 08/26/24. Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #59 documented oxygen was administered during the month of September 2024 at 2.5 L/min. On 09/19/24 11:27 AM, an interview was conducted with Employee A, CNA, who reported he has worked at the facility since 2003. He explained that he was familiar with the Resident # 59's care needs. In regards to the resident's oxygen care needs, he could not remember the prescribed oxygen (O2) liter flow rate. He said that he tries to keep the resident on her oxygen as long as possible. He further explained that sometimes the resident will complain that the oxygen annular is irritating to her nose and ears. The employee said that when he conduct his rounds, he would check the oxygen concentrator flow rate to ensure the flow rate is correct. If the flow rate is incorrect, he would tell the nurse. He said that he always makes sure the concentrator had enough room and that the nasal annular was placed correctly on the resident. If the oxygen bottle needed changing, he would tell the nurse. 09/19/24 11:50 AM Interview was conducted with Employee B, LPN, who reported she has worked worked at the facility for almost one year. She would monitor prescribed oxygen liter flow rates and ensure their oxygen level flow rates were accurate. In regard to Resident #59's oxygen therapy, she could not find a current order in the resident's electronic medical record for an oxygen order. She further explained that she knew there must have been a previous order for oxygen because the picture of the resident in the electronic medical record showed the resident wearing a nasal cannula. She also explained that the resident went to the hospital several times, so the lack of an O2 order may have been an oversight upon return from the hospital. 45153 4. On 09/16/24 at 12:34 PM, Resident #105 was observed lying in bed, with his eyes closed, wearing the nasal cannula. Resident #105's oxygen concentrator located at bedside was observed to be set at 2L/min. (Photographic evidence obtained) On 09/17/24 at 11:39 AM a second observation of Resident #105 lying in bed, with his eyes closed, wearing the nasal cannula with the oxygen concentrator revealed it was set at 2L/min. (Photographic evidence obtained) A review of the medical record active orders included but not limited to oxygen continuous at 3 L/min via nasal cannula for shortness of breath (SOB) every shift dated: 08/15/2024. Further review of the physician's orders revealed: change oxygen humidifier bottle every shift every Sun dated: 09/17/23, rinse or replace oxygen filters on concentrator every shift every sun dated: 9/17/23, vitas hospice services admitted to vitas hospice services on 11/1/23 for cerebral atherosclerosis dated: 3/19/22, enhanced barrier precautions: chronic wound every shift for multiple drug-resistant organism precautions dated 7/25/24, and do not resuscitate dated 5/27/24 (Copy obtained) On 09/18/24 at 02:37 PM, a third observation of Resident #105 lying in bed, with his eyes closed, wearing the nasal cannula with the oxygen concentrator revealed it was set at 2L/min. (Photographic evidence obtained) Record review indicated that Resident#105 was admitted to the facility on [DATE]. Primary diagnoses included: encounter for palliative care. Quarterly MDS dated [DATE] revealed hospice care resident with a brief interview of mental status score (BIMS) 9, indicating moderately impaired. The resident was assessed and required oxygen therapy, substantial/maximal assistance for eating and did not attempt toileting transfer due to medical condition. The care plan focuses and goals included hospice, altered respiratory status/difficulty breathing related to shortness of breath (SOB), and enhanced barrier precautions related to risk for multidrug-resistant organism (MDRO). Interventions included administer medication/puffers/nebs as ordered. Monitor for effectiveness and side effects; oxygen settings: oxygen settings and care per Medical Doctor order. Medication Administration Record for September 2024 indicated oxygen initialed was provided as ordered (copy obtained) On 09/18/2024 at 02:39 PM Employee I, Registered Nurse (RN), verified Resident #105's oxygen concentrator was set at 2L. When asked who provides ongoing monitoring of the resident's oxygen therapy, Employee I replied, nursing. Nurses are also responsible for ensuring that residents receive correct oxygen orders. Correct oxygen settings are identified in the order. Nursing on the night shift change residents' oxygen tubing. Correct oxygen settings are communicated from one staff person to another in reports and on the Medication Administration Record and Treatment Administration Record. Employee I stated Resident #105 does not change his own oxygen levels but will remove the nasal cannula sometimes. When this happens, Resident #105 is educated and nursing will place the nasal cannula back on the resident. On 09/18/2024 at 02:54 PM the ADON confirmed the correct oxygen settings are identified in the orders. 48947 5. A record review of Resident # 90 revealed an admitted [DATE] with diagnoses of encounter for palliative care, hemiplegia and hemiparesis following nontraumatic intracranial hemorrhage affecting right dominant side, dysphagia, aphasia, cognitive communication deficit, Chronic Obstructive Pulmonary Disease (COPD), and Asthma. A record review of a quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) was not conducted and long-term and short-term memory problems were indicated. The MDS review also revealed the resident was dependent for eating, transfers, bed mobility, and toileting tasks. The MDS revealed the resident had a prognosis which indicated a condition or chronic disease that may result in a life expectancy of less than 6 months. Hospice and oxygen therapy were also indicated. A review of the resident's orders revealed the following: head of bed elevated related to shortness of breath (SOB) when lying flat every shift (11/11/2023), rinse or replace oxygen filters of concentrators every night shift, every Sunday (11/12/2023), change oxygen set-up and bag weekly and as needed (11/12/2024), Oxygen continuous at 2 liters/ minute via nasal cannula (NC) for medical diagnosis SOB (11/11/2023), Do Not Resuscitate (11/28/2023), Admit to Hospice services on 12/05/2023 for diagnosis Cerebrovascular Disease (3/19/2024), Nothing by mouth (NPO) diet (11/11/2023). A review of progress notes was conducted which revealed a physician progress note dated 9/3/2024 which documented the resident was receiving antibiotic therapy for pneumonia. A review of hospice progress note dated 8/28/2024 which documented resident's bed has to be upright at 30-degree angle to avoid SOB, and for her feedings. A review of dietary progress note dated 8/20/2024 which documented resident had a diet of NPO, with enteral feeds. A review of the resident's care plan was conducted which revealed a FOCUS: DNR (initiated: 12/27/2021, revision: 12/26/2023), a FOCUS: Resident had a cerebrovascular accident (CVA) with right hemiparesis (initiated 9/20/2022, revision 9/20/2022), a FOCUS: Hospice (initiated 12/6/2023, revision: 12/06/2023), and a FOCUS: Altered respiratory status/difficulty breathing related to SOB, wheezing, cough. congestion, history of Pneumonia, vascular congestion, s/p COVID (initiated: 2/20/2023, revision: 9/1/2023). On 09/16/24 at 11:54 AM, the resident was observed to have oxygen infusing at between 2.5 liters and 3 liters via nasal cannula. On 9/17/24 at 03:52 PM, the resident was observed to have oxygen infusing at between 2.5 liters and 3 liters via nasal cannula. (photographic evidence obtained) On 09/19/24 at 01:38 PM, the resident was observed to have oxygen infusing at 1.5 liters via nasal cannula. (photographic evidence obtained). On 09/19/24 at 01:57 PM an interview was conducted with Registered Nurse (RN) E. She was asked to access the physician orders for Resident #90. The orders read, Oxygen continuous at 2 liters/ minute via nasal cannula. RN E was accompanied to the resident's bedside to verify the oxygen concentrator settings. RN E verified the settings as 1.5 liters. On 09/19/24 at 01:50 PM an interview was conducted with certified nurse assistant CNA F. He was asked if he'd had training for how to care for a resident with oxygen. He stated, I've had encounters with the nurse about the oxygen, but I haven't had any training, not since I've been here. He was asked to explain his role in caring for a resident requiring oxygen. He stated, I make sure the tubing is on correctly. I check behind their ears to make sure they don't have any breakdown, and if the patient is using a portable tank, I make sure they have enough oxygen in the tank. CNA F was asked if he ever changed or adjusted the settings on the concentrator. He stated, I ask the nurse about the settings to make sure it's correct, but I don't make any changes or adjustments, I get the nurse for that. Review of the facility's Policy and procedures: Tracheostomy Care and Suctioning/Oxygen revised date: 03/26/21, revealed: Policy: the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences .2. The facility will provide necessary respiratory care and services, such as oxygen therapy as ordered by physician, treatments, mechanical ventilation, tracheostomy care and/or suctioning.

Based on observations, record reviews, and interviews, the facility failed to protect the resident's right to a dignified experience for one resident (#53) related to catheter use and for one resident (#38) related to personal and medical information out of the 40 residents sampled. The findings include: 1. A record review for Resident #53 revealed he was admitted [DATE] with diagnoses of quadriplegia, contracture of muscle, multiple sites, other muscle spasms, anxiety disorder, neuromuscular dysfunction of bladder, and recurrent major depressive disorder. A review of a quarterly minimum date set (MDS) dated [DATE] indicated he had a brief interview for mental status (BIMS) score of 15/15, indicating no cognitive impairment. The MDS indicated he was dependent for bed mobility, toileting and transfer tasks. He required substantial/maximal assistance with eating. The MDS also indicated he had an indwelling catheter. Physician orders included suprapubic catheter: Size #20FR with size 10cc balloon for diagnosis neuromuscular dysfunction of bladder, to be changed at urology office monthly. (5/24/20). Change bedside drainage bag of urinary catheter as needed (3/30/22), suprapubic catheter care every shift and as needed (5/8/22), adaptive equipment: Dressing change to suprapubic site once daily and as needed (9/26/22), may irrigate indwelling suprapubic catheter with 60mL of normal saline every shift as needed for blockage, occlusion, leakage, etc., enhanced barrier precaution for suprapubic catheter (4/2/24). The resident's care plan included a FOCUS: Supra-pubic catheter due to neuromuscular dysfunction of the bladder. (initiated 5/4/2018, revision 4/26/2022). On 09/16/24 at 12:38 PM, the resident's suprapubic catheter urine collection bag was observed hanging on the left side of the bedrail (facing the room door), without a bag cover. On 09/17/24 at 03:55 PM, the resident's urine collection bag was observed on the floor, facing the door without a bag cover. (photographic evidence obtained). On 09/19/24 at 01:50 PM an interview was conducted with certified nursing assistant (CNA) F who was asked if he'd had training/education on how to care for a resident with a catheter. He stated, Yes, through Healthcare Academy. CNA F was asked what his role was in caring for a resident with a catheter. He stated, I make sure the tubing is not kinked, make sure I don't raise the bag above the patient's bladder and make sure the catheter is on the right side of the bed according to which side they are turned. CNA F was asked if he ever gave the resident with a supra pubic catheter any catheter care. He stated, I usually get the LPN to do the cleaning or apply the dressings. 2. A record review was conducted for Resident #38 which revealed she was admitted to the facility on [DATE] with diagnosis of Diffuse Traumatic Brain Injury with loss of consciousness of unspecified duration, unspecified injury of the head, dysarthria, anarthria, dysphagia, oropharyngeal, aphasia, quadriplegia, cognitive communication deficit, and seizures. A review of a quarterly minimum date set (MDS) revealed the resident had adequate hearing and vision but no speech. She had a brief interview for mental status (BIMS) score of 0. She was dependent for all ADLs, and she had a gastrostomy tube. An observation on 09/16/24 at 10:56 AM revealed signage that contained the resident's personal medical information that was posted on the wall above the head of the bed, in plain view. (photographic evidence obtained). An observation on 09/17/24 at 09:58 AM revealed the signage posted on the wall above the head of the bed, in plain view which contained the resident's personal medical information. Another observation on 09/19/24 at 01:46 PM revealed the same signage that contained the resident's personal medical information and was posted on the wall above the head of the bed, in plain view, from the door of the resident's room. (photographic evidence obtained). On 09/19/24 at 04:11 PM, an interview was conducted with CNA G who was asked if he could read the sign. He stated, Yes, it says New CNAs, see nurse about (Resident #38's) head, No skull on left side. CNA G was asked how long the sign had been hanging on the wall. He stated, I'm not sure but it's definitely been there for 2 months. CNA G was asked if he knew who hung the sign. He stated, I assume the nurse manager. CNA G was asked if he thought anyone who happened to walk into the room could see the sign. He stated, Yes. On 09/19/24 at 04:16 PM an interview was conducted with licensed practical nurse (LPN) H who was accompanied to the door of Resident #38's room to observe the signage on the wall at the head of the bed. She was asked who put the signs up. She stated, I'm not sure but I believe the family put them up. She was asked how long the signs had been hanging on the wall. She stated, I've worked here for less than a year and they have been there since I've worked here. She was asked if any facility staff had approached the family about an alternative method of communicating the resident's care needs to new staff. She stated, You know, I come to work and mind my business, I really try not to get too involved. She was asked (from where she was standing at the door of the room) if she believed anyone else would be able to view and read the signs. She stated, If they paid attention, they could but I usually pull the curtain so that she can have privacy when I'm on duty. The surveyor observed that the curtain was not pulled.

Based on observations, record review, staff and resident interviews, and facility policy review, the facility failed to provide the necessary care and services to ensure that one of two residents selected for Activities of Daily Living (ADLs) review (Resident #64) did not diminish in their abilities to maintain fingernails and toenails that were clean and neat from 40 sampled residents. The findings include: On 9/16/2024 at 11:19 am, during the initial tour, Resident #64 was observed in his room. He was awake, lying on his right side on his bed, with his hands and feet exposed. It was observed that his fingernails and toenails were dirty, elongated beyond the tip of his fingers and toes, respectively, and thickened, with a yellowish color. When asked about his care, Resident #64 expressed a need for assistance with nail care, emphasizing that he would like to have his nails trimmed. He stated that he had spoken with a staff member about having his nails trimmed. The resident could not recall the name of the staff member he had spoken to about trimming his nails. Record review for Resident #64 revealed that he was most recently admitted to the facility on [DATE], with an initial admitted [DATE]. The resident's diagnoses included but not limited to chronic obstructive pulmonary disease, muscle weakness (generalized), shortness of breath, major depressive disorder, primary insomnia, essential hypertension, gastroesophageal reflux disease without esophagitis, wheezing, and pain. The latest quarterly Minimum Data Set (MDS) was reviewed with an assessment reference date of 7/19/2024. Resident #64 had a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderately impaired mental status. There were no signs of psychosis, behavioral symptoms, or rejection of care. The MDS showed that Resident #64 had no functional limitations in ADLs and was found to be independent, in terms of mobility. A review of the care plan, initiated on 4/2/2020 and most recently revised on 4/18/2024, indicated that the resident was at risk for decline or fluctuation in ADLs related to health status. The care plan noted that the goal was to maintain the resident's current level of function. Interventions in the care plan included but not limited to checking nail length, trimming and cleaning them on bath day and as necessary, and reporting any changes to the nurse. Relevant physician orders included left U-bar side rail enabler is indicated to enable positional changes and bed mobility (ordered 9/12/2022), podiatry consult (ordered 8/17/2023), and complete weekly skin observation and enter in the Avante weekly summary with skin check assessment 3-11 shift (ordered 4/7/2022). The resident's medical record had evidence that the last podiatry consult note was dated 2/23/2023. The podiatry consult note showed that the provider debrided all of the resident's toenails to reduce their length and thickness. The provider recommended a podiatry follow-up two months from the date of the note (2/23/2023) and noted that care of this patient by a non-skilled professional may be hazardous to the patient's health. No nursing notes or physician progress notes related to fingernails or toenails care or documentation relevant to the resident rejecting care, were found, as reviewed from 2/23/2023 to 9/19/2024. There was no record or documentation related to overgrown nails for Resident #64 in the most recently reviewed Avante weekly summary with skin check assessments, dated 8/19/2024, 8/26/2024, 9/2/2024, and 9/16/2024. The weekly summary with skin checks described the skin as intact, and comments/observations were not documented. An interview was conducted with a Certified Nursing Assistant (CNA/ Employee D) on 9/19/2024 at 12:10 pm. When asked to explain the method of completing a resident's assessment and documenting the findings and to whom they are reported, the CNA stated that her routine begins by knocking and introducing herself to the resident before entering the room. The CNA stated that she proceeds to assist the resident with their ADLs depending on the severity of the assistance needed. The CNA added that Resident #64 was mostly independent and preferred to complete his ADLs on his own. When asked if the resident had requested any assistance with nail care recently, the CNA stated that the resident had not requested any assistance for any ADLs recently. The CNA mentioned that the resident usually performed his own nail care, except for his feet, which are cared for by podiatry. The CNA stated that she believed that podiatry came to see the resident recently but was unable to recall the date. The surveyor asked if the CNA was aware of the condition of the resident's nails. The CNA stated that she was aware of the condition of the resident's nails, but the resident always performed his own fingernail care. When asked to perform an assessment of the resident's fingernails and toenails, the CNA and was unable to perform an assessment because Resident #64 was sleeping and covered with his blankets. The CNA told the surveyor that she would remind the nurse about the condition of the resident's nails. When asked where in the record the surveyor would find documentation about nail care needs, the CNA stated that the assessments/observations would be documented under skin assessments, which CNAs and LPNs document. An interview was conducted with a Licensed Practical Nurse (LPN/Employee B) on 9/19/2024 at 12:59 pm. When asked, What can you tell me about Resident #64?, the LPN stated, The resident has severe COPD and is a current smoker. He is generally a pleasant resident. She was then asked, What is the process of assisting a resident with fingernail trimming? The LPN stated, He can trim his fingernails himself. If a resident needs assistance, we can help with fingernail trimming. She was also asked, Has the resident asked for help trimming his fingernails or toenails? The LPN stated, He has not asked me for help with trimming his fingernails. Podiatry will take care of the toenails. Per staff member, social services enter the residents onto a list to see podiatry, if they had a podiatry consult in place. Next, the LPN was asked How often are residents assessed for needs such as fingernail trimming or toenail trimming? She stated that every staff member providing direct care on their scheduled shift, including certified nursing assistants (CNAs), nurses, other providers, or any staff member interacting with the resident, will perform an assessment. An interview was conducted with the Social Services Director (SSD), on 9/18/2024 at 1:51 pm. She was asked about the facility's nail care provision for residents. The SSD mentioned that if residents are physically and cognitively capable, they can trim their own fingernails. The SSD added that CNAs and LPNs can assist with fingernail trimming if needed. When questioned about how often residents are assessed for ADL needs such as nail care, the SSD stated that they are assessed daily. The SSD further explained that residents are put on the podiatry consult list after a podiatry consult is requested for toenails care. Further, she stated that the podiatry provider is scheduled to visit the residents on the list every 45-55 days. When asked specifically about the last podiatry consultation date for Resident #64, the SSD provided the date as 2/23/2023, after reviewing the resident's record. This surveyor inquired if Resident #64 had refused care, and the SSD confirmed that the resident had not refused any care, including nail trimming. When asked if the resident should have been seen by podiatry after the last consult, which was placed on 8/17/2023, the SSD stated that Resident #64 should have had at least one visit since the consult was placed. The surveyor then requested the SSD to provide a copy of the most recent podiatry consultation note. The SSD provided a copy of the podiatry consultation note dated 2/23/2023 at 1:57 pm and acknowledged that there were no recent records or documentation of podiatry care since 2/23/2023. On 9/19/2024 at 2:20 pm, a review was conducted of the facility's policy and procedures titled Policies and Procedures: Activities of Daily Living (ADLs) Maintain Abilities, which was issued and revised on 3/2/2019. The facility's policy and procedure included: 1. The facility will provide necessary care and services to ensure that resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 2. The facility will ensure that a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out activities of daily living. 3. The facility will provide care and services for the following activities of daily living: Hygiene - bathing, dressing, grooming, and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Following the survey, on 9/23/24, the facility submitted documentation that Resident #64 received podiatry services on 5/22/24. This was after the request for additional information made on 9/18/24 and after the survey exit on 9/19/24. The podiatry consult on 5/22/24 was three months after the prior visit which recommended a follow up after two months. The appearance of Resident #64's nails during the survey and lack of documentation indicate that the established care plan was not being followed.

Based on observations, record review, and interviews the facility failed to maintain clinical records that were accurately documented for two (Residents 103 and 124) out of 40 sampled residents. The findings include 1. During the initial tour on [DATE] at 12:50 PM, Resident 103 was observed to have a tracheostomy (a surgically created hole in the neck/windpipe that provides an alternative airway for breathing) with humidified oxygen (O2) provided through a trach-mask. The date on the humidification bottle attached to the humidified O2 tubing was [DATE] (photographic evidence obtained). The resident was asleep at the time. Another observation on [DATE] at 11:50 AM found Resident 103 awake and alert but not interviewable. Review of the medical record for Resident 103 indicated an initial admission to the facility on [DATE] and a re-entry on [DATE]. The diagnoses included Huntington's disease, encephalopathy, dependence on supplemental oxygen, extrapyramidal movement disorder, and dysphagia. The resident's annual Minimum Data Set (MDS) from [DATE] revealed that the Brief Interview for Mental Status (BIMS) was not scored related to the resident not being interviewable. Review of the Treatment Administration Record (TAR) for the month of ,d+[DATE] for Resident 103 revealed documentation for the order to change the O2 tubing/humidification bottle/mask, etc. every week and as needed completed on [DATE], [DATE], and [DATE] (photographic evidence obtained). 2. A closed record review of Resident 124 indicated an initial admission to the facility on [DATE], a re-entry on [DATE], and a discharge date (date of death ) of [DATE]. The diagnoses included lymphedema, heart failure, atrial-fibrillation, and benign prostatic hyperplasia. The resident was [AGE] years old, and the death was expected. In an interview with the DON on [DATE] at 02:50 PM, she stated that the resident's medical doctor (MD) was notified of Resident 124's death on [DATE]. Review of documentation from Resident 124's chart revealed a witness statement from [DATE] at approximately 12:30 AM that indicated the MD was immediately notified of the resident's change in condition with a new order to pronounce time of death. Review of Resident 124's medical record revealed a progress note created on [DATE] by the Medical Director (Resident 124's Primary Care Physician/MD) which included, Care plan reviewed and shared with patient. It had an effective date of [DATE] (See photographic evidence). An interview with the Medical Director was attempted via telephone twice on [DATE], once at 12:37 PM and again at 12:43 PM, both times the calls ended without going to voicemail.

Based on observations, interviews and record review, the facility failed to ensure residents received adequate supervision to prevent accidents, by failing to supervise residents during smoking breaks for three (Residents #3, #4, and #5) of seven sampled residents who smoked, from a total sample of nine residents. Failure to supervise residents during smoking breaks could result in injury and/or death. The findings include: During a tour of the facility on 3/21/23 at 10:22 AM, two residents were observed smoking on the smoking porch (Residents #3 and #4). There were no staff members present. An interview was conducted with Resident #4 at 10:25 AM, and she explained that she had kept her cigarettes and lighter from the night before and gave one of her cigarettes to Resident #3. Resident #4 stated, The staff are supposed to supervise us during our smoking break, but they never show up. They were supposed to be here at 10:15 AM, but as you can see, there is no one here from the staff. They keep our cigarettes and treat us like kids, and we have to beg to get them. On 3/21/23 at 10:30 AM, Resident #5 was observed propelling herself in her wheelchair to the smoking area. She removed a small piece of cigarette and a lighter from her purse and lit the cigarette. There were no staff members present. On 3/21/23 at 10:35 AM, Licensed Practical Nurse (LPN)/Unit Manager A came to the smoking porch area and asked the residents what they were doing. Resident #3 said Resident #4 gave her a cigarette. LPN A told Resident #3 that she did not have a smoking assessment and needed to have one completed to see if she was a safe smoker. LPN A told Resident #3 and Resident #4 that they could not share their cigarettes. Resident #4 said she wanted to start smoking and asked the nurse to notify her son and daughter-in-law. LPN A asked Resident #5, who was smoking, if she was back on the smoking list. Resident #5 said, No, and discarded the cigarette. Resident #3 asked LPN A if she could get the cigarette box because they had not had their smoking break. LPN A asked Certified Nursing Assistant (CNA)/Medical Records Clerk B to assist the residents with their smoking break. On 3/21/23 at 10:45 AM, an interview was conducted with CNA B who confirmed that the residents were supposed to be supervised during smoking breaks. She explained the schedule notated the designated staff person assigned on each smoking break. When asked how staff ensured residents did not retain their cigarettes, she replied, We are supposed to check that all the cigarettes and the lighters are taken at the end of the break. We actually should be handing the residents one cigarette at time and not the whole packet, and then light their cigarettes. When asked how many cigarettes each resident was permitted to have during the smoking break, she replied, They are allowed around two cigarettes per smoking break. A review of Resident #3's medical record revealed an admitted [DATE] with a re-entry date of 10/10/22. The resident's Quarterly Minimum Data Set (MDS) assessment, dated 2/1/23, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points (10/15), indicating moderate cognitive impairment. A review of the resident's comprehensive care plan revealed no evidence that she was care planned for smoking. Further record review revealed no evidence that Resident #3 had a smoking assessment. A review of Resident #4's medical record revealed an admitted [DATE] with a primary diagnosis of hyposmolality and hyponatremia. Her secondary diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and psychosis. The resident's Quarterly MDS assessment, dated 2/8/23, revealed a BIMS score of 15/15, indicating she was cognitively intact. A review of Resident #4's comprehensive care plan, dated 1/27/22, revealed a focus area for Smoking with Interventions including: Give positive reinforcement for compliant behavior with the smoking policy. Ensure resident does not leave designated smoking area with smoking materials. Notify charge nurse immediately if it is suspected the resident has violated the smoking policy. The resident's smoking supplies are stored in designated areas. (Photographic evidence obtained) A review of Resident #5' medical record revealed an admitted [DATE] with diagnoses including dementia without behavior disturbance, psychotic disturbance, and mood disturbance. The resident's Significant Change MDS assessment, dated 1/8/23, revealed a BIMS score of 5/15, indicating severe cognitive impairment. The resident required supervision with transfers. A review of Resident #5's comprehensive care plan, dated 1/26/23, revealed the resident was a smoker and was at risk for injury related to unsafe smoking. Interventions included: Assist resident as needed to designated smoking area at designated times and supervise smoking. Smoking assessment to be completed on admission, quarterly and with any significant change in condition. Smoking will be supervised by staff members. (Photographic evidence obtained) A review of Resident #5's smoking assessments, conducted on 1/26/23 and 2/7/23, indicated the resident was moderately impaired and was permitted to smoke but must be supervised by staff or family. (Photographic evidence obtained) On 3/21/23 at 1:31 PM, an interview was conducted with CNA C concerning the resident smoking protocol. He stated CNAs were assigned each shift to supervise the smoking breaks. During the break, staff were expected to obtain the cigarette box from the nursing station, light the residents' cigarettes and stay within the residents' vicinity during the break. After the break was over, the staff should ensure that all cigarettes and lighters were back in the box, and then escort the residents who needed assistance back into the building. When asked if he supervised smoking breaks, he stated, Yes, but most of the time when he was assigned, he could not go to the smoking porch because he was normally tied up providing resident care. When asked if he was assigned to the smoking break scheduled from 10:15- 10:30 AM on 3/21/23, he replied, Yes, but I did not make it because I was busy at that time. On 3/21/23 at 4:45 PM, an interview was conducted with the Administrator who explained that residents were assessed for smoking upon admission, quarterly and as needed (PRN). If a resident had a history of smoking and showed interest in smoking, an assessment was completed. She explained she had completed a Quality Assurance and Improvement Plan in June 2022 about smoking. Staff were educated about the expectations during smoking breaks and she expected all smoking breaks to be supervised. Staff should not be distracted to ensure they were always watching the residents while they were smoking. Residents should have two cigarettes during each break, and staff should light the cigarettes. After two cigarettes, staff should ensure that residents did not retain any cigarettes or lighters. If a resident refused to give back the cigarettes or the lighter, they should be educated on the smoking policy and smoking contract. Staff should also document the incident to ensure that the staff were aware of behaviors and could monitor them. If a resident had up to three incidences of not following the smoking policy, they were issued a 30-day discharge notice. A review of the facility's Safe Smoking Policy and Procedure (rev.1/11/19) revealed the following: Under Policy, Page 1, Paragraph 2: Reduce risks of passive smoking for others. On Page 2 under Interventions: Screening - A safe Screen is performed on admission for a resident who wishes to smoke. - Assess resident's cognitive status to determine if the resident is capable of safe smoking. - Observe the resident's ability to smoke in a safe manner. - Reassessment of the resident occurs annually and/or after a significant change in condition, as is needed. Page 2, Planning, Paragraph 1: If the IDT (interdisciplinary team) members determine that the resident is an unsafe smoker, the resident may be required to wear a protective smoking vest/apron and have a greater degree of staff supervision while smoking. It continued to say that lighters/ignition materials must be returned to the nursing station or designated area and not remain on their person. Page 2, Outcome evaluation: Smoking accidents/incidents that occur while a resident is smoking, necessitates a rescreening of the resident. This includes assisting, enabling, or sharing smoking materials (lighter, matches, or cigarettes) with other residents. Page 3, Paragraph 1 and 2: The facility reserves the right to prohibit a previously determined safe smoker from retaining smoking materials and/or smoking without supervision if they are witnessed assisting or enabling an unsafe smoker or failure to adhere to the policy of returning lighters/ignition materials to the nurses' station or designated area. Smoker's noted to fail to adhere to the safe smoking policy, including returning lighters/ignition materials may be issued a 30 day notice of discharge in order to ensure the protection of the other residents. Residents who demonstrate an immediate threat to other residents, themselves, visitors, or staff may be immediately transferred/discharged from the facility to maintain the safety of residents and others.

Based on observations, staff interviews and policy and procedure review, the facility failed to ensure staff served meals in a safe and sanitary manner and maintained food service equipment. Failure to clean and maintain cooking and baking equipment and to ensure that food provided to residents is prepared in a clean environment in accordance with professional standards for food service, can place all residents who consumed foods prepared in the facility's kitchen at risk of exposure to food-borne illnesses. The findings include: An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 09/19/2022 at 8:30 AM. During the tour, the dry storage pantry, throughout the kitchen and on the wall behind the preparation table built-up debris and dirt were observed. Food debris was observed in the grooves between the floor tiles. The ice machine room floor had what appeared to be built-up dirt in the grooves between the tiles. The side of the counter next to the trash can was covered with grease buildup and food debris. The trash can lid was covered with food debris. The plastic covering over the standing mixer and meat slicer was heavily soiled with grease and food debris. When asked about the condition of the mixer and meat slicer, Cook E stated the mixer was not in use. The leg pipes of the steamer, sitting on the countertop were coated with a brown substance. There were two ovens located next to the convection oven; both were filled with food debris. When asked about the condition of the two ovens next to the convection oven, Cook E stated the ovens had not worked in two months. Spillage was observed in the top and bottom convection ovens. Trash and debris were observed on the floor in the dry storage pantry and ice machine room, as well as underneath the steam table and convection oven. A water spillage filled with food debris was observed on the side arm of a food cart. These observations were made again on 09/20/2022 at 10:00 AM and on 09/21/2022 at 11:08 AM. (Photographic evidence obtained) On 09/20/2022 at 10:00 AM, a second observation of the kitchen was conducted. The dry storage pantry and the cook area had built-up dirt and a grainy substance on the floor and food debris in the grooves between tiles. The side of the counter next to the trash can was covered with grease buildup and food debris. The two ovens next to the convection oven were filled with food debris. Cook E reported that he tried cleaning the ovens yesterday. The leg pipes of the steamer, sitting on the countertop, were coated with a brown substance. The water spillage, still filled with food debris, remained on the side arm of a food cart next to the food prep area. Spillage was observed in the bottom convection oven. Cook E reported that he tried cleaning the ovens yesterday, 9/19/2022. The trash was removed, however, built-up dirt in the grooves between the floor tiles remained on the ice machine room floor. The cleaning schedule was obtained on 9/20/2022. The schedule indicated the floors had been scrubbed, but there was no indication of deep cleaning. (Photographic evidence obtained) On 09/21/2022 at 11:08 AM, an interview with the CDM and a third observation of the kitchen was conducted. During this tour, built-up dirt and food debris in the grooves between floor tiles was observed throughout the kitchen. The side of the counter next to the trash can was covered with grease build-up and food debris. The two ovens next to the convection oven were filled with food debris. The CDM reported she tried cleaning the ovens yesterday, 9/20/2022. She stated she did not recall the kitchen using the two ovens since February 2022. A white plastic container on top of a cart and water spillage filled with food debris was observed on the side arm of the food cart next to the food prep area. Built-up dirt observed in the grooves between the tiles remained on the ice machine room floor. When asked about staff in-service trainings, the CDM reported in-service trainings were based on concerns that come up. There are no trainings from corporate. (Photographic evidence obtained) On 09/22/2022 at 1:23 PM, an interview was conducted with Dietary Aide B. When asked who was responsible for cleaning and maintaining the kitchen equipment, she reported all staff were responsible for cleaning. Cooks are responsible for pots and pans, scoops, cooking equipment, and the work area. Dietary Aides are responsible for plates/bowls, utensils, and the work area. She stated staff reported equipment failures to the supervisor, and the supervisor submitted work orders to the maintenance department. On 09/22/2022 at 1:25 PM, an interview was conducted with the CDM. When asked who was responsible for cleaning and maintaining kitchen equipment, she stated, It is everyone's responsibility that is employed in the kitchen. If there is a problem with any equipment or the sink is not working, it is reported to the CDM and the CDM will submit a work order to maintenance. She stated the kitchen had a cleaning schedule. The floor is swept or mopped whenever there is a spillage and at the end of the day when closing the kitchen down. The cook completes a walk through at the end of the night to ensure no spillage is on the floor. Everything is wiped down and sanitized clean. The CDM will walk through in the morning to check the cleanliness of the kitchen. On 09/22/2022 at 2:44 PM, an interview with The Director of Plant Operations revealed he had not received a work order for the two ovens that were not working, nor had he heard of any problems related to the condition of the two ovens. On 09/22/2022 at 2:50 PM, an interview with the CDM revealed the two ovens that were not working were not used because staff are having to bend down and it's bad on your back, so the convection ovens are used. It's harder to take food out when staff are that low to the ground. Staff only use the top burners of the oven. A review of the facilty's policy and procedure entitled Food and Nutritional Services, revised date: 3/2/2019, revealed it read: 13. The facility will procure food from sources approved or considered satisfactory by the Federal, State, or local authorities and store, prepare, distribute, and serve food under sanitary conditions following proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 14. Staff maintain the sanitation of department by assuring that: Floors are kept clean, free of debris, and spills are cleaned-up immediately to avoid accidents. Cleaning schedules are followed, and cleaning procedures are utilized. 17. The facility will dispose of garbage and refuse properly, garbage and refuse containers will be maintained in good condition, and garbage receptacles will be covered when transported to the dumpster from the kitchen. Reference: United States Food and Drug Administration Food Code 2017. 3. Public Health and Consumer Expectations. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 9/26/2022): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met, and that food is unadulterated, prepared in a clean environment, and honestly presented. Reference: United States Food and Drug Administration Food Code 2017. 4.602.12. Cooking and Baking Equipment. Page 568. https://www.fda.gov (Accessed 0n 9/26/2022): Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Because of the nature of the equipment, it may not be necessary to clean cooking equipment as frequently as the equipment specified in S 4-602.11.

Based on observations, interviews, and record review, the facility failed to honor the resident's right to a dignified existence by not covering a urinary catheter bag with a dignity cover for 1 (Resident #60) of 36 residents in the sample. The findings include: An observation was made of Resident #60 in his room on 9/19/22 at 7:15 AM. His urinary catheter bag with urine in it was observed from the hallway. There was no dignity cover on the catheter bag. (Photographic evidence obtained) On 9/19/22 at 9:00 AM another observation was made of Resident #60 in his room. His catheter bag remained uncovered and was visible from the hallway. (Photographic evidence obtained) A third observation was made of Resident #60 on 9/20/22 at 10:40 AM. His catheter bag was observed hanging from his bed and was facing the doorway. There was no dignity cover on the bag and it could be seen from the hallway. (Photographic evidence obtained) An interview was conducted with Resident #60 on 9/19/22 at 9:05 AM. He stated he did not like that his urinary catheter bag was uncovered allowing others to see the contents of the bag. He further stated the catheter bag was left uncovered when he was out of his room in his wheelchair as well. A medical record review for Resident #60 revealed an admitted [DATE] and diagnoses including [CONDITION(S)], pain, anxiety disorder, neuromuscular dysfunction of bladder, and major depressive disorder. Resident #60's Minimum Data Set (MDS) assessment, dated 8/8/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. His Activities of Daily Living (ADLs) revealed he was totally dependent with the assistance of two staff members for bed mobility and transfers. He was assessed as totally dependent with assistance of one staff member for eating, and required total care of one staff member for bathing. A review of the resident's physician's orders revealed a 5/8/22 order for suprapubic catheter care every shift and as needed. A review of the resident's care plan, dated 8/16/22, revealed a suprapubic catheter due to neuromuscular dysfunction of the bladder and the resident was at risk for recurrent Urinary Tract Infection ([CONDITION(S)]). Interventions included. Administer medications, position catheter bag and tubing below level of bladder, maintain privacy bag, and empty catheter bag every shift. (Photographic evidence obtained) An interview was conducted with Certified Nursing Assistant (CNA) F on 9/22/22 at 1:40 PM. CNA F reported that part of the care she provided for residents with urinary catheters was that she emptied the catheter bag and cleaned the area around the catheter site. She was asked when a privacy bag would be placed on a catheter bag, and she reported, at all times. At this time she stated, Resident #60 does not have a privacy bag and he should have one. A review of the facility's policy for Resident Rights-Exercise of Rights (dated 3/2/2019) revealed: Each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff, temporary agency staff or volunteers, must focus on assisting the resident in maintaining and enhancing his or her self-esteem and self-worth and incorporating the resident's goals, preference and choices.

Based on observation, medical record review and interviews, the facility failed to develop a comprehensive person-centered [MEDICATION NAME] care plan for one (Resident #74) of 28 residents whose care plans were reviewed from a total sample of 45 residents. The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. She reported she had a [MEDICATION NAME] and the [MEDICATION NAME] bags she used were not available when she first came to the facility. This resident used a [MEDICATION NAME] bag, which had a separate flange and bag. The clinical staff assisted her with applying the appliance. She had to use the one the facility kept in stock which she stated irritated her skin. A record review was conducted for Resident #74, which noted an original admission date of [DATE] with a readmission on 2/5/2021. The Minimum Data Set (MDS) 5-day assessment, dated on 2/11/21, noted under section H that the resident had a [MEDICATION NAME]. A review of the updated care plan noted there was no [MEDICATION NAME] focus, goal or interventions to guide staff as to the resident's care needs. An interview was conducted with Employee G, Licensed Practical Nurse (LPN)/MDS Coordinator, on 03/03/21 at 1:24 p.m. Employee G was asked to review Resident #74's care plans and indicate if there was a care plan with a focus on Resident #74's [MEDICATION NAME]. The LPN confirmed there was no care plan for the [MEDICATION NAME] and there should have been.

Based on record review, interviews and a review of the policy and procedure for implanted venous access, the facility failed to provide appropriate treatment and care for a portacath (implanted central line) for one (Resident #74) of a total sample of 45 residents, by not changing the(NAME)needle in accordance with professional standards of practice. The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. The resident reported a portacath was located in her left upper chest which was observed. She reported it was not being flushed daily, the dressing was not changed as ordered, and no one had changed the(NAME)needle since she was admitted . She reported having had at least six portacaths and knew a lot about them. A medical record review noted an admission date of [DATE], and a readmission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The care plan, updated 2/23/21, included a focus area for a portacath at the left upper chest area with interventions to change the dressing per physician's orders [REDACTED]. The medical record was reviewed for documentation verifying the changing of the(NAME)needle, and no documentation was found to indicate it had been changed since the resident was admitted to the facility. A review of current physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON), Registered Nurse (RN), at 2:30 p.m. on 3/4/2021. The DON was asked when the portacath(NAME)needle was changed, and she reported she did not know. A review of the facility's policy and procedure for Implanted Venous Access Ports, revised May 1, 2016, noted under guidance: Non corning needles are changed every 7 days and correspond with dressing changes. An interview was conducted via telephone with the Medical Director on 3/4/21 at 2:10 p.m. He was asked about the frequency of changing the dressing and changing the(NAME)needle for the portacath. He reported the(NAME)needle should be changed every seven days with the dressing. He stated the length of dressing changes depended upon physician's orders [REDACTED].

Based on observations, staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure the accurate and safe provision of narcotic medication to one (Resident #47) of five residents who underwent medication review from a total of 45 residents in the sample. Resident #47 received expired narcotic medication ([MEDICATION NAME]) on two occasions. The findings include: During an observation of medication administration on [DATE] at 12:00 p.m. with Employee E, Licensed Practical Nurse (LPN), she was asked to pull a random narcotic blister card for an audit of her narcotic count. The card pulled belong to Resident #47. The card contained [MEDICATION NAME] (narcotic pain reliever) ,[DATE] mg (milligrams) with a physician's orders [REDACTED]. The card contained six tablets. The reconciliation sheet for this card contained in the narcotic count book showed six tablets remained. Upon inspection, it was noted that the card containing the pills had an expiration date of [DATE]. The reconciliation sheet showed that two doses had been administered after that expiration date. On February 13, 2021 one dose was given at 3:30 p.m., and another dose was given that same day at 9:00 p.m. These doses were signed out by Employee C, Registered Nurse (RN). During an interview with Employee E on [DATE] at 12:05 p.m., she was asked what her practice was if she came across expired medication in a blister card. She stated, I remove it and for this, it's a narcotic, so I am also removing the sign-out sheet, and I will remove the card from the card count too. Then I will lock this in my narcotic drawer and call the DON (Director of Nursing) to come remove it. She was asked when she checked the expiration dates on the medication blister cards to ensure the medication was not expired. She replied that she checked the dates before she administered medication from each card. She stated this was always her practice. During inspection of the West Wing medication cart (front hall) on [DATE] at 1:45 p.m., Employee C, RN, was asked what she should do if she identified a blister card with expired medication in her narcotic count. She stated, I would pull it from the count and put it's page with it, and lock it in the narcotic drawer on the side until the DON can come down and remove it from the count. She was asked if she checked the expiration date each time before removing a medication from the blister card and administering it to a resident. She stated yes. A review of the facility's policy/procedure titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles (effective [DATE], revised [DATE], [DATE] and [DATE]), revealed that the facility should ensure medications and biologicals that 1. have an expired date on the label; 2. have been retained longer than recommended by the manufacturer or supplier guidelines; or 3. have been contaminated or deteriorated, are stored separately from other medications until destroyed or returned to the pharmacy or supplier.

Based on staff interviews, clinical record review, and facility policy and procedure review, the facility failed to ensure a gradual dose reduction (GDR) of an antipsychotic medication for one (Resident #18) of five residents whose medication regimens were reviewed, from a total of 45 residents in the sample. The findings include: A review of pharmacy consultation reports revealed that on December 1, 2020, the pharmacist recommended a gradual dose reduction for the medication Quetiapine (antipsychotic) 25 mg (milligrams) to be reduced to 12.5 mg with the end goal of discontinuation, while concurrently monitoring for reemergence of target symptoms. This recommendation was signed by the resident's physician on December 7, 2020 with the response, I accept the recommendation, please implement as written. Further review revealed that on January 14, 2021, the pharmacist gave a repeat recommendation: In a consultation report dated December 1, 2020: Please respond promptly to assure facility compliance with Federal regulations. (Resident #18) was recently admitted with an order for [REDACTED]. This consult report was not signed by the physician. A review of the pharmacist's GDR tracking review revealed: 1/15/2021: GDR tracking reviewed for: Quetiapine (next GDR eval due 2/28/2021) 2/15/2021: GDR tracking reviewed for: Quetiapine (next GDR eval due 2/28/2021) A review of the Medication Administration Records (MARs) for Resident #18 for the months of December 2020, January 2021, February 2021 and March 2021, revealed that the resident received Quetiapine 25 mg daily by mouth for the duration of December, January and February, with the last dose given on March 2, 2021. A review of current physician's orders [REDACTED]. Further review of all physician's orders [REDACTED]. A review of Resident #18's quarterly Minimum Data Set (MDS) assessment, dated February 28, 2021, revealed documentation under the medications section which read, Did resident receive antipsychotic medications since admission/reentry or prior OBRA assessment? Yes (routine basis only) Has a GDR been attempted? No MD documented GDR as clinically contraindicated? No. A review of the person-centered care plan for Resident #18, with the last revision date of February 24, 2021, revealed: Focus: (Resident #18) uses [MEDICAL CONDITION] medications r/t (related to) dx (diagnoses) of anxiety, depression, [MEDICAL CONDITION], and [MEDICAL CONDITION] disorder. Goals: (Resident #18) will have no untreated s/s (signs and symptoms) of [MEDICAL CONDITION] drug related to complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation, or cognitive/behavioral impairment through next review date. Interventions: Administer meds (medications) as ordered, observe for side effects and effectiveness PRN (as needed). Completes AIMS (assessment) as required and PRN. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD, family re: ongoing need for medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness per facility policy. Educate the resident/family about risks/benefits and the side effects and/or toxic symptoms. Observe/document/report PRN any adverse reactions of [MEDICAL CONDITION] medication: unsteady gait, tardive dyskinesia, EPS, frequent falls, refusal to eat, diff swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, fatigue, weight loss, [MEDICAL CONDITION], n/v (nausea/vomitting), muscle cramps, behavioral symptoms not usual to the person. Refer to psychiatry as ordered. During an interview with the Director of Nursing (DON) on March 3, 2021 at 3:40 p.m., she was asked when the pharmacy made a GDR recommendation, and the physician agreed with the recommendation, what happened next. She replied, The nurse will take the signed recommendations and transcribe the order. Then the order is implemented. She was asked if the nurse on the unit at the time, caring for the resident, was the nurse who transcribed and implemented the order, or was someone specific responsible for this task, she replied, It's the nurse who is caring for the resident when the order comes in. She was then asked whether there was a specific time frame during which the new order should be transcribed and implemented, and she replied, No, it should just be done when the order is received.

Based on record review and interviews, the facility failed to administer [MEDICATION NAME] [MEDICATION]) as ordered for one (Resident #74) of five residents whose medications were reviewed, from a total of 45 residents in the sample. Failure to administer anti-[MEDICAL CONDITION] medication per the physicians' order can result [MEDICAL CONDITION] activity. The findings include: An observation and interview was conducted with Resident #74 on 3/1/21 at 11:32 a.m. in her room. She reported going to the hospital on [DATE] with multiple [MEDICAL CONDITION], and she did not believe she was receiving her [MEDICATION NAME] as ordered. A medical record review was conducted, which noted an admission date of [DATE] and a readmission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The care plan, updated 2/23/21, included a focus area for a [DIAGNOSES REDACTED]. A review of the nursing notes revealed that on 2/1/21 at 12:50 p.m., a CNA (certified nursing assistant) reported the resident was having [MEDICAL CONDITION]. Upon assessment, the resident was noted to have several back to back grand mal [MEDICAL CONDITION]. The Physician's Assistant was notifed and an order was received to send the resident to the emergency room for evaluation and a CT scan. (a medical imaging technique) A review of the hospital History and Physical, dated 2/2/2021, noted the resident was at the nursing home, had 13 [MEDICAL CONDITION], and was admitted to the hospital following the [MEDICAL CONDITION]. The resident reported her physician's orders [REDACTED]. While in the Emergency Department the patient was loaded with [MEDICATION NAME]. A record review of the Medication Administration Record (MAR) for January 2021, revealed [MEDICATION NAME] was not signed out as having been administered to Resident #74 on 1/21, 1/29 or 1/30/21. The resident was hospitalized with [MEDICAL CONDITION] on 2/1/2021. The MAR for February 2021 was reviewed and revealed [MEDICATION NAME] was not signed out as having been administered on 2/1 (the date of hospitalization , left facility after medication should have been given at 9:00 a.m.), 2/9, 2/14 or 2/26/21. An interview was conducted with Employee C, Registered Nurse (RN), at 1:30 p.m. on 3/4/2021. She stated she reviewed the MAR, pulled the medication, checked off each medication, saved the screen until after the medication was taken, and then it was locked. If a resident refused the medication, there was a space to enter that information, and it populated on the MAR. If there was a blank space where initials should have been documented on the MAR, the medication was not given. An interview was conducted with the facility's Medical Director (MD) at 2:10 p.m. on 3/4/2021. The primary physician for Resident #74 was not available. The MD stated, I tell my patients to not miss one dose of [MEDICATION NAME] because they could have a [MEDICAL CONDITION], and I encourage them to take it as ordered. They should not be missing any doses of [MEDICATION NAME].

Based on observation, medical record review and interviews, the facility failed to ensure accuracy of the medical record by 1) Signing off a treatment as having been completed when it was not completed, and 2) Failing to sign out ordered medications as having been administered for one (Resident #74) of five residents whose medications and treatments were reviewed from a total of 45 residents in the sample. The findings include: An observation and interview was conducted with Resident #74 on 3/1/2021 at 11:32 a.m. in her room. She reported that a portacath was located in her left upper chest, which was observed. She stated the dressing was not being changed as ordered. An observation of the portacath on her left chest revealed a dressing dated 2/24/2021. Resident #74 reported having had at least six portacaths and stated she knew a lot about them. A medical record review was conducted, which noted an admission date of [DATE] and a readmission date of [DATE]. Her [DIAGNOSES REDACTED]. The care plan, updated on 2/23/21, included a focus area for a portacath to the left upper chest area with interventions including: change the dressing per physician's orders [REDACTED]. A review of the current physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. They included the following: Atorvastatin 40 mg (milligrams) at bedtime, not initialed as having been given on 1/21, 1/28, 1/29, 1/30, 2/5, 2/9, 2/14 or 2/26/21 [MEDICATION NAME] 100 mg, 2 capsules at bedtime orally, not initialed as having been given on 1/28, 1/29, 1/30, 2/9, 2/13, 2/14 or 2/26/21 [MEDICATION NAME] 100 mg, 2 tablets at bedtime orally, not initialed as having been given on 1/21, 1/28, 1/29, 1/30, 2/9, 2/12, 2/14 or 2/21/21 Sertaline HCL ([MEDICATION NAME]) 100 mg every day orally, not initaled as having been given on 2/9, 2/14 or 2/26/21 A review of the March 2021 Treatment Administration Record (TAR), revealed a dressing change was signed off as having been completed by Employee F, Licensed Practical Nurse (LPN), on 3/2/21. An interview was conducted with the resident in her room on 3/3/21 at 9:07 a.m. She reported the dressing was not changed. The dressing was observed at the time of the interview and it was dated 2/24/21. Employee I, Registered Nurse (RN), was asked to check the portacath dressing for Resident #74 on 3/3/21 at 12:55 p.m. The RN applied gloves and observed the portacath dressing. She reported it was changed and dated 2/24/21, and the order was to change the dressing every seven days. The RN went to the medication cart and pulled up the TAR. She confirmed the dressing was signed off as having been changed yesterday (3/2/21) by Employee F. An interview was conducted with the Director of Nursing (DON) on 3/4/21 at 10:10 a.m. concerning the portacath dressing that was signed off on 3/2/21 for Resident #74, but was not done. She reported she spoke to the employee about signing off the dressing for the portacath when it had not been completed. The DON stated, (Employee F) was going in to do it, and the resident had gone out of her room. Education is being provided for not signing off until the task is completed for her. She is coming in today to sign the education piece and answer any questions you may have. An interview was conducted with Employee C, Registered Nurse (RN), at 1:30 p.m. on 3/4/2021. The RN reported she reviewed the MAR, pulled medication, checked off each medication, and saved the computer screen until after the medication was taken, and then it was locked. If a resident refused the medication, there was a space for that information, and it populated on the MAR. If there was a blank space on the MAR indicated [REDACTED]. An interview was conducted with Employee F, LPN, on 3/4/21 at 3:34 p.m. concerning the portacath dressing. The LPN reported, I signed off on the dressing, but she (Resident #74) was not in the room. I thought I would come back, but she never returned to the room. She reported she received new training instructing her not to sign off treatments until they had been completed. .

Based on record review, policy and procedure review and staff and resident interviews, the facility failed to thoroughly investigate grievances and document the date of notification of a decision and who it was provided to for three (Residents #13, #47 and #57) of three residents reviewed for grievances, in a total sample of 46 residents. The findings include: An interview was conducted with Resident #13 on 02/25/19 at 12:20 PM. He stated that a week or two ago, he was in bed at night and was very thirsty. He pressed his call button and no one came for about 45 minutes, so he got himself into his wheelchair and went to look for someone. He eventually found someone and asked for water. The staff member allegedly told him, You are already up, go get it yourself. The resident stated his legs were really hurting him at the time and he was not feeling well. He further stated he was so upset over the incident that he wrote a complaint and submitted it. He stated the facility did nothing and the person who told him that still worked there. No one from the facility ever told him what was done about his complaint. He did not want to complain anymore because he was afraid of retribution. On 02/26/19 at 3:05 PM, the Director of Nursing (DON) was asked if Resident #13 had any complaints about his care. She stated that there had been multiple grievances received from Resident #13. A review of a 02/14/19 Resident Concern/Grievance Form, written by Resident #13, revealed the resident asked Employee G, a Certified Nursing Assistant (CNA) for a glass of water after waiting 45 minutes for the call light to be answered. Employee G told him to get it himself. He asked her What?. Employee G repeated herself. The follow up on the grievance report was documented as follows: The Unit Manager spoke to the CNA, and she stated the resident normally gets his stuff himself, because he was independent with most activities. When she tried to help he got upset and rolled away. The Social Services Director (SSD) was interviewed on 02/26/19 at 4:55 PM. He stated he received this complaint from the resident, though he could not recall what date he received it. The resident wrote it himself. It was dated 02/14/19 and the date of the incident was 02/13/19. The SSD stated he brought it to the next morning meeting and gave it to Employee B (the Unit Manager on the resident's nursing unit) to be investigated. Employee B was interviewed on 02/26/19 at 4:57 PM. She confirmed she did the investigation of this grievance. She stated she spoke with Employee G about the incident, and Employee G did say to the resident that she thought the resident was independent. She did offer to get him the water, but he rolled away in his wheelchair. Employee B did not ask her to write a statement of this interaction. Employee B stated when she finished the investigation she signed the grievance 02/20/19 and handed it back to the SSD. Further review of the Resident Concern/Grievance Form under the 02/20/19 date resolved was a question that asked whether the grievance had been confirmed or not. The questions was not checked yes or no, and remained blank. The Date of Notification of Decision: Notification Provided To: was also left blank. The clinical record did not have any other documentation indicating that the resident was made aware of the investigative findings and resolution. On 02/26/19 at 5:29 PM, the SSD was asked if he had any documentation to show that the results of the complaint investigation were discussed with the resident. He stated no. He further stated they did discuss complaint investigation outcomes with residents, but they did not document it. Employee G was interviewed via telephone on 02/27/19 at 3:56 PM. She confirmed Resident #13 came to her and asked her for water. She stated she was giving another CNA a break who was performing 1:1 services for another resident. She politely told Resident #13 that she thought he could do it himself. She did not mean anything by it. She was going to arrange for him to get the water but he rolled off. The resident was so upset with her that she told the supervisor (Employee B) that same morning. Facility staff never came back to her to discuss the incident or ask her to write a statement. Employee B was interviewed again on 02/27/19 at 10:10 AM. She stated when she came in that morning around 6-6:30 AM, Employee G came to her over the incident that occurred previously that shift. Resident #13 became angry after asking for a glass of water. There was no grievance made at that time. She did not do anything about it until she received the formal grievance from the SSD. She did not go back to Employee G for any further investigation after receiving the written grievance. She had already been told of the findings by Employee G that morning. The facility's Resident Grievance Policy (Effective Date 11/28/2016) was reviewed. It appointed a Grievance Official (which was the SSD or designee). The Grievance Official was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility, maintaining confidentiality of all records, issuing written grievance decisions and informing the resident of that decision, and coordinating with state and federal agencies if necessary. The facility also prohibited retribution or retaliation against any person who in good faith, reported concerns or grievances in a manner that was consistent with the policy and with all applicable laws and regulations. On 02/27/19 at 4:50 PM, the SSD stated that the Interdisciplinary Team (IDT) did an Ad hoc Quality Assurance review for their grievance process. They recognized some areas for improvement. Two random additional grievances were selected for review: Resident #47 had a written grievance made on his behalf on 01/07/19. It was resolved on 01/08/19 and was confirmed. Under Date of Notification of Decision and Notification Provided To the form was left blank. Resident #57 made a written grievance on 01/07/19. It was resolved on 01/08/19. The form was not completed to indicate whether the issue was confirmed or not. The Date of Notification of Decision and Notification Provided areas on the form were left blank. On 02/27/19 at 5:15 PM, the SSD confirmed that these two other grievance forms from Residents #47 & #57 did not have documentation verifying notification was given to the respective resident/person of the resolution of their grievance.

Based on observation, interview, and record review, the facility failed to provide services to meet professional standards of quality related to a delay in treating an allergic reaction that progressed and persisted for two days for 1 resident (Resident #71), out of 3 residents reviewed for pain. This resulted in harm due to unrelieved itching and raised rash extending all over the resident's body, the resident experiencing symptoms of anxiety and prolonged, avoidable physical discomfort, with intense scratching and scratch marks on the resident, warranting action taken on the part of the resident and family to intervene for the resident for relief from symptoms, and potential for worsening of condition and health complications related to the allergic reaction. The findings include: The Florida Nurse Practice Act, Chapter 464.003, (3)(a) in part defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. Additionally, the Act defines the practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing. Record review for Resident #71 found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A brief interview for mental status on admission scored 13 out of a possible 15, no cognitive impairment. Review of the Resident Change in Condition report dated 9/28/15, and signed by the 11-7 shift nurse, revealed that Resident #71 had red spots on her left arm, and she was recently started on antibiotic treatment. The report stated that the resident would not receive her next scheduled dose of antibiotic until 5:00 pm the next day. The report stated, Will follow-up in AM with physician. Review of Resident #71's Progress Notes dated 9/29/15 at 6:38 pm, and signed as a late entry for 9/28/2015 by Employee F, Licensed Practical Nurse (LPN), revealed that Resident #71 complained of left arm itching. The nurse looked at the resident ' s arm, and noted some intermittent pinkish areas. The nurse asked the resident if her bedding was the cause of the itching, and instructed the Certified Nursing Assistant (CNA) to change the resident's sheet and blanket. The note stated that the nurse would notify the physician in the morning, and that the resident's symptoms were posted on the 24 hour Change in Condition report. The note also documented that the on-coming nurse and Unit Manager (UM) were notified of the resident's symptoms. On 9/29/2015 at 4:36 pm in an interview with Employee F she stated that she became aware of Resident #71's rash last night (9/28/15), before the resident went to bed. Employee F said she observed splotchy areas, like an allergic reaction, on the resident's left arm. She stated she checked the resident's medications and there was nothing related to the rash. She said she did not call the physician about the resident's rash. She said she gave the resident a pain pill last night around 10:00 pm, and told the night nurse about the rash in report. An observation of Resident #71 during an interview on 9/29/2015 at 9:42 am revealed she was constantly scratching herself all over her body. She was sitting in a wheelchair in her room. She said she was itching terribly right now. She said, The itching is driving me nuts. She said she had a rash all over her body. She said she reported the itching to her nurse yesterday, and told her that the last time she broke out like this was when she had an allergic reaction to Sulfa medication. She said her nurse looked at her prescribed medications, and told her she was not taking anything with Sulfa in it. She said the rash started last night, and the nurse put A and D ointment (petroleum and [MEDICATION NAME]) on the rash during the night. She said the ointment did not help at all, and she was waiting to see what the staff were going to do for her rash and itching. On 9/29/2015 at 4:42 pm an interview was conducted with Employee B, Registered Nurse and Unit Manager (UM). She said she was told today by Employee H, CNA, that Resident #71 was itching, and that the resident ' s son was getting the resident a cream to put on it. She said she did not call the doctor today about the resident's symptoms, or observe the resident's rash. She said Employee F told the resident's physician about the rash this afternoon. On 9/30/2015 at 8:30 am in an interview with Employee H, she said Resident #71 had hives all over. She said the resident's entire body was covered with the rash, and the day before yesterday it started on her back. She said yesterday as soon as she came in she saw it (the rash), it was obvious. She said she told the resident ' s nurse, Employee G, Licensed Practical Nurse (LPN). She said when we give a bed bath or shower we complete a skin sheet; she said she recorded the resident ' s rash there. She said she gave the UM, Employee B, the skin sheet by placing it in her box. She said at the end of the shift she spoke to the UM about the rash. She said she also told the desk nurse about the resident ' s hives about 2:30 pm yesterday. She said the resident's son came in with Cortisone cream, and someone put it on the resident's legs. She said the resident's son said the nurse told him to go to the store to buy the cream. She said the resident was upset and agitated, itching to death, going crazy trying not to scratch, but couldn't help it. She said the resident was very upset. She said Employee G told her to put A and D ointment on the resident. She said Employee G said she didn't think the A and D ointment would help the resident ' s hives, so she only applied it to the rash between the resident's thighs and groin. She said the resident is still itching bad this morning. On 9/29/2015 at 4:04 pm in an interview with Employee G, she said the night shift nurse told her in report this morning that Resident #71 had red blotches on her on her legs, arms and torso. She confirmed she did not call the resident's physician to report this. Employee G said she thinks the rash is from the resident's yeast infection. She confirmed that the resident recently started an antibiotic, [MEDICATION NAME]. Employee G also confirmed that the resident asked her today around noon for anti-itch cream, or other medication to relieve the itching. The nurse said she spoke to Employee F about the resident's symptoms, and Employee F said she would call the resident's doctor. On 9/29/15 at 5:25 pm in a phone interview with Resident #71's son, he said he visited the resident around 11:45 am on 9/29/15. He said his mother was itching from head to toe. He said the resident ' s nurse said the facility did not have any Cortisone or anti-itch cream. He said he went to the pharmacy to buy it because his mother could not take it anymore, and needed relief. He said she was miserable and angry because the staff hadn't given her anything to relieve her itching. He said she needs another tube of anti-itch cream because he used almost all of it on her; the rash was everywhere. In a further interview with Resident #71's son on 09/30/2015 at 3:33 pm, he stated that someone told him he could get the Cortisone cream for his mother. He said she wore glasses with dark brown hair (he accurately described Employee G). He said, They then told me I couldn't use the cream, but I did and used about the whole tube. On 9/29/2015 at 3:56 pm in an interview with Resident #71 she said she asked for [MEDICATION NAME] and Cortisone for relief of the itching early this afternoon, between 1:00 and 2:00 pm. She said the nurse replied that it would be awhile because she had to call the doctor. The resident said her son went to the store to get Cortisone cream, and put it on her. She stated that the doctor came in to see her about 10 minutes ago. She said he told her the [MEDICATION NAME] she was on was causing the rash and welts. She said this is exactly what happens when she takes Sulfa. She was continuing to scratch herself all over and stated, I know I shouldn't be scratching, but I can't help it. Review of a Nursing Progress Note for Resident #71, authored by Employee F and dated 9/29/15 at 6:21 pm, revealed that Employee H reported that the resident ' s son provided the resident with a tube of cortisone cream due to her itching. Employee F stated in her note that the resident had a red splotchy rash. Employee H was instructed to give the tube of cortisone cream back to the resident ' s son to take home. Nursing would follow up with primary care physician when he arrived, and obtain orders for her today. On 9/29/2015 at 5:10 pm in an interview with Employee I, CNA, she said she saw the rash on Resident #71's leg, and it itches her. She said the resident told her the rash was all over her body. Review of Resident #71's physician progress notes [REDACTED]. The resident developed a generalized rash, pruritic (itching). Rash started today. Possible allergic. Start [MEDICATION NAME]. Stop [MEDICATION NAME]. A physician's orders [REDACTED]. On 9/30/2015 at 4:52 pm Resident #71 was observed sitting up in her wheelchair as her bed linens were being changed. She stated the night nurse didn't do anything about her symptoms all night. She said she asked the nurse to call her doctor for relief, but she told me she couldn't call him at night. The resident said, I went out to the desk to ask her for some [MEDICATION NAME] this morning, and she finally gave it to me. She said if it wasn't for the pain pill and the anxiety pill, she would not have slept at all last night. She said she woke every few hours and was scratching and itching all over. She said she's still itching and she was observed scratching her back and arms. She had scratch marks and large raised welts from head to toe on her body. She said I'm miserable. In an interview on 9/30/2015 at 2:03 pm with the UM, she stated that Resident #71's physician ordered [MEDICATION NAME] for her rash yesterday. She reviewed the resident's Medication Administration Record [REDACTED]. She said she was told this morning that Resident #71 had been scratching. The UM said she got an order for [REDACTED]. She confirmed that the resident had not had any relief from the itching yesterday, until her son applied the cortisone cream. She also confirmed the resident was not given anything by nursing to relieve the itching until today. On 9/30/2015 at 3:10 pm in an interview with Employee Q, Registered Nurse (RN), she said today is her first day working here. She said Resident #71 had a rash all over her body. She said the resident hasn't had any [MEDICATION NAME], but she will give it now. She reviewed the resident's MAR, and said she gave the resident her first dose of [MEDICATION NAME] this morning. On 9/30/2015 at 3:21 pm the Director of Nurses (DON) was in Resident #71's room speaking to the resident and her son. The DON was applying cool compresses on Resident #71's right inner ankle. Observed a large inflamed welt on the resident's ankle. Upon exiting the room, the DON was told by staff that they had [MEDICATION NAME] in their emergency kit. The DON said she did not know why the resident's [MEDICATION NAME] was not started yesterday. She said she will complete a medication error report for the delay in treatment. Record review of Resident #71's September, 2015 MAR indicated [REDACTED]. Review of an order for [REDACTED]. MD made aware and new order obtained. The first dose of [MEDICATION NAME] 5 mg, ordered on [DATE], was signed as given on 9/30/2015 at 9:00 am. Record review of the Emergency kit contents revealed [MEDICATION NAME] 5 mg was in the kit, a total of 8 tablets. In an interview on 10/1/15 at 12:15 pm with the DON, she said there was no reason the [MEDICATION NAME] wasn't removed from the E-kit and started for Resident #71 on 9/29/15; it was available. On 10/01/2015 at 11:42 am Resident #71 stated she feels better, a lot less itching, but still has the welts all over. She said she was actually digging her flesh up when it started. Review of the package insert for [MEDICATION NAME] revealed that possible side effects include skin rash, itching, redness of the skin, and hives.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being related to a delay in treating an allergic reaction that progressed and persisted for two days for 1 resident (Resident #71), out of 3 residents reviewed for pain. This resulted in harm due to unrelieved itching and raised rash extending all over the resident's body, the resident experiencing symptoms of anxiety and prolonged, avoidable physical discomfort, with intense scratching and scratch marks on the resident, warranting action taken on the part of the resident and family to intervene for the resident for relief from symptoms, and potential for worsening of condition and health complications related to the allergic reaction. Additionally, the facility failed to provide the necessary care and services by not providing recommended services from a dentist for 1 resident (Resident #175), out of 4 residents identified with dental concerns. This resulted in harm due to persistent tooth pain for 6 weeks that required treatment with [MEDICATION NAME] and [MEDICATION NAME]. The facility also failed to provide care and services for 1 resident (Resident #81), related to the dressing to her access site for [MEDICAL TREATMENT], out of 6 residents in the facility receiving [MEDICAL TREATMENT]. The findings include: 1. Record review for Resident #71 found she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A brief interview for mental status on admission scored 13 out of a possible 15, no cognitive impairment. Review of the Resident Change in Condition report dated 9/28/15, and signed by the 11-7 shift nurse, revealed that Resident #71 had red spots on her left arm, and she was recently started on antibiotic treatment. The report stated that the resident would not receive her next scheduled dose of antibiotic until 5:00 pm the next day. The report stated, Will follow-up in AM with physician. Review of Resident #71's Progress Notes dated 9/29/15 at 6:38 pm, and signed as a late entry for 9/28/2015 by Employee F, Licensed Practical Nurse (LPN), revealed that Resident #71 complained of left arm itching. The nurse looked at the resident's arm, and noted some intermittent pinkish areas. The nurse asked the resident if her bedding was the cause of the itching, and instructed the Certified Nursing Assistant (CNA) to change the resident's sheet and blanket. The note stated that the nurse would notify the physician in the morning, and that the resident's symptoms were posted on the 24 hour Change in Condition report. The note also documented that the on-coming nurse and Unit Manager (UM) were notified of the resident's symptoms. On 9/29/2015 at 4:36 pm in an interview with Employee F she stated that she became aware of Resident #71's rash last night (9/28/15), before the resident went to bed. Employee F said she observed splotchy areas, like an allergic reaction, on the resident's left arm. She stated she checked the resident's medications and there was nothing related to the rash. She said she did not call the physician about the resident's rash. She said she gave the resident a pain pill last night around 10:00 pm, and told the night nurse about the rash in report. An observation of Resident #71 during an interview on 9/29/2015 at 9:42 am revealed she was constantly scratching herself all over her body. She was sitting in a wheelchair in her room. She said she was itching terribly right now. She said, The itching is driving me nuts. She said she had a rash all over her body. She said she reported the itching to her nurse yesterday, and told her that the last time she broke out like this was when she had an allergic reaction to Sulfa medication. She said her nurse looked at her prescribed medications, and told her she was not taking anything with Sulfa in it. She said the rash started last night, and the nurse put A and D ointment (petroleum and [MEDICATION NAME]) on the rash during the night. She said the ointment did not help at all, and she was waiting to see what the staff were going to do for her rash and itching. On 9/29/2015 at 4:42 pm an interview was conducted with Employee B, Registered Nurse and Unit Manager (UM). She said she was told today by Employee H, CNA, that Resident #71 was itching, and that the resident ' s son was getting the resident a cream to put on it. She said she did not call the doctor today about the resident's symptoms, or observe the resident's rash. She said Employee F told the resident's physician about the rash this afternoon. On 9/30/2015 at 8:30 am in an interview with Employee H, she said Resident #71 had hives all over. She said the resident's entire body was covered with the rash, and the day before yesterday it started on her back. She said yesterday as soon as she came in she saw it (the rash), it was obvious. She said she told the resident ' s nurse, Employee G, Licensed Practical Nurse (LPN). She said when we give a bed bath or shower we complete a skin sheet; she said she recorded the resident ' s rash there. She said she gave the UM, Employee B, the skin sheet by placing it in her box. She said at the end of the shift she spoke to the UM about the rash. She said she also told the desk nurse about the resident ' s hives about 2:30 pm yesterday. She said the resident's son came in with Cortisone cream, and someone put it on the resident's legs. She said the resident's son said the nurse told him to go to the store to buy the cream. She said the resident was upset and agitated, itching to death, going crazy trying not to scratch, but couldn't help it. She said the resident was very upset. She said Employee G told her to put A and D ointment on the resident. She said Employee G said she didn't think the A and D ointment would help the resident ' s hives, so she only applied it to the rash between the resident's thighs and groin. She said the resident is still itching bad this morning. On 9/29/2015 at 4:04 pm in an interview with Employee G, she said the night shift nurse told her in report this morning that Resident #71 had red blotches on her on her legs, arms and torso. She confirmed she did not call the resident's physician to report this. Employee G said she thinks the rash is from the resident's yeast infection. She confirmed that the resident recently started an antibiotic, [MEDICATION NAME]. Employee G also confirmed that the resident asked her today around noon for anti-itch cream, or other medication to relieve the itching. The nurse said she spoke to Employee F about the resident's symptoms, and Employee F said she would call the resident's doctor. On 9/29/15 at 5:25 pm in a phone interview with Resident #71's son, he said he visited the resident around 11:45 am on 9/29/15. He said his mother was itching from head to toe. He said the resident ' s nurse said the facility did not have any Cortisone or anti-itch cream. He said he went to the pharmacy to buy it because his mother could not take it anymore, and needed relief. He said she was miserable and angry because the staff hadn't given her anything to relieve her itching. He said she needs another tube of anti-itch cream because he used almost all of it on her; the rash was everywhere. In a further interview with Resident #71's son on 09/30/2015 at 3:33 pm, he stated that someone told him he could get the Cortisone cream for his mother. He said she wore glasses with dark brown hair (he accurately described Employee G). He said, They then told me I couldn't use the cream, but I did and used about the whole tube. On 9/29/2015 at 3:56 pm in an interview with Resident #71 she said she asked for [MEDICATION NAME] and Cortisone for relief of the itching early this afternoon, between 1:00 and 2:00 pm. She said the nurse replied that it would be awhile because she had to call the doctor. The resident said her son went to the store to get Cortisone cream, and put it on her. She stated that the doctor came in to see her about 10 minutes ago. She said he told her the [MEDICATION NAME] she was on was causing the rash and welts. She said this is exactly what happens when she takes Sulfa. She was continuing to scratch herself all over and stated, I know I shouldn't be scratching, but I can't help it. Review of a Nursing Progress Note for Resident #71, authored by Employee F and dated 9/29/15 at 6:21 pm, revealed that Employee H reported that the resident ' s son provided the resident with a tube of cortisone cream due to her itching. Employee F stated in her note that the resident had a red splotchy rash. Employee H was instructed to give the tube of cortisone cream back to the resident ' s son to take home. Nursing would follow up with primary care physician when he arrived, and obtain orders for her today. On 9/29/2015 at 5:10 pm in an interview with Employee I, CNA, she said she saw the rash on Resident #71's leg, and it itches her. She said the resident told her the rash was all over her body. Review of Resident #71's physician progress notes [REDACTED]. The resident developed a generalized rash, pruritic (itching). Rash started today. Possible allergic. Start [MEDICATION NAME]. Stop [MEDICATION NAME]. A physician's order dated 9/29/15 prescribed [MEDICATION NAME] 5mg one time a day for red splotchy irritated skin, take for 3 days. On 9/30/2015 at 4:52 pm Resident #71 was observed sitting up in her wheelchair as her bed linens were being changed. She stated the night nurse didn't do anything about her symptoms all night. She said she asked the nurse to call her doctor for relief, but she told me she couldn't call him at night. The resident said, I went out to the desk to ask her for some [MEDICATION NAME] this morning, and she finally gave it to me. She said if it wasn't for the pain pill and the anxiety pill, she would not have slept at all last night. She said she woke every few hours and was scratching and itching all over. She said she's still itching and she was observed scratching her back and arms. She had scratch marks and large raised welts from head to toe on her body. She said I'm miserable. In an interview on 9/30/2015 at 2:03 pm with the UM, she stated that Resident #71's physician ordered [MEDICATION NAME] for her rash yesterday. She reviewed the resident's Medication Administration Record [REDACTED]. She said she was told this morning that Resident #71 had been scratching. The UM said she got an order for [REDACTED]. She confirmed that the resident had not had any relief from the itching yesterday, until her son applied the cortisone cream. She also confirmed the resident was not given anything by nursing to relieve the itching until today. On 9/30/2015 at 3:10 pm in an interview with Employee Q, Registered Nurse (RN), she said today is her first day working here. She said Resident #71 had a rash all over her body. She said the resident hasn't had any [MEDICATION NAME], but she will give it now. She reviewed the resident's MAR, and said she gave the resident her first dose of [MEDICATION NAME] this morning. On 9/30/2015 at 3:21 pm the Director of Nurses (DON) was in Resident #71's room speaking to the resident and her son. The DON was applying cool compresses on Resident #71's right inner ankle. Observed a large inflamed welt on the resident's ankle. Upon exiting the room, the DON was told by staff that they had [MEDICATION NAME] in their emergency kit. The DON said she did not know why the resident's [MEDICATION NAME] was not started yesterday. She said she will complete a medication error report for the delay in treatment. Record review of Resident #71's September, 2015 MAR indicated [REDACTED]. Review of an order for [REDACTED]. MD made aware and new order obtained. The first dose of [MEDICATION NAME] 5 mg, ordered on [DATE], was signed as given on 9/30/2015 at 9:00 am. Record review of the Emergency kit contents revealed [MEDICATION NAME] 5 mg was in the kit, a total of 8 tablets. In an interview on 10/1/15 at 12:15 pm with the DON, she said there was no reason the [MEDICATION NAME] wasn't removed from the E-kit and started for Resident #71 on 9/29/15; it was available. On 10/01/2015 at 11:42 am Resident #71 stated she feels better, a lot less itching, but still has the welts all over. She said she was actually digging her flesh up when it started. Review of the package insert for [MEDICATION NAME] revealed that possible side effects include skin rash, itching, redness of the skin, and hives. 2. Record review for Resident # 175 revealed that she was a [AGE] year old female who was admitted to the facility on [DATE]. Review of the physician's progress note dated 7/27/15 revealed the resident had [DIAGNOSES REDACTED]. She had chronic joint pain, mostly in the hands. She had deteriorating dentition, with a tooth extraction for decay in July, 2015. Review of Resident # 175's Minimum Data Set (MDS) Quarterly Assessment with a reference date of 8/17/15 revealed that her Brief Interview for Mental Status score was 11 out of 15 (moderately impaired cognition). The resident complained of frequent pain at a level of 8 on a scale of 1-10, with 1 being the least amount of pain and 10 being the highest level of pain possible. She was assessed as alert and oriented. Review of the nurses' notes and medication administration notes for Resident # 175 revealed the following complaints of pain: 10/1/15 at 5:19 p.m. medicated with [MEDICATION NAME] 800mg for complaint of (c/o) oral pain 10/1/15 at 6:03 a.m. - c/o toothache pain at a level of 8 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/30/15 at 9:56 p.m. c/o toothache and headache 9/30/15 at 7:06 p.m. - c/o toothache pain at a 5 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/29/15 at 11:29 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/28/15 at 3:35 p.m. - c/o headache and toothache pain, unnamed pain medication administered 9/27/15 at 9:30 p.m. - c/o toothache pain 9/27/15 at 1:45 p.m. - c/o teeth hurt, medicated with [MEDICATION NAME] 5-325mg 9/26/15 at 1:08 p.m. - c/o headache and toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/25/15 at 9:13 a.m. - c/o toothache pain, [MEDICATION NAME] administered 9/24/15 at 6:06 p.m. - c/o sore teeth, [MEDICATION NAME] 800mg administered 9/24/15 at 8:57 a.m. - c/o toothache pain on both upper sides of mouth, medicated with [MEDICATION NAME] 800mg 9/23/15 at 6:08 a.m. - c/o toothache pain at a 7 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/22/15 at 9:03 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/21/15 at 9:46 p.m. - c/o tooth pain 9/21/15 at 2:39 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/21/15 at 9:31 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/17/15 at 9:00 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/16/15 at 3:47 p.m. - c/o teeth pain, medicated with [MEDICATION NAME] 800mg 9/16/15 at 9:53 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg Dental hygienist was in and will schedule resident to see in-house dentist. 9/15/15 at 6:20 p.m. - c/o mouth pain, medicated with [MEDICATION NAME] 800mg 9/15/15 at 8:44 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/14/15 at 6:24 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/12/15 at 2:04 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg 9/11/15 at 6:25 p.m. - c/o toothache pain 9/11/15 at 9:19 a.m. - c/o tooth pain at an 8 out of 10. Dental hygienist just cleaned her teeth. 9/10/15 at 7:31 p.m. - c/o toothache pain at 9 out of 10 9/10/15 at 12:50 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg 9/9/15 at 1:19 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg. Will refer to dentist. 9/9/15 at 8:39 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/8/15 at 7:06 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/8/15 at 1:04 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/6/15 at 10:12 a.m. - c/o teeth pain 9/5/15 at 1:43 p.m. - c/o toothache pain 9/4/15 at 4:54 p.m. - c/o mouth/teeth pain 9/3/15 at 9:36 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/2/15 at 9:24 a.m. - c/o teeth and hand pain, medicated with [MEDICATION NAME] 5-325mg 9/1/15 at 8:50 a.m. - Ever since they cleaned my teeth it has been hurting. Medicated with [MEDICATION NAME] 5-325mg 9/1/15 at 12:57 a.m. - c/o dental/oral pain. Wandering around hallway in pain. Medicated with [MEDICATION NAME] 5-325mg 8/30/15 at 9:01 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 8/29/15 at 7:17 p.m. - c/o toothache pain at a 9 out of 10 8/28/15 at 9:22 a.m. - c/o toothache pain 8/26/15 at 1:58 p.m. - c/o teeth bothering her, medicated with [MEDICATION NAME] 5-325mg 8/26/15 at 8:33 a.m. - c/o ever since they cleaned her teeth it has been hurting, medicated with [MEDICATION NAME] 50mg 8/22/15 at 4:29 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 8/22/15 at 12:28 p.m. - c/o tooth pain 8/21/15 at 9:10 a.m. - c/o pain hand, head, eyeballs, my tooth hurts, medicated with [MEDICATION NAME] 5-325mg 8/19/15 at 4:39 p.m. - Nutritional note indicates that resident had mouth pain 8/19/15 at 8:36 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 8/16/15 at 2:28 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg The facility's Dental Health Evaluation, completed on 11/18/14 shortly after admission by the admitting nurse, showed that the resident had cracked or fractured teeth, dental caries (tooth decay), and pain/tenderness/discomfort. Physician order for [REDACTED]. In an interview on 10/2/15 at 10:05 a.m. with Employee N, Unit Manager, when asked why the form was not completed, she could not provide an answer. A review of the resident's physician's orders revealed that there were no orders for a dental consult in her record. A visiting dental service consent for services form was observed for Resident #175. It was dated 6/6/15, then marked out with the date changed to 7/6/15. The resident's responsible party signed the form giving consent on 7/1/15. A review of Resident #175's clinical record revealed no physician's orders for the resident to see a dentist. A review of physician's progress notes revealed no notation of the resident's oral pain. A review of orders for Resident #175 dated 7/15/2015, signed by a Doctor of Medicine in Dentistry (DMD), revealed that the DMD prescribed antibiotics and pain medications for the resident. There was no progress note by the DMD in the resident's record for the 7/15/15 consult. When asked about the 7/15/15 DMD consult, Employee N (Unit Manager) stated on 10/2/15 at 10:05 a.m. that she remembered that the DMD prescribed antibiotics and pain medication for the resident prior to pulling a tooth. When asked for documentation related to the tooth extraction, Employee N stated that she'd have to check on the unit. She said, It may not have been filed yet. The facility did not provide documentation of the tooth extraction. A visiting dental service screening list dated 7/22/15 was provided to the surveyor by Social Services. The screening form had Resident #175's name typed on it, but was otherwise blank. There were places on the form to note whether the resident was treated, whether they refused, whether a denture was needed, and whether there was a conference with the Social Services Director. All of these areas were left blank. Review of Resident #175's visiting dental service's note dated 7/22/15 revealed that the resident had a recent extraction of tooth #14 by a surgeon (1.5 weeks ago). Gross decay was noted for tooth #10. No pain. Resident desires hygienist. Other teeth in good condition. Signed by DDS (Doctor of Dental Surgery). Resident #175's dental hygienist note dated 8/19/15 stated evaluate for toothache on upper left. The resident presented that day for her first oral [MEDICATION NAME]. Missing teeth, and light to moderate soft and hard deposits were noted, with removal of same that day. Teeth were polished and [MEDICATION NAME] was applied. No visible decay. The resident described tooth pain as more of an ache than a sharp pain. The note stated it could be heavy occlusion (the closure of the teeth). Advised that the resident may need a dentist to take x-rays to evaluate and determine cause if it gets worse. Hygienist's notes for Resident #175 on 9/11/15 and 9/16/15 revealed that the resident refused oral [MEDICATION NAME] on those dates, no reason given. On 10/2/15 at 10:20 a.m. when asked whether that could have been due to oral pain/toothache, Employee N replied, I don't know. A review of Resident #175's most recent care plan conference summary, which was completed on 8/19/15, revealed no documentation related to the resident's oral/toothache pain. A review of the resident's care plans revealed that there was no care plan for dental caries, tooth pain or dental visits. The pain care plan did not mention oral/toothache pain, and the Activities of Daily Living care plan mentioned nothing about dental caries or tooth pain. An interview on 10/1/15 at 3:45 p.m. with Employee J, Social Services Assistant (SSA), revealed that the facility used a visiting dental service. She stated that a dental hygienist came out monthly to perform cleanings for approximately eight residents per month. She stated that if a resident had a broken tooth, a cavity or tooth pain, nursing would have to communicate that to the social services department in order that they could follow up with the dental service. She stated that on the next monthly visit, the dentist would come out and evaluate the resident. A 10/2/15 interview at 9:55 a.m. with Resident # 175 confirmed that she was having significant toothache pain on both sides of her mouth. She began to cry and stated that she had been complaining of toothache pain forever, and the facility hadn't done anything about it yet. She stated, They keep telling me that the dentist is coming, but I haven't seen him yet. The lady has cleaned them, but then they hurt even worse. The only thing that helps at all is when they give me my pain medicine. I sure would appreciate it if you could help me get an appointment. An interview on 10/2/15 at 10:05 a.m. with Employee N revealed that she was aware that Resident # 175 was having toothache pain, but she was not aware that Resident # 175 had been complaining nearly daily about toothache pain since August 16, 2015. Employee N stated that Resident # 175 had complained to her of mild pain, and that she had pain medication for that. She said that she was not informed by nursing about the frequency of the resident's tooth pain. She said if she had been aware of it, she would have communicated it to Social Services. She stated that the dental service came monthly and touched base with the resident, but she would need to speak with Social Services to see what they were doing for her as far as setting up a dentist appointment. A 10/2/15 interview at 11:15 a.m. with Employee K, Social Services Director (SSD), revealed that Resident # 175 had dental pain upon admission. That's when we signed her up. He said, A lot of times when someone else has pain, (Resident #175) will also have pain, and it's for attention; but when we decided that she really did have some pain, we signed her up for the dentist. After that I never did hear anything else about tooth pain. The Unit Manager never did tell me anything about tooth pain either. No follow-up with a dentist or dental x-rays had been arranged for the resident by the facility. 3. Record review for Resident #81 revealed that she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident had a fistula (access to the blood) to her right upper arm for [MEDICAL TREATMENT]. Review of an undated initial assessment for the resident showed no mention of the right upper arm fistula. Review of the resident's care plan conference dated 9/24/15 showed the resident received [MEDICAL TREATMENT] 3 times per week. There was no mention of the resident's right upper arm fistula. Review of the Certified Nursing Assistant's (CNA) skin observation sheet, dated 8/26/15, showed no mention of the resident's right upper arm fistula. Review of Resident #81's [MEDICAL TREATMENT] communication form dated 9/8/15 showed instructions from the [MEDICAL TREATMENT] center to remove the resident's dressing to the right upper arm fistula no later than the next morning (after [MEDICAL TREATMENT]), or the access will clot off. The note went on to say that the resident came back to [MEDICAL TREATMENT] every day that week with the dressing still on. The note said, This is her life line! Observation of Resident #81 in physical therapy on 10/2/15 at 10:00 AM showed the resident sitting and performing upper extremity exercises. A dressing was noted applied to the right upper arm fistula, with tape on all four sides. In an interview on 10/2/15 at 10:02 AM with the Unit Manager, she confirmed that this was the dressing from [MEDICAL TREATMENT] the previous day. Observation of the resident at 12:30 PM eating lunch in the dining room revealed the dressing to the right upper arm fistula was still in place. Review of the physician's orders for Resident #81 revealed an order dated 9/15/15 to remove the pressure dressing to [MEDICAL TREATMENT] site on [MEDICAL TREATMENT] days. The order was written as a one time only order, with a stop date of 9/16/15. In an interview on 10/2/15 at 2:00 PM with the Director of nursing, she stated that she would clarify the order after talking to [MEDICAL TREATMENT]. In an interview on 10/2/15 at 11:45 AM with the charge nurse at the [MEDICAL TREATMENT] center, he confirmed that Resident #81's dressing needed to be removed after [MEDICAL TREATMENT]. He said the dressing would cause an indentation at the site, and cause the access to clot off. According to the National Kidney Foundation at www.kidney.org, only gentle pressure should be applied to the [MEDICAL TREATMENT] after the needle is removed. Too much pressure will stop the flow of blood through the access.

Based on observation, interview, and record review, the facility failed to provide recommended services from a dentist for 1 resident (Resident #175). This resulted in harm due to persistent tooth pain for 6 weeks that required treatment with [MEDICATION NAME] and [MEDICATION NAME]. The facility also failed to provide dental services for 1 resident (Resident #24) with missing teeth, out of 4 residents identified with dental concerns, out of 35 total residents sampled. The findings include: 1. Record review for Resident #175 revealed that she was a [AGE] year old female who was admitted to the facility on [DATE]. Review of the physician's progress note dated 7/27/15 revealed the resident had [DIAGNOSES REDACTED]. She had chronic joint pain, mostly in the hands. She had deteriorating dentition, with a tooth extraction for decay in July, 2015. Review of Resident # 175's Minimum Data Set (MDS) Quarterly Assessment with a reference date of 8/17/15 revealed that she complained of frequent pain at a level of 8 on a scale of 1-10, with 1 being the least amount of pain and 10 being the highest level of pain possible. She was assessed as alert and oriented. Review of the nurses' notes and medication administration notes for Resident # 175 revealed the following complaints of pain: 10/1/15 at 5:19 p.m. medicated with [MEDICATION NAME] 800mg for complaint of (c/o) oral pain 10/1/15 at 6:03 a.m. - c/o toothache pain at a level of 8 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/30/15 at 9:56 p.m. c/o toothache and headache 9/30/15 at 7:06 p.m. - c/o toothache pain at a 5 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/29/15 at 11:29 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/28/15 at 3:35 p.m. - c/o headache and toothache pain, unnamed pain medication administered 9/27/15 at 9:30 p.m. - c/o toothache pain 9/27/15 at 1:45 p.m. - c/o teeth hurt, medicated with [MEDICATION NAME] 5-325mg 9/26/15 at 1:08 p.m. - c/o headache and toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/25/15 at 9:13 a.m. - c/o toothache pain, [MEDICATION NAME] administered 9/24/15 at 6:06 p.m. - c/o sore teeth, [MEDICATION NAME] 800mg administered 9/24/15 at 8:57 a.m. - c/o toothache pain on both upper sides of mouth, medicated with [MEDICATION NAME] 800mg 9/23/15 at 6:08 a.m. - c/o toothache pain at a 7 out of 10, medicated with [MEDICATION NAME] 5-325mg 9/22/15 at 9:03 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/21/15 at 9:46 p.m. - c/o tooth pain 9/21/15 at 2:39 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/21/15 at 9:31 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/17/15 at 9:00 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/16/15 at 3:47 p.m. - c/o teeth pain, medicated with [MEDICATION NAME] 800mg 9/16/15 at 9:53 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg Dental hygienist was in and will schedule resident to see in-house dentist. 9/15/15 at 6:20 p.m. - c/o mouth pain, medicated with [MEDICATION NAME] 800mg 9/15/15 at 8:44 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/14/15 at 6:24 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/12/15 at 2:04 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg 9/11/15 at 6:25 p.m. - c/o toothache pain 9/11/15 at 9:19 a.m. - c/o tooth pain at an 8 out of 10. Dental hygienist just cleaned her teeth. 9/10/15 at 7:31 p.m. - c/o toothache pain at 9 out of 10 9/10/15 at 12:50 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg 9/9/15 at 1:19 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 50mg. Will refer to dentist. 9/9/15 at 8:39 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/8/15 at 7:06 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 9/8/15 at 1:04 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/6/15 at 10:12 a.m. - c/o teeth pain 9/5/15 at 1:43 p.m. - c/o toothache pain 9/4/15 at 4:54 p.m. - c/o mouth/teeth pain 9/3/15 at 9:36 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 9/2/15 at 9:24 a.m. - c/o teeth and hand pain, medicated with [MEDICATION NAME] 5-325mg 9/1/15 at 8:50 a.m. - Ever since they cleaned my teeth it has been hurting. Medicated with [MEDICATION NAME] 5-325mg 9/1/15 at 12:57 a.m. - c/o dental/oral pain. Wandering around hallway in pain. Medicated with [MEDICATION NAME] 5-325mg 8/30/15 at 9:01 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 8/29/15 at 7:17 p.m. - c/o toothache pain at a 9 out of 10 8/28/15 at 9:22 a.m. - c/o toothache pain 8/26/15 at 1:58 p.m. - c/o teeth bothering her, medicated with [MEDICATION NAME] 5-325mg 8/26/15 at 8:33 a.m. - c/o ever since they cleaned her teeth it has been hurting, medicated with [MEDICATION NAME] 50mg 8/22/15 at 4:29 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 800mg 8/22/15 at 12:28 p.m. - c/o tooth pain 8/21/15 at 9:10 a.m. - c/o pain hand, head, eyeballs, my tooth hurts, medicated with [MEDICATION NAME] 5-325mg 8/19/15 at 4:39 p.m. - Nutritional note indicates that resident had mouth pain 8/19/15 at 8:36 a.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg 8/16/15 at 2:28 p.m. - c/o toothache pain, medicated with [MEDICATION NAME] 5-325mg The facility's Dental Health Evaluation, completed on 11/18/14 shortly after admission by the admitting nurse, showed that the resident had cracked or fractured teeth, dental caries (tooth decay), and pain/tenderness/discomfort. Physician order for [REDACTED]. In an interview on 10/2/15 at 10:05 a.m. with Employee N, Unit Manager, when asked why the form was not completed, she could not provide an answer. A review of the resident's physician's orders revealed that there were no orders for a dental consult in her record. A visiting dental service consent for services form was observed for Resident #175. It was dated 6/6/15, then marked out with the date changed to 7/6/15. The resident's responsible party signed the form giving consent on 7/1/15. A review of Resident # 175's clinical record revealed no physician's orders for the resident to see a dentist. A review of physician's progress notes revealed no notation of the resident's oral pain. A review of orders for Resident #175 dated 7/15/2015, signed by a Doctor of Medicine in Dentistry (DMD), revealed that the DMD prescribed antibiotics and pain medications for the resident. There was no progress note by the DMD in the resident's record for the 7/15/15 consult. When asked about the 7/15/15 DMD consult, Employee N (Unit Manager) stated on 10/2/15 at 10:05 a.m. that she remembered that the DMD prescribed antibiotics and pain medication for the resident prior to pulling a tooth. When asked for documentation related to the tooth extraction, Employee N stated that she'd have to check on the unit. She said, It may not have been filed yet. The facility did not provide documentation of the tooth extraction. A visiting dental service screening list dated 7/22/15 was provided to the surveyor by Social Services. The screening form had Resident #175's name typed on it, but was otherwise blank. There were places on the form to note whether the resident was treated, whether they refused, whether a denture was needed, and whether there was a conference with the Social Services Director. All of these areas were left blank. Review of Resident #175's visiting dental service's note dated 7/22/15 revealed that the resident had a recent extraction of tooth #14 by a surgeon (1.5 weeks ago). Gross decay was noted for tooth #10. No pain. Resident desires hygienist. Other teeth in good condition. Signed by DDS (Doctor of Dental Surgery). Resident #175's dental hygienist note dated 8/19/15 stated evaluate for toothache on upper left. The resident presented that day for her first oral [MEDICATION NAME]. Missing teeth, and light to moderate soft and hard deposits were noted, with removal of same that day. Teeth were polished and [MEDICATION NAME] was applied. No visible decay. The resident described tooth pain as more of an ache than a sharp pain. The note stated it could be heavy occlusion (the closure of the teeth). Advised that the resident may need a dentist to take x-rays to evaluate and determine cause if it gets worse. Hygienist's notes for Resident #175 on 9/11/15 and 9/16/15 revealed that the resident refused oral [MEDICATION NAME] on those dates, no reason given. On 10/2/15 at 10:20 a.m. when asked whether that could have been due to oral pain/toothache, Employee N replied, I don't know. A review of Resident #175's most recent care plan conference summary, which was completed on 8/19/15, revealed no documentation related to the resident's oral/toothache pain. A review of the resident's care plans revealed that there was no care plan for dental caries, tooth pain or dental visits. The pain care plan did not mention oral/toothache pain, and the Activities of Daily Living care plan mentioned nothing about dental caries or tooth pain. An interview on 10/1/15 at 3:45 p.m. with Employee J, Social Services Assistant (SSA), revealed that the facility used a visiting dental service. She stated that a dental hygienist came out monthly to perform cleanings for approximately eight residents per month. She stated that if a resident had a broken tooth, a cavity or tooth pain, nursing would have to communicate that to the social services department in order that they could follow up with the dental service. She stated that on the next monthly visit, the dentist would come out and evaluate the resident. A 10/2/15 interview at 9:55 a.m. with Resident #175 confirmed that she was having significant toothache pain on both sides of her mouth. She began to cry and stated that she had been complaining of toothache pain forever, and the facility hadn't done anything about it yet. She stated, They keep telling me that the dentist is coming, but I haven't seen him yet. The lady has cleaned them, but then they hurt even worse. The only thing that helps at all is when they give me my pain medicine. I sure would appreciate it if you could help me get an appointment. An interview on 10/2/15 at 10:05 a.m. with Employee N revealed that she was aware that Resident # 175 was having toothache pain, but she was not aware that Resident # 175 had been complaining nearly daily about toothache pain since August 16, 2015. Employee N stated that Resident #175 had complained to her of mild pain, and that she had pain medication for that. She said that she was not informed by nursing about the frequency of the resident's tooth pain. She said if she had been aware of it, she would have communicated it to Social Services. She stated that the dental service came monthly and touched base with the resident, but she would need to speak with Social Services to see what they were doing for her as far as setting up a dentist appointment. A 10/2/15 interview at 11:15 a.m. with Employee K, Social Services Director (SSD), revealed that Resident # 175 had dental pain upon admission. That's when we signed her up. He said, A lot of times when someone else has pain, (Resident #175) will also have pain, and it's for attention; but when we decided that she really did have some pain, we signed her up for the dentist. After that I never did hear anything else about tooth pain. The Unit Manager never did tell me anything about tooth pain either. No follow-up with a dentist or dental x-rays had been arranged for the resident by the facility. 2. Record review for Resident #24 revealed that she was admitted to the facility on [DATE]. Review of the resident's Nursing Admission assessment dated [DATE] showed broken/missing teeth on her oral assessment. Review of the resident's Minimum Data Set (MDS) assessment, with a reference date of 8/27/15, showed the resident had obvious or likely cavity, or broken natural teeth. There was no documentation that Resident #24 had been screened by dental services. An observation of Resident #24 on 10/01/2015 at 2:57 pm revealed she was sitting in the hallway in her wheelchair outside of the social services office. She smiled and revealed some teeth missing. An interview with Resident #24 revealed that her teeth hurt sometimes. On 10/1/15 at 4:00 pm in an interview with Employee J, Social Services Assistant, she confirmed that Resident #24 had not been seen by the facility dental services. She said she would add the resident to her list to be seen.