Every finding on record at Bay Pointe Rehabilitation and Nursing

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review (MRR) policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, potentially affecting all residents but specifically for five of 33 residents in the survey sample; Residents #15, #69, #16, #67 and #39. The findings include: 1. For Resident #15 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. Resident #15 was admitted to the facility on [DATE]. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 12/1/22, failed to reveal time frames for pharmacist's review and physician's response. On 8/23/23 at 10:38 AM an interview was conducted with ASM #2 (Administrative Staff Member), the Director of Nursing. When asked about the policy not containing time frames for the physician to act upon pharmacy recommendations, ASM #2 stated, our [MRR] policy does not include timeframes for response. It just states in a timely manner. Our expectation and what we review with our physicians is a 7-day turnover. Nursing gives the recommendations to the physicians and tell them when it needs to be done. On 8/24/23 at 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #69, the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response Resident #69 was admitted to the facility on [DATE]. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 12/1/22, failed to reveal time frames for pharmacist's review and physician's response. On 8/23/23 at 10:38 AM an interview was conducted with ASM #2 (Administrative Staff Member), the Director of Nursing. When asked about the policy not containing time frames for the physician to act upon pharmacy recommendations, ASM #2 stated, our [MRR] policy does not include timeframes for response. It just states in a timely manner. Our expectation and what we review with our physicians is a 7-day turnover. Nursing gives the recommendations to the physicians and tell them when it needs to be done. On 8/24/23 at 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the findings. No further information was provided by the end of the survey. 29125 3. For Resident #16, the facility staff failed to ensure the Medication Regimen Review policy contained specified time frames for the physician to respond to pharmacy recommendations. A review of the clinical record for Resident #16 revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility policy, Medication Regimen Review failed to specify specific time frames for the physician to respond to any pharmacy recommendations. On 8/23/23 at 10:38 AM, an interview was conducted with ASM #2, (Administrative Staff Member) the Director of Nursing. She stated that the facility's policy did not include timeframe for physician's response to pharmacy recommendations. She stated that the policy just says in a timely manner. She stated that it was the facility's expectation and what they review with the physicians is a seven day turnover. She stated that they give the pharmacy recommendation to the physicians and tell them when it needs to be done. On 8/24/23 at 2:28 PM, ASM #1 (Administrative Staff Member, the Administrator) and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #67, the facility staff failed to ensure the Medication Regimen Review policy contained specified time frames for the physician to respond to pharmacy recommendations. A review of the clinical record for Resident #67 revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility policy, Medication Regimen Review failed to specify specific time frames for the physician to respond to any pharmacy recommendations. On 8/23/23 at 10:38 AM, an interview was conducted with ASM #2, (Administrative Staff Member) the Director of Nursing. She stated that the facility's policy did not include timeframe for physician's response to pharmacy recommendations. She stated that the policy just says in a timely manner. She stated that it was the facility's expectation and what they review with the physicians is a seven day turnover. She stated that they give the pharmacy recommendation to the physicians and tell them when it needs to be done. On 8/24/23 at 2:28 PM, ASM #1 (Administrative Staff Member, the Administrator) and ASM #2, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 42106 5. For Resident #39 (R39), the facility staff failed to develop and maintain a comprehensive MRR (medication regimen review) policy to include time frames for the steps in the process of the medication regimen review procedure. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/9/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R39 receiving an antidepressant seven of the seven days during the assessment period and an antianxiety medication seven of seven days during the assessment period. R39 was selected for unnecessary medication review during the survey dates. On 8/22/2023 at 12:51 p.m., during entrance conference with ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing, a request was made for the facility medication regimen review policy. Review of the provided policy failed to evidence time expectations for physician and facility response to pharmacy recommendations. On 8/23/2023 at 10:38 a.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that the facilities current medication regimen review policy did not include a time frame for physician response. She stated that it only said in a timely manner. She stated that their expectation and what they reviewed with the physicians was in a 7 day turnover. She stated that they gave the pharmacy reviews to the physicians and told them when they needed to be done. On 8/24/2023 at 2:27 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to provide food in a palatable and appetizing manner from one of one facility kitchens. The findings include: On 8/23/23 at 12:00 PM, observation of the tray line service began. Food temperatures were obtained by OSM #9 (Other Staff Member) a cook, with a facility thermometer, as follows: Mashed potatoes was 185 degrees Puree carrots was 175 degrees Puree bread was 180 degrees Puree barbeque chicken was 178 degrees Minced chicken was 180 degrees Gravy was 190 degrees Tomato soup was 175 degrees Chicken without barbeque sauce was 175 degrees Rice was 160 degrees Carrots was 180 degrees Baked beans was 178 degrees Barbeque chicken was 172 degrees On 8/23/23 at 1:05 PM, OSM #8, the dietary manager, was notified that a test tray was being requested. The test tray was prepared and the cart the test tray was on was then taken to the upstairs unit. At 1:20 PM, OSM #8 obtained the temperatures on the test tray with a facility thermometer as follows: Mashed potatoes was 120 degrees Puree carrots was 118 degrees Puree bread was 115 degrees Puree barbeque chicken was 115 degrees Carrots was 115 degrees Baked beans was 118 degrees Barbeque chicken was 120 degrees. Two surveyors and OSM #8 all taste tested the food. There was agreement that the food was not warm enough for meal enjoyment. The regular carrots had an odd vinegar-like flavor. The puree carrots had the same flavor but stronger and was off-putting. The baked beans were lacking flavor. The chicken was fair on flavor but was not hot. The puree bread tasted like thickener and was disliked by all. The facility policy, Food Preparation Guidelines was reviewed. This policy documented, .Food shall be prepared by methods that conserve nutritive value, flavor and appearance .Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature . On 8/23/23 at 4:01 PM, at the end-of-day meeting, ASM #1 (Administrative Staff Member, the Administrator) and ASM #2, the Director of Nursing, were made aware of the findings. ASM #1 stated that the facility switched from an outsourced dietary service company to in-house dietary department staff and have already been working on some of the things identified.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 8/22/23 at approximately 12:15 PM, the kitchen inspection was conducted with OSM #8 (Other Staff Member) the dietary manager. A thick wet black substance noted on the floor along wall behind ice machine. This substance was noted to be a strip of approximately 6 inches wide, starting at the wall and out into the floor for approximately 6 inches, and ran along the edge of the floor / wall behind the ice machine. An air vent on the wall next to meat slicer was heavily caked with brown dust and lint substance. The wire racks on which dishware was stored was noted to have a tacky residue all over them. On 8/23/23 during tray line observation, at 12:05 PM, OSM #9, a cook, was obtaining temperatures of the food on the steam table. As she reached over one steam table tray of food to obtain the temperature of an item on the back row, her apron was noted to come in contact with the serving end of serving scoops that were on the steam table to be used during meal service. OSM #8 had facial hair and was not wearing a beard guard the entire time. He was noted to be plating and wrapping the desserts that were served for this lunch meal. At one point, he was assisting another kitchen staff member with lifting a stack of trays. His uncovered chin was noted to be hovering approximately one inch above the surface of the top tray. This tray was the next tray used during this meal service. On 8/23/23 at 3:12 PM, an interview was conducted with OSM #8. He stated that the dish racks, vent, and floor behind the ice machine should not be in the condition they were identified in. He stated that he has been with the facility about a week and did not know when the facility last did a deep clean of the kitchen and that he would be scheduling a deep clean. When asked about the beard guard, he stated, I will put one on. The facility policy, Sanitation Inspection was reviewed. This policy documented, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . On 8/23/23 at 4:01 PM, at the end-of-day meeting, ASM #1 (Administrative Staff Member, the Administrator) and ASM #2, the Director of Nursing, were made aware of the findings. ASM #1 stated that the facility switched from an outsourced dietary service company to in-house dietary department staff and have already been working on some of the things identified.

Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for seven of 33 residents in the survey sample, Residents #68, #89, #39, #22, #62, #25 and #101. The findings include: 1. For Resident #68 (R68), the facility staff failed to implement the comprehensive care plan to keep their fingernails short. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/2023, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented R68 requiring extensive assistance of one person for bathing and personal hygiene. The comprehensive care plan for R68 documented in part, The resident has potential/actual impairment to skin integrity r/t (related to) fragile skin. Date Initiated: 01/09/2023. Revision on: 01/09/2023. Under Interventions it documented in part, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 01/09/2023 . On 8/22/2023 at 4:10 p.m., R68 was observed in bed asleep with their hands visible on top of the blanket. The fingernails on both hands were observed to be approximately one-quarter inch long. On 8/23/2023 at 8:36 a.m., an interview was conducted with R68 in their room. When asked if they performed nail care themselves, R68 stated No. When asked if the nursing staff trimmed their fingernails, R68 stated No. R68 proceeded to show the nails on the right hand and open up their left hand to show the nails further. R68 stated that they were long and Need cutting. The third and fourth nail on the left hand were observed to be long, uneven and jagged on the edges. All of the fingernails were observed to be approximately one-quarter inch long. On 8/23/2023 at 2:14 p.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that they trimmed resident's fingernails as needed. She stated that residents fingernails were assessed for trimming on shower days and as needed and cleaned underneath daily. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the CNA staff should be assessing the fingernails daily when providing ADL (activities of daily living) care to residents and trim them as needed. She stated that the purpose of the care plan was so the staff could have direction of what the goals of the patient were and that it was integrated so they could all see what the goals were and the whole plan of care. She stated that the care plan should be implemented so that they provided the best outcome and care for the patient and so everyone was on the same page. She observed R68's fingernails and stated that they were long and needed to be trimmed. She stated that the staff may have overlooked the nails needing trimming due to R68 being more independent in some parts of their care. She asked R68 if she could trim the fingernails and they stated Thank you. The facility provided policy Care planning Special Needs-Dialysis revised 12/1/2022, failed to evidence guidance on implementing the care plan. The policy documented in part, .Comprehensive care plans will be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures . The facility policy Activities of Daily Living (ADLs) revised 12/1/2022, documented in part, .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 . On 8/23/2023 at 4:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. 2. For Resident #89 (R89), the facility staff failed to develop the comprehensive care plan to include psychotropic medication use. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/2023, the resident scored 6 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented R89 receiving an antidepressant six of the seven days during the assessment period. The physician orders for R89 documented in part, Sertraline HCl (1) Oral Tablet 50 MG (milligram) (Sertraline HCl) Give 1.5 tablet by mouth one time a day for Anxiety 75 mg. Order Date: 04/13/2023. The comprehensive care plan for R89 failed to evidence documentation of the use of an antidepressant medication. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the purpose of the care plan was so the staff could have direction of what the goals of the patient were and that it was integrated so they could all see what the goals were and the whole plan of care. She stated that any nurse or the MDS staff could update the care plan. On 8/24/2023 at 12:10 p.m., an interview was conducted with LPN #3, MDS coordinator. LPN #3 stated that the MDS staff were responsible for creating the care plan and the nursing staff helped with updating and adding to the care plans. She stated that upon admission they did a baseline care plan and then after the MDS assessment was completed, the comprehensive care plan was developed. She stated that there were certain medications that should be addressed on the care plan such as antidepressants. She reviewed R89's care plan and stated that the antidepressant should be addressed on the care plan and they did not see it. On 8/24/2023 at 2:27 p.m., ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations were made aware of the above concern. No further information was presented prior to exit. Reference: (1) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). It is also used to relieve the symptoms of premenstrual dysphoric disorder, including mood swings, irritability, bloating, and breast tenderness. Sertraline is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amounts of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a697048.html 3. For Resident #39 (R39), the facility staff failed to implement the comprehensive care plan to monitor for adverse effects daily from psychotropic medications. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/9/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R39 receiving an antidepressant seven of the seven days during the assessment period and an antianxiety medication seven of seven days during the assessment period. The physician orders for R39 documented in part, Buspirone HCl (1) Tablet 10 MG (milligram) Give 1 tablet by mouth three times a day for depression. Order Date: 07/25/2023 . Amitriptyline HCl (2) Tablet 150 MG Give 1 tablet by mouth at bedtime for depression. Order Date: 07/25/2023 . Escitalopram Oxalate (3) Tablet 20 MG Give 1 tablet by mouth one time a day for Depression. Order Date: 07/25/2023 . The comprehensive care plan for R39 documented in part, (Name of R39) has use of psychotropic medications r/t (related to) antidepressant, anxiety. Date Initiated: 01/23/2020. Revision on: 02/20/2020. Under Interventions it documented in part, . Monitor for adverse effects daily. Notify MD (medical doctor) prn (as needed) and document. Date Initiated: 01/23/2020. The care plan further documented The resident uses antidepressant medication (SPECIFY medications) r/t Depression. Date Initiated: 10/28/2022. Revision on: 04/21/2023. Under Interventions it documented in part, Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-Shift (every shift). Date Initiated: 10/28/2022. Revision on: 04/21/2023 . The care plan also documented, The resident uses anti-anxiety medication r/t Anxiety disorder. Date Initiated: 10/29/2022. Revision on: 04/21/2023. Under Interventions it documented in part, Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-Shift. Date Initiated: 10/29/2022. Revision on: 04/21/2023 . The eMAR (electronic medication administration record) for R39 dated 7/1/2023-7/31/2023 and 8/1/2023-8/31/2023 failed to evidence psychotropic medication monitoring for R39. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that there was a prompt on the eMAR where they documented behavior and side effect monitoring of psychotropic medications. She stated that monitoring was done every shift and documented on the eMAR. She stated that the purpose of the care plan was so the staff could have direction of what the goals of the patient were and that it was integrated so they could all see what the goals were and the whole plan of care. She stated that the care plan should be implemented so that they provided the best outcome and care for the patient and so everyone was on the same page. She reviewed R39's eMAR and stated that she did not see the behavior monitoring and side effect monitoring on the eMAR. On 8/23/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of behavior and side effect monitoring for R39. On 8/24/2023 at 10:03 a.m., ASM #2, the director of nursing stated that they did not have any behavior or side effect monitoring to provide for R39 and they had placed an order to start documenting the monitoring now. On 8/24/2023 at 2:27 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations were made aware of the above concern. No further information was presented prior to exit. Reference: (1) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html (2) Amitriptyline is used to treat symptoms of depression. Amitriptyline is in a class of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682388.html (3) Escitalopram is used to treat depression in adults and children and teenagers [AGE] years of ago or older. Escitalopram is also used to treat generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults, teenagers, and children 7 years of age and older. Escitalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603005.html 42183 4. For Resident #22, the facility staff failed to develop a care plan for the use of side rails, and failed to implement the care plan to include providing a meal to take to dialysis appointments. 4.a. Resident #22 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: bilateral BKA (below the knee amputation). Resident #22 was observed in bed with 1/2 side rails on 8/22/23 at 3:50 PM and on 8/23/23 at 10:45 AM. A review of the comprehensive care plan dated 3/21/22, which revealed, FOCUS: The resident is High risk for falls related to Confusion, Deconditioning, Gait/balance problems and Hypotension. INTERVENTIONS: Anticipate and meet the resident's needs. There was no evidence of bed rail use on the care plan. A review of the facility's Bed Rail Safety Review dated 9/11/22 and 6/23/23, revealed, List bed rail(s) to be implemented: half rails. List side(s): both. There were no physician order for the bed rails. On 8/23/23 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4. When asked the purpose of the care plan, LPN #4 stated, the purpose is to provide everyone the plan of care for the resident. When asked who is responsible for developing the care plan, LPN #4 stated, the MDS coordinator initiates the care plan. When asked if bed rails should be on the care plan, LPN #4 stated, yes, it should be. On 8/24/23 at 12:05 PM, an interview was conducted with LPN #3, the MDS coordinator. When asked who is responsible for initiating care plans, LPN #3 stated, it is my responsibility. On 8/24/23 at approximately 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 4. b. For Resident #22, the facility staff failed to implement the care plan to include providing a meal to take to dialysis appointments. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/11/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O- Special Procedures/Treatments: coded the resident dialysis-yes. A review of the comprehensive care plan dated 3/21.22, which revealed, FOCUS: The resident needs dialysis type hemo/peritoneal related to renal failure. The resident is at nutrition and/or hydration risk due to diagnosis of ESRD. INTERVENTIONS: HD (hemodialysis) every Monday-Wednesday-Friday. Monitor and record pre and post wt. Provide, serve Regular-CCHO-NAS (carbohydrate controlled no added salt) diet with Double Protein at all meals, as ordered. Monitor intake and record each meal. On 8/23/23 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4. When asked the purpose of the care plan, LPN #4 stated, the purpose is to provide everyone the plan of care for the resident. When asked who is responsible for developing the care plan, LPN #4 stated, the MDS coordinator initiates the care plan. When asked if Resident #22 was not receiving a bagged sandwich and drink to take to dialysis, was the dialysis care plan implemented, LPN #4 stated, no, it is not implemented. On 8/24/23 at approximately 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 5. For Resident #62, the facility staff failed to develop a care plan for the use of an anticoagulant. Resident #62 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: long-term anticoagulant use. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section N- Medications: coded the resident anticoagulant-no. A review of the physician orders dated 6/30/23 revealed, Eliquis Oral Tablet 5 milligram (mg). Give 5 mg by mouth two times a day. A review of the comprehensive care plan dated 7/24/23, which revealed, FOCUS: The resident has a behavior problem related to Major Depressive Disorder and Heart Failure. INTERVENTIONS: Anticipate and meet the needs of resident. There was no evidence of anticoagulant use on the care plan. On 8/23/23 at 3:30 PM, an interview was conducted with LPN (licensed practical nurse) #4. When asked the purpose of the care plan, LPN #4 stated, the purpose is to provide everyone the plan of care for the resident. When asked who is responsible for developing the care plan, LPN #4 stated, the MDS coordinator initiates the care plan. When asked if anticoagulants should be on the care plan, LPN #4 stated, yes, it should be. When asked why it should be on the care plan, LPN #4 stated, so the team knows to assess for bleeding and bruising and report it immediately. On 8/24/23 at 12:05 PM, an interview was conducted with LPN #3, the MDS coordinator. When asked who is responsible for initiating care plans, LPN #3 stated, It is my responsibility. On 8/24/23 at approximately 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. A review of the facility's High Risk Medication policy, revealed, The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool) b. Fall in hematocrit or blood pressure c. Thromboembolism 5. The resident's plan of care shall include interventions to minimize risk of adverse consequences. Examples include (depending on the medication): a. Limit venipunctures and injections, as possible. Be aware of the need to apply pressure following these procedures. b. Use soft toothbrush and electric razors. Limit intake of foods high in vitamin K: broccoli, cabbage, collard greens, spinach, kale, turnip greens, and brussel sprouts. d. Avoid cranberry juice and cranberry products. e. Caution resident/family about alcohol use while taking anticoagulants. f. Educate resident/family on risks of bleeding, dietary modifications, and symptoms to report to nurse/physician. g. Avoid (strenuous) activities that may lead to injury. No further information was provided prior to exit. 32642 6. For Resident #25 (R25), the facility staff failed to develop a care plan for the resident's diagnosis of PTSD (post-traumatic stress disorder) (1). R#25's admitting diagnoses included PTSD (1). A review of R25's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/11/23, R25's diagnoses list included PTSD. A review of R25's care plan revealed no information related to interventions for PTSD. On 8/24/23 at 9:32 a.m., OSM (other staff member) #3, the director of social services, was interviewed. She stated R25 should have a care plan for PTSD. She stated she was not sure who was responsible for developing this care plan. On 8/24/23 at 11:36 p.m., LPN (licensed practical nurse) #3, the MDS coordinator, was interviewed. She stated she is responsible for developing a resident's comprehensive care plan, with input from the whole team. When asked if R25 should have a care plan for PTSD, she stated: That is a good question. I wouldn't unless the resident was demonstrating behaviors. She stated just because a resident has a diagnosis of PTSD, we don't need to give the staff assumptions about it. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. ASM #2 stated the MDS coordinator is responsible for developing the care plan to address a resident's needs. No further information was provided prior to exit. NOTES (1) Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event .Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened, even when they are not in danger. This information is taken from the website https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd. 7. For Resident #101 (R101), the facility staff failed to develop a care plan for the resident's diagnosis of schizoaffective disorder (1). R#101's admitting diagnoses included schizoaffective disorder (1). A review of R101's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 6/5/23, R101's diagnoses list included schizoaffective disorder. A review of R101's care plan revealed no information related to interventions for schizoaffective disorder. On 8/24/23 at 11:36 p.m., LPN (licensed practical nurse) #3, the MDS coordinator, was interviewed. She stated she is responsible for developing a resident's comprehensive care plan, with input from the whole team. When asked if R101 should have a care plan for schizoaffective disorder, she stated: Maybe. She stated it depended on the resident's current status. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. ASM #2 stated the MDS coordinator is responsible for developing the care plan to address a resident's needs. No further information was provided prior to exit. Reference: (1)Schizoaffective disorder is a mental condition that causes both a loss of contact with reality (psychosis) and mood problems (depression or mania). This information is taken from the website https://medlineplus.gov/ency/article/000930.htm.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for five out of 33 residents in the survey sample, Residents ##11, #62, #57, #32 and #111. The findings include: 1. For Resident #11, the facility staff failed to complete an accurate MDS (minimum data set); annual assessment for anticoagulant use. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/17/23, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Section N- Medications: coded the resident anticoagulant-yes. A review of the physician orders dated 1/4/23 revealed, Clopidogrel Bisulfate Tablet 75 milligram po every morning. Clopidrel (Plavix) is classified as an antiplatelet. On 8/23/23 at 2:30 PM, an interview was conducted with LPN (licensed practical nurse) #3, the MDS coordinator. When asked to verify the coding Resident #11's 8/17/23 Section N: anticoagulant, LPN #3 stated, yes, it is incorrectly coded. It should have been coded anticoagulant 'no'. When asked what standard is followed for completing a MDS, LPN #3 stated, the RAI (resident assessment instrument) manual. On 8/23/23 at approximately 4:00 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 2. For Resident #62, the facility staff failed to complete an accurate MDS (minimum data set); annual assessment for anticoagulant use. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section N- Medications: coded the resident anticoagulant-no. A review of the physician orders dated 6/30/23 revealed, Eliquis (anticoagulant) Oral Tablet 5 milligram (mg). Give 5 mg by mouth two times a day. On 8/24/23 at 12:05 PM, an interview was conducted with LPN (licensed practical nurse) #3, the MDS coordinator. When asked to verify the coding for Resident #62's 7/6/23 Section N: anticoagulant, LPN #3 stated it was coded as a no. After looking at the physician orders and medication administration record LPN #3 stated, It was incorrectly coded on the 7/6/23 [MDS], anticoagulant should have been coded 'yes'. When asked what standard is followed for completing a MDS, LPN #3 stated, the RAI (resident assessment instrument) manual. On 8/24/23 at approximately 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. No further information was provided prior to exit. 31753 3. For Resident #32 (R32), the facility staff failed to accurately code section N of the quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 8/17/23. R32 was coded as having received insulin seven out of the last seven days however the resident did not receive insulin. A review of Resident #32's physician's order summary for August 2023 failed to reveal any orders for insulin but did contain an order dated 5/25/23 for Trulicity 0.75 milligrams/0.5 milliliters-inject one dose subcutaneously every Friday for diabetes mellitus. Section N0350 of R32's quarterly MDS with an ARD of 8/17/23 coded the resident as having received insulin seven out of the last seven days. On 8/23/23 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the MDS coordinator). LPN #3 stated that since Trulicity was a subcutaneous injection for diabetes, she assumed the medication was insulin. The Trulicity website documented the drug classification for this medication as a glucagon-like peptide-1 (GLP-1) receptor agonist used to treat diabetes. This information was obtained from the website: https://uspl.lilly.com/trulicity/trulicity.html#s3. On 8/23/23 at 4:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. 4. For Resident #57 (R57), the facility staff failed to accurate code section N of the quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 6/14/23. R57 was coded as having received insulin seven out of the last seven days however the resident did not receive insulin. A review of R57's physician's order summary for August 2023 failed to reveal any orders for insulin but did contain an order dated 12/6/22 for Trulicity 1.5 milligrams/0.5 milliliters-inject 1.5 milligrams every Thursday for diabetes mellitus. Section N0350 of R57's quarterly MDS with an ARD of 6/14/23 coded the resident as having received insulin seven out of the last seven days. On 8/23/23 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the MDS coordinator). LPN #3 stated that since Trulicity was a subcutaneous injection for diabetes, she assumed the medication was insulin. The Trulicity website documented the drug classification for this medication as a glucagon-like peptide-1 (GLP-1) receptor agonist used to treat diabetes. This information was obtained from the website: https://uspl.lilly.com/trulicity/trulicity.html#s3. On 8/23/23 at 4:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. 5. For Resident #111 (R111), the facility staff failed to accurately code the resident's discharge status on the resident's discharge MDS (minimum data set) assessment with an ARD (assessment reference date) of 6/21/23. The staff coded R111 discharged to an acute hospital, but the resident discharged to another nursing home. R111 discharged from the facility on 6/21/23. A social services note dated 6/21/23 documented R111 was discharging to another nursing facility for long term care services. Section A2100 of R111's discharge MDS with an ARD of 6/21/23 coded the resident discharged to, 03. Acute hospital. On 8/23/23 at 1:46 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (the MDS coordinator). LPN #3 stated she coded R111's discharge MDS wrong and needed to make a correction. LPN #3 stated she references the CMS (Centers for Medicare and Medicaid) RAI (Resident Assessment Instrument) manual when completing MDS assessments. The CMS RAI manual documented, A2100: OBRA Discharge Status Steps for Assessment 1. Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions Select the 2-digit code that corresponds to the resident's discharge status. Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. Includes swing beds . On 8/23/23 at 4:12 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 33 residents in the survey sample, Residents #7, #68 and #89. The findings include: 1. For Resident #68 (R68), the facility staff failed to revise the comprehensive care plan to include the use of bed rails. The comprehensive care plan for R68 documented in part, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) Hemiplegia. Date Initiated: 04/15/2022. Revision on: 08/15/2022. The care plan failed to evidence bed rail usage. On 8/22/2023 at 4:10 p.m., an observation was made of R68 in their room. R68 was observed in bed asleep with bilateral upper bed rails in place. Additional observations of R68 in bed with bilateral bed rails in place were made on 8/23/2023 at 8:36 a.m. and 2:20 p.m. The clinical record documented a bed rail assessment and consent dated 4/9/2023. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the purpose of the care plan was so the staff could have direction of what the goals of the patient were and that it was integrated so they could all see what the goals were and the whole plan of care. She stated that nursing staff and MDS staff updated the care plan. She stated that bed rail use should be addressed on the care plan. On 8/23/2023 at 4:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. 2. For Resident #89 (R89), the facility staff failed to revise the comprehensive care plan to update the advance directive/code status. The comprehensive care plan for R89 documented in part, Advance Directive - (Name of R89) is Full Code. Date Initiated: 12/19/2022. Revision on: 03/26/2023. The physician orders for R89 documented in part, ADC: DNR (do not resuscitate). Order Date: 06/28/2023. The clinical record contained a durable do not resuscitate order form dated 6/27/2023 for R89 signed by the physician and the resident representative. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the purpose of the care plan was so the staff could have direction of what the goals of the patient were and that it was integrated so they could all see what the goals were and the whole plan of care. She stated that nursing staff and MDS staff updated the care plan. She stated that she would expect the code status to be updated on the care plan when the code status was changed. She stated that the process would be to put in the order and then update the care plan after the proper paperwork was signed. She reviewed R89's care plan and stated that the code status had not been updated there and should have been to reflect the DNR status. On 8/23/2023 at 4:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. 31753 3. For Resident #7, the facility staff failed to review and revise the resident's comprehensive care plan when a male resident touched the resident's breast on 7/12/22. A facility synopsis of events documented that on 7/12/22, an employee witnessed a male resident touching himself and fondling R7's breast. A review of R7's comprehensive care plan revised on 12/9/22 failed to reveal the care plan was reviewed and revised regarding the 7/12/22 event. On 8/23/23 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated, The purpose of the care plan is so we can have direction of what the goals of the patient are, it is integrated so we can all see what the goals are, the whole plan of care. On 8/24/23 at 9:42 a.m., an interview was conducted with OSM (other staff member) #3 (the director of social services). OSM #3 stated R7's care plan should have been reviewed and revised when the resident's breast was fondled because this was an event that happened to the resident. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not provide a policy regarding care plans.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 33 residents in the survey sample, Resident #7. The findings include: For Resident #7 (R7), the facility staff failed to document an incident where a male resident touched the resident's breast on 7/12/22. A facility synopsis of events documented that on 7/12/22, an employee witnessed a male resident touching himself and fondling R7's breast. A review of R7's clinical record failed to reveal documentation regarding the 7/12/22 event. On 8/24/23 at 8:55 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated a progress note should definitely be made in the clinical record if a male resident touches a female resident's breast. LPN #2 stated this should be documented in both residents' clinical records. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Documentation in Medical Record documented, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a clean, comfortable, and homelike environment for two of 33 residents in the survey sample, Residents #32 and #106. The findings include: 1. For Resident #32 (R32), the facility staff failed to maintain the resident's room in a clean and homelike manner. Trash was observed and remained on the floor beside the bed from 8/22/23 through 8/24/23 and a film of dust was observed on the resident's dressers from 8/22/23 through 8/24/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/22/23 at 1:27 p.m., an interview was conducted with R32. The resident voiced concern regarding dirt and trash on the floor by the bed, and dust on the dressers. R32 stated the housekeepers clean the room most of the time, but there have been times the room hasn't been cleaned for five days, and sometimes the room isn't cleaned on the weekends. R32 stated that when the housekeeping employees do clean the room, they are not good and thorough. At this time, three yellow foam pieces (less than an inch in diameter), a stack of plastic cups and a Ziplock bag was observed on the floor beside the bed. Also, a film of dust was observed on the resident's dressers. On 8/23/23 at 2:58 p.m., and 8/24/23 at 8:29 a.m., the trash remained on R32's floor and the dust remained on the dressers. On 8/24/23 at 9:07 a.m. an interview was conducted with OSM (other staff member) #1 (the environmental services director). OSM #1 stated resident rooms should be swept and mopped every day, and all surfaces in resident rooms should be cleaned every day. On 8/24/23 at 9:18 a.m., an observation of R32's room was conducted with OSM #1. OSM #1 stated the trash and dust was not acceptable, and this was not clean, comfortable, and homelike. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Safe and Homelike Environment documented, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . 2. For Resident #106 (R106), the facility staff failed to maintain the resident's bathroom in a clean and homelike manner. Black stains were observed on the floor, along the perimeter of the walls, and black dirt and hairs were observed around the base of the toilet from 8/22/23 through 8/24/23. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/10/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 8/22/23 at 1:21 p.m., an interview was conducted with R106. R106 voiced concern about black stains on the floor, along the perimeter of the walls in the bathroom, and black substance around the base of the toilet. R106 stated the resident voiced concern about the floor to someone a couple of months before, but the floor was still dirty. At this time, R106's bathroom was observed. Black stains were observed on the floor, along the perimeter of the walls, and black substance and hairs was observed around the base of the toilet. On 8/23/23 at 3:03 p.m. and 8/24/23 at 8:33 a.m., black stains remained on the floor, and black substance and hairs remained around the base of the toilet. On 8/24/23 at 9:07 a.m., an interview was conducted with OSM (other staff member) #1 (the environmental services director). OSM #1 stated resident bathrooms should be cleaned every day and this cleaning should include sweeping the floor, mopping the floor, cleaning the tub, wiping the mirrors, and cleaning the toilet. On 8/24/23 at 9:22 a.m., R106's bathroom was observed with OSM #1. OSM #1 stated the base around the toilet should be part of daily cleaning. OSM #1 further stated the floor would have to be scrubbed, and she was working on a list of rooms that needed this. OSM #1 stated R106's bathroom was not clean, comfortable, and homelike. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on staff interview and clinical record review, it was determined that the facility staff failed to provide written notification to the Office of the State Long-Term Care Ombudsman of a hospital transfer for one of 33 residents in the survey sample; Resident #67. The findings include: For Resident #67, the facility staff failed to send the ombudsman written notification of transfers to the hospital. A review of the clinical record revealed that on 6/30/23, Resident #67 was sent to the emergency room for abdominal pain; and on 7/3/23 for chest pain. Further review of the clinical record failed to reveal any evidence of a written notification to the ombudsman of the hospital transfers. A review of the fax that was sent to the ombudsman on 7/4/23 for June 2023 transfers and discharges failed to reveal Resident #67's name as being transferred on 6/30/23. A review of the fax that was sent to the ombudsman on 8/1/23 for the July 2023 transfers and discharges failed to reveal Resident #67's name as being transferred on 7/3/23. On 8/24/23 at 11:24 AM, when ASM #1 (Administrative Staff Member, the Administrator) provided the above two fax lists, she stated that Resident #67 was not on the list for ombudsman notification for the hospital transfers on 6/30/23 and 7/3/23 because the resident went to the emergency room and back to the facility on the same day and therefore was not captured on the discharge report that is printed and provided to the ombudsman for the notification each month. She stated that she called the ombudsman to inquire his expectation and that he did not expect notifications under these circumstances. The regulations do not identify exceptions to the ombudsman notification requirement. A facility policy for hospital transfers/ombudsman notification was requested however none was provided.

Based on observation, resident interview, clinical record review, staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice for medication administration for one of 33 residents in the survey sample, Resident #89. The findings include: For Resident #89 (R89), the facility staff failed to ensure medications were ingested and not left at the bedside in a medication cup unattended. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/2023, the resident scored 6 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. On 8/22/2023 at 2:17 p.m., an observation was made of R89 in their room. R89 was observed in bed watching television. A small clear plastic medication cup approximately 30 ml (milliliter) in size was observed sitting on the overbed table to the right of R89. Inside of the plastic cup were seven pills of various shapes and colors. When asked about the cup, R89 stated that they were their medications and they were going to take them later. R89 stated that someone had left them for her that morning and they would take them later. The physician orders for R89 failed to evidence an order to leave medications at the bedside for self-administration. The comprehensive care plan for R89 failed to evidence documentation of self-administration of medications. The clinical record failed to evidence documentation of R89's ability to self-administer medications. On 8/22/2023 at 2:31 p.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that medications were not supposed to be left at the bedside. She stated that R89 was not able to self-administer medications and should be observed taking medications prior to them leaving the room. She observed the clear plastic medication cup with the seven pills inside on top of R89's overbed table in the room and stated that she thought they were her morning medications. She stated that the medications should not be left in the room because they may not be able to be taken at a later time, may cause adverse effects if taken later or anyone could come in a pick them up. The facility policy Medication Administration revised 12/1/2022 documented in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 15. Observe resident consumption of medication . On 8/23/2023 at 4:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review it was determined that the facility staff failed to provide ADL (activities of daily living) care to a dependent resident for one of 33 residents in the survey sample, Resident #68. The findings include: For Resident #68 (R68), the facility staff failed to trim their fingernails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/2023, the resident scored 4 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. The assessment documented R68 requiring extensive assistance of one person for bathing and personal hygiene. On 8/22/2023 at 4:10 p.m., R68 was observed in bed asleep with their hands visible on top of the blanket. The fingernails on both hands were observed to be approximately one-quarter inch long. On 8/23/2023 at 8:36 a.m., an interview was conducted with R68. When asked if they performed nail care themselves, R68 stated No. When asked if the nursing staff trimmed their fingernails, R68 stated No. R68 proceeded to show the nails on the right hand and open up their left hand to show the nails further. R68 stated that they were long and Need cutting. The third and fourth nail on the left hand were observed to be long, uneven and jagged on the edges. All of the fingernails were observed to be approximately one-quarter inch long. The comprehensive care plan for R68 documented in part, The resident has potential/actual impairment to skin integrity r/t (related to) fragile skin. Date Initiated: 01/09/2023. Revision on: 01/09/2023. Under Interventions it documented in part, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated: 01/09/2023 . On 8/23/2023 at 2:14 p.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that they trimmed resident's fingernails as needed. She stated that residents fingernails were assessed for trimming on shower days and as needed and cleaned underneath daily. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the CNA staff should be assessing the fingernails daily when providing ADL care to residents and trim them as needed. She observed R68's fingernails and stated that they were long and needed to be trimmed. She stated that the staff may have overlooked the nails needing trimming due to R68 being more independent in some parts of their care. She asked R68 if she could trim the fingernails and they stated Thank you. The facility policy Activities of Daily Living (ADLs) revised 12/1/2022, documented in part, .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 . On 8/23/2023 at 4:00 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to store respiratory equipment in a sanitary manner for two of 33 residents The findings include: 1. For Resident #6 (R6), the facility staff failed to store nebulizer equipment in a sanitary manner. On 8/22/23 at 1:58 p.m., and 8/23/23 at 9:09 a.m. and 12:52 p.m., R6's nebulizer tubing and mouthpiece were observed lying in direct contact with R6's nebulizer machine; there was no covering on the tubing or the mouthpiece. A review of R6's orders revealed the following order dated 5/18/23: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML (milligrams/milliliter) (Ipratropium-Albuterol) 1 application inhale orally every 6 hours for SOB (shortness of breath). A review of R6's August 2023 MAR (medication administration record) revealed the resident received the medication as ordered. On 8/24/23 at 10:21 a.m., LPN (licensed practical nurse) #6, a unit manager, was interviewed. When asked where the tubing and mouthpiece for a nebulizer should be stored, she stated: There should be a clear bag for it. It should be stored in a plastic bag. She stated storage in a plastic bag would prevent the nebulizer equipment from touching dirty surfaces. On 8/24/23 at 11:30 a.m., LPN #7 was interviewed. She stated nebulizer mouthpieces and tubing should be stored in a clear, protective bag to prevent contamination. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. A review of the facility policy, Cleaning and Disinfection of Resident-Care Equipment, revealed, in part: Semi-critical items are exposed to mucous membranes (i.e. [for example] respiratory equipment) or non-intact skin. The policy did not contain information about the storage of respiratory equipment. No further information was provided prior to exit. 31753 2. For Resident #32 (R32), the facility staff failed to store an incentive spirometer in a sanitary manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/17/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R32's clinical record revealed a physician's order dated 5/22/23 to document the total minutes of direct resident bedside care for incentive spirometer medication administration- 12-15 breaths, total of 15-20 minutes. On 8/22/23 at 1:27 p.m., 8/23/23 at 1:24 p.m. and 8/24/23 at 8:29 a.m., an uncovered incentive spirometer with the mouthpiece exposed to air was observed sitting on R32's dresser. On 8/22/23 at 1:27 p.m., R32 stated they sometimes uses the incentive spirometer. On 8/24/23 at 8:29 a.m., R32 stated the staff have never provided a cover for the incentive spirometer. On 8/24/23 at 8:55 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated incentive spirometers should be stored by the bedside so residents can use them. LPN #2 stated she did not have a particular thing to cover incentive spirometers, but maybe something could be used for germs. LPN #2 stated incentive spirometers definitely need to be wiped down, and the nurses wipe incentive spirometers down, but there is not a set schedule or documentation that this is done. On 8/24/23 at 10:22 a.m., R32 stated staff do not wipe down or clean the incentive spirometer. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Cleaning and Disinfection of Resident-Care Equipment did not document specific information regarding incentive spirometers.

Based on resident and staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 33 residents in the survey sample, Resident #22. The findings include: The facility failed to provide a bagged lunch for Resident #22 to take with him to the dialysis appointment. Resident #22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), dialysis, and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/11/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Section O- Special Procedures/Treatments: coded the resident dialysis-yes. A review of the comprehensive care plan dated 3/21.22, which revealed, FOCUS: The resident needs dialysis type hemo/peritoneal related to renal failure. The resident is at nutrition and/or hydration risk due to diagnosis of ESRD. INTERVENTIONS: HD (hemodialysis) every Monday-Wednesday-Friday. Monitor and record pre and post wt. Provide, serve Regular-CCHO-NAS (carbohydrate controlled no added salt) diet with Double Protein at all meals, as ordered. Monitor intake and record each meal. A review of the physician's order dated 3/2/23, revealed, Outpatient hemodialysis: Days Scheduled: Monday, Wednesday, Friday. Chair time 6:00am. An interview was conducted on 8/22/23 at 3:45 PM with Resident #22, when asked what items he took with him to dialysis, Resident #22 stated, There is a book I take. When asked if he takes a bagged meal, Resident #22 stated, Not for the last week. They used to send me with a sandwich and drink. Resident #22 stated they did not take one on 8/21/23. An interview was conducted on 8/22/23 at 4:15 PM with LPN (licensed practical nurse) #1. When asked what is sent with a resident who goes to dialysis, LPN #1 stated, we send a communication book with all his current information. When asked if a bagged meal is sent with the resident, LPN #1 stated, there have not been any bagged meal for him the last few days. He goes to dialysis early, so the bagged meal would need to get sent up in the evening. An interview was conducted on 8/24/23 at 10:15 AM with Resident #22. When asked if they had taken a bagged meal with them to dialysis on 8/23/23, Resident #22 stated, no, there was no food. An interview was conducted on 8/24/23 at 10:30 AM with OSM (other staff member) #8, the dietary manager. When asked if brown bag meal was provided to Resident #22 for his dialysis appointments, OSM #8 stated, Yes, we provide a bagged meal. For this resident who leaves about 5:30 AM, we send the bagged meal up the evening before with the evening snacks. We have been sending them up. On 8/24/23 at approximately 2:30 PM, ASM #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. According to the facility's Care Planning Special Needs-Dialysis policy reveals, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving dialysis. Interventions will include, but not limited to a. Documentation and monitoring of complications b. Pre- and post- weights c. Assessing, observing, and documenting care of access sites, as applicable d. Nutrition and hydration, including the provision of meals and snacks on treatment days. Nursing staff will provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis treatment day, and as needed. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of a current bed rail assessment and consent, for one of 33 residents in the survey sample, Residents #109. The findings include: For Resident #109 (R109), the facility failed to evidence a consent for the use of bed rails and a bed rail assessment. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 7/26/2023, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were moderately impaired to make daily decisions. The resident was coded as being totally dependent on two or more persons for bed mobility and transfers. On 8/22/2023 at 1:51 p.m., an observation was made of R109 in bed with bilateral bar shaped bed rails in place in the up position on the upper portion of the bed. At this time an interview was conducted with R109. R109 stated that they used the bed rails to grab onto during care provided by facility staff. R109 stated that they had the rails on the bed since admission and wanted them on the bed. Additional observations of R109 in bed with the bilateral bar shaped bed rails in place were made on 8/22/2023 at 3:44 p.m. and 8/23/2023 at 9:23 a.m. The nursing admission assessment dated [DATE] for R109 documented in part, Side Rails: Sides: Both. Rails: Half. Indicated to promote independence with bed mobility . The assessment failed to evidence a consent obtained for use of bed rails, alternatives used prior to bed rails, and a review of the risks and benefits of bed rails with the resident and/or the resident representative. The nursing admission assessment dated [DATE] for R109 documented in part, Side Rails: Sides: Both. Rails: Half . The assessment failed to evidence a consent obtained for use of bed rails, alternatives used prior to bed rails, indication for use and a review of the risks and benefits of bed rails with the resident and/or the resident representative. On 8/23/2023 at approximately 4:00 p.m., a request was made via written list to ASM (administrative staff member) #1, the executive director, for evidence of the bed rail assessment and consent for use of bed rails for R109. On 8/24/2023 at 9:35 a.m., ASM #2, the director of nursing stated that they did not have a bed rail assessment for R109. She stated that the bed rail assessment was triggered by the admission assessment and they did not consider the grab bars that R109 had bed rails. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that the bed rail assessment was completed during the admission assessment. She stated that the nurse assessed the resident to see if they could safely use the bed rails to assist in turning or positioning themselves prior to putting them in place and they obtained a verbal consent from the resident or the family and documented it in the clinical record. She reviewed R109's admission assessment and clinical record and stated that she did not see a bed rail assessment or consent and there should be one because they used the bed rails to grab on to during care. On 8/24/2023 at 2:27 p.m., ASM #1, the executive director, ASM #2, the director of nursing, and ASM #4, the regional director of operations were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide medically related social services for one of 33 residents in the survey sample, Resident #7. The findings include: For Resident #7, the facility staff failed to assess and monitor the resident's psychosocial well-being after a male resident fondled the resident's breast on 7/12/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/3/23, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. A facility synopsis of events documented that on 7/12/22, an employee witnessed a male resident touching himself and fondling R7's breast. The residents were immediately separated, the male resident was placed on two-hour checks, and discharged on [DATE]. The synopsis of events documented a skin check was completed for all residents (including R7), and R7 would be monitored for changes in behavior. A review of R7's clinical record (including assessments, progress notes, the medication administration record, and the treatment administration record for July 2022) failed to reveal documentation regarding the 7/12/22 event, and any evidence that R7 was assessed for and monitored for any psychosocial concerns. On 8/24/23 at 9:42 a.m., an interview was conducted with OSM (other staff member) #3 (the director of social services). OSM #3 stated that if a male resident touches a female resident's breast, the resident should be monitored for depression or any signs of decline. OSM #3 stated that from her perspective, she would refer the female resident to a licensed clinical social worker or send the resident out for counseling. OSM #3 stated an incident such as this is a lot for someone to process and staff, Can't not address an issue. On 8/24/23 at 2:31 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy for medically related social services or a policy for what should be done for a resident who is inappropriately touched by another resident. The social services director job description documented, Summary: Identify and provide for each resident's social, emotional and psychological needs, and the continuing development of the resident's full potential during his/her stay at the facility .

Based on observation, resident interview, facility document review, and clinical record review, the facility staff failed to maintain a resident's dignity for one of 33 residents in the survey sample, Resident #6. The findings include: For Resident #'6 (R6), the facility staff failed to store R6's urinary catheter collection bag in a privacy cover. On the following dates and times, R6 was observed. At each observation, her urinary catheter collection bag with urine in it was without a privacy cover, and was visible to anyone who passed by: 8/22/23 at 1:58 p.m. (resident sitting up in bed); 8/23/23 at 9:09 a.m. (resident sitting up in bed); 8/23/23 at 12:51 p.m. (resident self-propelling in her wheelchair in the hallway by the central desk). On 8/23/23 at 1:58 p.m., R6 was interviewed. When asked if she was bothered by the catheter collection bag, she stated: I guess I haven't thought about it. But it would be nice if everyone couldn't see my [urine] in the bag. A review of R6's care plan dated 10/23/19 revealed, in part: [R6] is s/p (status/post) suprapubic catheter replacement .position catheter bag and tubing below the level of the bladder and away from the entrance room door. On 8/24/23 at 11:30 a.m., LPN (licensed practical nurse) #7 was interviewed. When asked if urinary collection bags should be positioned or stored in any special way, she stated: They should have some kind of privacy cover. She stated the facility used to keep the in stock, but she was not sure if that was the case at the current time. She stated an exposed urinary collection bag does not promote a resident's dignity. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. A review of the facility policy, Promoting/Maintaining Resident Dignity, revealed, in part: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality .Maintain resident privacy. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to evidence monitoring of psychotropic medication for one of 33 residents in the survey sample, Resident #39. The findings include: For Resident #39 (R39), the facility staff failed to monitor behaviors and for adverse effects of an antianxiety and antidepressant medication. R39 was admitted to the facility with diagnoses that included but were not limited to bipolar disorder, major depressive disorder and alcohol dependence with alcohol-induced persisting dementia. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/9/2023, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R39 receiving an antidepressant seven of the seven days during the assessment period and an antianxiety medication seven of seven days during the assessment period. The physician orders for R39 documented in part, Buspirone HCl (1) Tablet 10 MG (milligram) Give 1 tablet by mouth three times a day for depression. Order Date: 07/25/2023 . Amitriptyline HCl (2) Tablet 150 MG Give 1 tablet by mouth at bedtime for depression. Order Date: 07/25/2023 . Escitalopram Oxalate (3) Tablet 20 MG Give 1 tablet by mouth one time a day for Depression. Order Date: 07/25/2023 . The eMAR (electronic medication administration record) for R39 dated 7/1/2023-7/31/2023 and 8/1/2023-8/31/2023 failed to evidence psychotropic medication monitoring for R39. The eMAR documented the medications above administered each day as ordered. The comprehensive care plan for R39 documented in part, (Name of R39) has use of psychotropic medications r/t (related to) antidepressant, anxiety. Date Initiated: 01/23/2020. Revision on: 02/20/2020. Under Interventions it documented in part, . Monitor for adverse effects daily. Notify MD (medical doctor) prn (as needed) and document. Date Initiated: 01/23/2020. The care plan further documented The resident uses antidepressant medication (SPECIFY medications) r/t Depression. Date Initiated: 10/28/2022. Revision on: 04/21/2023. Under Interventions it documented in part, Administer Antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-Shift (every shift). Date Initiated: 10/28/2022. Revision on: 04/21/2023 . The care plan also documented, The resident uses anti-anxiety medication r/t Anxiety disorder. Date Initiated: 10/29/2022. Revision on: 04/21/2023. Under Interventions it documented in part, Administer Anti-Anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-Shift. Date Initiated: 10/29/2022. Revision on: 04/21/2023 . The clinical record failed to evidence monitoring for adverse effects and side effects of psychotropic medications each shift as documented in the plan of care. On 8/23/2023 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that there was a prompt on the eMAR where they documented behavior and side effect monitoring of psychotropic medications. She stated that monitoring was done every shift and documented on the eMAR. She reviewed R39's eMAR and stated that she did not see the behavior monitoring and side effect monitoring on the eMAR. On 8/23/2023 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the executive director for evidence of behavior and side effect monitoring for R39. On 8/24/2023 at 10:03 a.m., ASM #2, the director of nursing stated that they did not have any behavior or side effect monitoring to provide for R39 and they had placed an order to start documenting the monitoring now. The facility policy Use of Psychotropic Drugs revised 12/1/2022 documented in part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . 9. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial wellbeing will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS review (quarterly, annually, significant change), and d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 10. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . On 8/24/2023 at 2:27 p.m., ASM #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations were made aware of the above concern. No further information was presented prior to exit. Reference: (1) Buspirone is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety. Buspirone is in a class of medications called anxiolytics. It works by changing the amounts of certain natural substances in the brain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a688005.html (2) Amitriptyline is used to treat symptoms of depression. Amitriptyline is in a class of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682388.html (3) Escitalopram is used to treat depression in adults and children and teenagers [AGE] years of ago or older. Escitalopram is also used to treat generalized anxiety disorder (GAD; excessive worry and tension that disrupts daily life and lasts for 6 months or longer) in adults, teenagers, and children 7 years of age and older. Escitalopram is in a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). It works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a603005.html

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to securely store a medication for one of 33 residents in the survey sample, Resident #52. The findings include: For Resident #52 (R52), the facility staff failed to store the resident's Midodrine (1) in a secure manner. On 8/24/23 at 8:35 a.m., the surveyor retrieved R52's dialysis communication notebook from an open shelf behind the nurses' desk. In the front of the notebook, a medication card containing 16 tablets of Midodrine was clipped inside the notebook by way of a three whole punch and three ring prongs. On 8/24/23 at 11:30 a.m., LPN (licensed practical nurse) #7 was interviewed. She stated that all medications should be locked inside the medication cart, or stored in the locked medication refrigerator in the medication room. She stated: We have to keep them locked up for resident safety. When shown R52's dialysis notebook with the Midodrine medication card clipped inside the notebook, LPN #7 shook her head and stated: Well that is inappropriate. She acknowledged the medication was unsecured. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing were informed of these concerns. A review of the facility policy, Medication Storage, revealed, in part: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms .to ensure proper .security .All drugs and biologicals will be stored in locked compartments .Only authorized personnel will have access to the keys in locked compartments. No further information was provided prior to exit. NOTES (1) Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position). Midodrine is in a class of medications called alpha-adrenergic agonists. It works by causing blood vessels to tighten, which increases blood pressure. This information is taken from the website https://medlineplus.gov/druginfo/meds/a616030.html#:~:text=Midodrine%20is%20used%20to%20treat,tighten%2C%20which%20increases%20blood%20pressure.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a current dialysis contract for two of 33 residents in the survey sample, Residents #52 and #22. The findings include: 1. For Resident #52 (R52) the facility staff failed to evidence a current dialysis contract. A review of R52's clinical record revealed the following order, dated 2/3/23: Outpatient Hemodialysis .Outside Center .Days Scheduled: Monday, Wednesday, Friday chair time 7:30am. A review of R52's MARs (medication administration records) from February through August 2023 revealed the resident had been receiving dialysis services as ordered. At the entrance conference on 8/22/23 at 12:25 p.m., ASM (administrative staff member) #1, the executive director, was asked to provide current contracts for the current companies from which residents were receiving dialysis services. On 8/24/23 at 2:28 p.m., ASM (administrative staff member) #1, the executive director was asked again to provide evidence of current dialysis contracts. She stated she could not provide a current dialysis contract at that time. No further information was provided prior to exit. 42183 2. For Resident #22, the facility failed to evidence a written dialysis agreement with one dialysis center. Resident #22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), and dialysis. A review of the comprehensive care plan dated 3/21.22, which revealed, FOCUS: The resident needs dialysis type hemo/peritoneal related to renal failure. The resident is at nutrition and/or hydration risk due to diagnosis of ESRD. INTERVENTIONS: HD (hemodialysis) every Monday-Wednesday-Friday . During the entrance conference to the facility on [DATE], a request was made for the dialysis contracts/agreements to be provided. On 8/24/23 at approximately 8:45 AM, ASM (administrative staff member) #1, the executive director stated, We have a contract but not a current copy. The dialysis company keeps sending us to legal. Someone before me signed the contract, the executive director or the director of regional operations signed the contract. We have been trying to get a copy of the contract since you all came in. On 8/24/23 at 2:30 PM, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing and ASM #4, the regional director of operations, were made aware of the findings. ASM #1 stated, we should have a dialysis contract. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to post daily staffing for one of three days reviewed. The findings include: The facility staff failed to post the nurse staffing data on a daily basis at the beginning of each shift. The facility shifts were 7 AM-3 PM, 3 PM-11 PM, 11 PM-7 AM, and at times, 7 AM-7 PM and 7 PM-7 AM. On 8/22/23 at 11:45 AM upon entrance to the facility for the survey, the bulletin board in the main lobby had staffing posted with a date of 8/22/23 on posting. On 8/23/23 at 8:00 AM, the daily staffing posted on the bulleting board in the main lobby was dated 8/22/23; at 8:35 AM, the date remained 8/22/23. On 8/23/23 at 10:00 AM, the date was 8/23/23. The daily staffing was posted correctly on 8/24/23 at 8:00 AM. On 8/23/23 at 9:00 AM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked to describe the staff posting process, ASM #2 stated, they have centralized staffing and the daily staffing form is emailed to us the evening before. The receptionist posts the daily staffing form in the evening prior to the next day. On 8/23/23 at 10:00 AM, an interview was conducted with OSM (other staff member) #1, the receptionist. When asked to describe the staff posting process, OSM #1 stated, It is emailed the evening before. I work till 4:00 PM and if it is not emailed by then, it is posted the next day. When asked what time the daily staffing is posted, OSM #1 stated, it is posted by 8:00 AM. On 8/24/23 at approximately 2:30 PM, ASM #1, the executive director, ASM #2, the director of nursing, ASM #4, the regional director of operations was made aware of the findings. According to the facility's Facility Required Posting policy revised 12/22, The facility will post required postings in an area that is accessible to all staff and residents. The facility must also post the following: Staffing Information. No further information was provided prior to exit.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to assure a resident's environment remained as free of accident hazards as possible by safely storing green rubbing alcohol to prevent oral use for one (1) of 37 residents (Resident #15), in the survey sample. Immediate Jeopardy (IJ) was called on 2/21/23 at 4:56 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 2/23/23 at 1:11 PM. The scope and severity was lowered to a level 2, pattern. The findings included: Resident #15 was originally admitted to the facility 4/11/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; heart failure, renal insufficiency, coronary artery disease and reflux. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/4/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #15's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring physical help of one person with bathing, limited assistance of one person with personal hygiene, dressing, and toileting, supervision of one person with bed mobility, transfers, and in-room walking, and supervision after set-up with eating. On 2/21/23 at 1:02 p.m. Resident #15 was observed sitting on the side of the bed with a bottle of green rubbing alcohol, 70% isopropyl to her mouth. The resident swished the rubbing alcohol around in her mouth twice and spit it out on the floor to her left. The resident was also observed having a cotton ball with the same color of green on it in her right ear. An interview was conducted with the resident on 2/21/23 at approximately 1:04 p.m., the resident put her finger into her mouth and rubbed the right lower gum and stated it was painful. The resident further stated sometimes her right ear hurts, throat and neck is sore, and the medicine (the green rubbing alcohol 70%) burns when she rinses her mouth, but it helps and when she awakes during the night the pain is gone or better. The resident stated the pain sometimes reached 7 out of a pain scale of 0 through 10. Resident #1 stated she inhales the rubbing alcohol when her head hurts and she rubs it on her body. After the resident completed use of the green rubbing alcohol, she placed the bottle on the floor to her right. The resident was observed again at approximately 2:20 p.m., in her room seated on the side of the bed and the green alcohol bottle remained on the floor beside her bed. The green alcohol bottle was 50% empty. Resident #1 was observed again in her room on 2/21/23 at approximately 3:05 p.m., by two other surveyors with the bottle of green rubbing alcohol on the floor beside the right foot. Other items visibly observed in the room included, a full bottle of green rubbing alcohol, Florida water (a cologne containing 70% alcohol), Sani-cloths, Clorox wipes, a can of Lysol spray, and a bucket of pink water holding clothing. On 2/21/23 at 5:21 p.m., an interview was conducted with Certified Nursing Assistant (CNA) #4. CNA #4 stated she was working a 16 hour shift that day and quite often she worked 16 hours on the assignment which included Resident #15. CNA #4 stated she does not assist the resident with bathing but she is in out out the room to bring meal trays to the resident. CNA #4 stated she had never seen the green rubbing alcohol, Florida water, or other biological products in the resident's room before that day and she removed one and a half bottles of green rubbing alcohol from the room, as well as two bottles of Florida water, one can of Lysol spray, one container of Febreze spray, a bottle of Maalox, two bottles of multivitamins and Vicks vapor rub. On 2/21/23 at 5:29 p.m., an interview was also conducted with Licensed Practical Nurse (LPN) #4. LPN #4 stated the resident was a very private person who has family which visits often. LPN #4 stated she was unaware the resident was experiencing ear, mouth, throat and neck pain or utilized alcohol in room to aid with the pain. LPN stated she was aware the resident often complained of back pain for which she is medicated. A nurse's note dated 2/21/23 7:30 p.m. read this writer had both Florida water and rubbing alcohol in her hand and asked the resident which one of those products she used to swish in her mouth. the resident pointed to and said she used the Florida water to swish in her mouth for freshness. An interview was conducted with Family Member (FM) #2 on 2/22/23 at approximately 11:16 a.m. FM #2 stated every 45 to 60 days for seven years the following items had been brought into the facility for Resident #15's use, green rubbing alcohol, Florida water cologne,Vicks vapor rub, and Lysol spray. FM #2 stated the resident rubs a little alcohol on the hands and head for aches and pains and used the Florida water in the bath water or just rub a little on for the pleasant aroma. FM #2 further stated she knew the facility's staff was aware the items were provided for Resident #15 because during much of the pandemic the package could not be given directly to the resident, they were left at a drop off area and the staff picked up the package and delivered it to the resident, which afforded the staff the opportunity to see what was in the packages. FM #2 stated she was not aware that the resident was putting the isopropyl alcohol and or Florida water in her mouth as well as soaking cotton balls with the isopropyl alcohol in her left ear. During the above interview, FM #2 also stated over the seven years the resident had resided at the facility items were kept at bedside visible to all who were in the resident's care area and at no time did anyone contact her to say do not supply the items to the resident. FM #2 stated she requested an evaluation of Resident #15's ears during a care plan conference because a decline in hearing was noticed during visits but no one had informed her of an evaluation taking place. FM #2 also stated she definitely knew the resident had not left the facility for an Ears/Nose/Throat evaluation because all appointments which takes place outside the facility she accompany's the resident. A review of Resident #15's physician orders revealed an order dated 10/11/22 for an ear, nose and throat evaluation and treatment but after reviewing the resident's records the evaluation was not identified. The in-house physician/practitioner notes from 10/4/22 through 2/22/23 read, 10/4/22 Ears/Nose/Mouth/Throat: Hard of hearing, no dysphagia, or change in dental status The practitioner's progress note dated 12/5/22 did not include an assessment or documentation regarding the resident's Ears/Nose/Mouth/Throat. The 1/3/23 practitioner's assessment read, Ears/Nose/Mouth/Throat: Hard of hearing, no dysphagia, or change in dental status and a 2/22/23 practitioner's assessment read, Ears/Nose/Mouth/Throat: Hard of hearing, no dysphagia, or change in dental status. The 2/22/23 narrative note read the resident has no cognitive impairment and has the capacity to make decisions and do activities of daily living independently. The physician/practitioner notes did not evidence a treatment for the ears, gumline, throat or neck discomfort the resident was experiencing. On 2/22/23 at approximately 2:15 p.m., the Director of Nursing was asked for information (the Ears/Nose/Mouth/Throat consultation report or the in-house physician/practitioner notes) regarding the 10/11/22 order for an ear/nose/throat consult. The DON stated the resident did not need an Ears/Nose/Mouth/Throat consult therefore the order was discontinued. On 2/27/23 at approximately 10:20 a.m., Family member #2 was in the facility to visit Resident #15 and have a meeting with the Interdisciplinary Team. She stated during the visit with the resident, all of the personal items she supplied were no longer in the room and she asked what happened to them for the facility's staff had not talked with her about the items. Family Member #2 was referred by this writer to the facility's staff for answers. On 2/27/23 at approximately 2:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no concerns were voiced. One problem is that the body absorbs this alcohol faster than the alcohol in liquor. It absorbs up to 80 percent in just 30 minutes. This doesn't give your liver enough time to process and detoxify the alcohol before it goes into your bloodstream. Even a small amount can result in alcohol poisoning and death. The next risk is the potency of isopropyl alcohol, which is much higher than ethanol. Isopropanol alcohol is typically about 70 percent alcohol by volume. It's so high that your liver can only process a small amount, about 200 milliliters for adults and much less for children. For example, since the Covid-19 pandemic, the National Poison Data System has recorded more accidental deaths in children under 5 years old, who unknowingly drank hand sanitizers (many of which contain isopropanol); even a little is too much. Information obtained from-(https://www.ncbi.nlm.nih.gov/books/nbk493181/) (https://www.healthline.com) (https://www.aapcc.org) (https://www.webmd.com/mental-health). On 2/21/23 at approximately 3:25 p.m., the survey team contacted the Long-term Care Supervisor to make aware of the above observations and interviews. On 2/21/23 at 4:56 p.m., the facility's Administrator, Director of Nursing and one Corporate Consultant was informed that the above non-compliance constituted Immediate Jeopardy identified in F-689 Free of accident hazards Supervision/Devices at a Scope and Severity Level 4, isolated. The facility staff presented the following final revised abatement plan: Provider/Supplier IJ Abatement plan February 23, 2023 This Plan of Correction serves as (name of the provider) response to the Immediate Jeopardy called by surveyors during a complaint survey on February 21, 2023. The survey team relayed to the facility the template for F689. The Center has removed the immediate concern to ensure the resident's safety. The facility took immediate action to remove the immediate concern the Immediate Jeopardy related to, ensuring a resident's environment was free of green rubbing alcohol that was found in the resident's possession. o Director of Nursing held an ad-hoc safety meeting on 2/21/2023 at 6:30pm to discuss survey findings and creation of this plan; o Director of Nursing notified the facility medical director on 2/21/23 at 7:15pm and was made aware of the safety meeting and action plan; In addition, the facility took the following actions: o In the event of a similar situation in the future, the unsafe material will immediately be secured outside of resident access and 911 initiated if resident condition warranted. o After unsafe/unidentified material was removed, room rounds would be conducted by department heads to assure absence of any other unsafe/unidentified materials. o Director of Nursing immediately disposed of this resident material once notified by survey team members. Completed 2/21/2023 at 5pm. o Family/representative of this resident was notified of findings. Family verbalized to DON the rubbing alcohol and the Florida Water Cologne (for external use only) were used regularly at home. Family member will be notified 2/22/23 to not bring in these items moving forward. o Director of Nursing/ Director of Nursing representative/ Carefeed and Hostedtime (electronic mass communication system) educated all staff that items brought in from the community need to be reported to their supervisor and removed until deemed safe. Completed 2/21/2023 at 7pm. Director of Nursing/ Director of Nursing representative will continue to remind staff of the importance of this education. o Resident was last rounded on at 21:15. Order has been placed for monitoring the resident every two hours for the next 12 hours for safety on 2/21/23 starting at 22:00. o Room rounds were conducted for all residents on 2/21/2023 at 7pm to ensure the absence of any other unsafe materials. o Room rounds were conducted 2/22/23 4:30pm for all residents to ensure hazardous items are not present. o Room rounds for all residents will occur 3 times weekly x 4 weeks, then weekly x4 weeks then monthly x 1 month. Staff will continuously use their education to observe resident rooms when in them, not only during room rounds, to ensure hazardous items are reported to their supervisor for further investigation and deemed safe/unsafe for the resident to possess. The nurse practitioner will assess the patient and deem safe/unsafe. If deemed safe, an order will be placed for the resident to keep the item at bedside. The care plan for the resident will be updated accordingly. o Director of Nursing/ Director of Nursing representative/ Carefeed and Hostedtime (electronic mass communication system) will educate all staff that items brought in from the community need to be reported to their supervisor and removed until deemed safe beginning on 2/21/2023. Education will remain ongoing for any facility staff that did not receive the education by 2/21/23 and those staff will receive the education prior to working their next scheduled shift. o Director of Nursing/designee will conduct care plan audits of any like residents identified to have cultural preferences. These audits will be conducted weekly x4 weeks. o Data obtained during the care plan audit process will be analyzed for patterns and trends and reported to QAPI by the Administrator and/or Director of Nursing monthly for three months. At that time, the QAPI committee will evaluate the effectiveness of the intervention to determine if continued auditing is necessary to maintain compliance. The survey team verified the IJ removal plan as evidenced by the following actions: The survey team reviewed the 100% audits of room rounds to ensure the facility identified any unsafe items in all resident rooms. The survey team made observations of Resident #15 in her room to ensure the items identified as dangerous to her were removed. The survey team made observations of all resident rooms to ensure they were free from any hazardous items. The survey team re-interviewed FM#2 to ensure she was made aware of the restricted items for Resident #15. The survey team reviewed the all staff education that included reporting any items brought in to residents from the community had received the mandatory education. The survey team interviewed staff on duty to ensure they had received the aforementioned staff education outlined by the facility prior to starting their shifts. The IJ was validated through implementation of the removal plan and IJ was removed on 2/23/23 at 1:11 p.m. The deficient practice was assigned a Scope and Severity level of Level two, isolated. Severity Level 2 indicates noncompliance that results in a resident outcome of no more than minimal discomfort and/or has the potential to compromise the resident's ability to maintain or reach his or her highest practicable level of well-being.

Based on observation, record review, interviews, policy review, review of the disinfectant label, review of manufacturer's guidelines, and review of Centers for Disease Control and Prevention (CDC) guidelines for COVID-19, the facility failed to: 1. ensure that three of four Licensed Practical Nurses (LPN) (LPN 1, LPN2, and LPN4) on Unit 2 cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing (accuchecks) between residents; and 2. ensure that a new agency staff was screened for signs and symptoms of COVID-19 upon entrance to the facility. The failure to ensure the staff cleaned and disinfected multi-use glucometers per the device manufacturer's instructions and per the EPA-approved disinfectant's instructions for use when performing fingerstick blood glucose testing created a likelihood for the transmission of bacteria, viruses, and/or blood-borne pathogens between residents. Findings include: On 10/13/21 at 9:19 PM, the Administrator was notified that the failure to ensure that staff properly disinfected the multiuse glucometers before and after resident use constituted immediate jeopardy at F880-K: Infection Control. The facility provided an acceptable plan for removal of the immediate jeopardy on 10/15/21 at 3:38 PM. The removal plan for F880-K included: 1. An update of the Glucometer - Disinfection Policy, completed on 10/15/21; 2. Each resident requiring blood glucose monitoring was assigned a single-use glucometer; 3. All current facility licensed nursing staff completed training by 10/15/21; 4. Licensed nursing staff, including agency staff, will receive education and skills validation starting 10/13/21 on glucometer cleaning and disinfection per policy and manufacturer's instructions and per the EPA approved disinfectant's instructions 5. Facility will ensure competency of agency staff through a combination of: 1:1 education by the Staff Development coordinator (SDC) or designee, bulletin notices in the electronic medical record (EMR), assigned orders in the EMR which will require nurses' signature prior to accuchecks, and education sign off sheet in narcotics book to be completed at shift change during the medication cart handoff for any nurse not previously educated prior to nurse completing any glucometer procedure; 6. Director of Nursing (DON) or designee will observe and validate proper glucometer cleaning and disinfection technique of two nurses on staff per shift for four weeks. The survey team conducted the following to verify implementation of the removal plan for F880-K: 1. The survey team reviewed the revised Glucometer-Disinfection Policy. 2. The survey team reviewed the Glucometer Cleaning and Disinfection training materials provided by the SDC on glucometer cleaning and disinfection. 3. The survey team reviewed the training logs for all the staff completed on 10/14/21 and 10/15/21. 4. The survey team verified that each resident requiring accuchecks had resident specific single-use glucometers 5. The survey team interviewed and observed staff working on 10/14/21 and 10/15/21 performing glucometer cleaning for knowledge and proper techniques for glucometer cleaning and disinfection. 6. The survey team verified that an education sign off sheet was in each narcotics book and was completed at shift change during the medication cart handoff for any nurse not previously educated prior to nurse completing any glucometer procedure. Following validation of the removal plan, the immediate jeopardy was removed on 10/15/21 at 8:20 PM. The deficient practice remained at a lower scope and severity of E (pattern of potential for more than minimal harm) following the removal of the immediate jeopardy. Findings include: Review of the facility policy titled Glucometer Disinfection, dated 10/31/20 and revised on 03/11/21, directs The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use . the glucometers should be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant that is effective against [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] B virus. Review of the User Instruction Manual for the Assure Prism Multi Blood Glucose Monitoring System, revised 02/2020, revealed the device manufacturer, . Validated Clorox Healthcare Bleach Germicidal Wipes .and Super Sani-cloth Germicidal Disposable Wipe [sic] for disinfecting the Assure Prism multi meter. Observations on 10/12/21 and 10/13/21 revealed that three of four Licensed Practical Nurses (LPN) (LPN 1, LPN2, and LPN4) on Unit 2 failed to appropriately clean and disinfect two of two multi-use glucometers by not cleaning the glucometers after use and/or by not allowing the treated surfaces of the glucometers to remain wet for the full required contact time (four minutes) with the EPA-registered disinfectant, specifically Clorox Disinfecting Wipes, that was currently used by the facility. During an observation on 10/12/21 at 4:21 PM, LPN1 performed an accucheck on Resident (R) 48 with an Assure Prism glucometer. When LPN1 was finished, she wiped the glucometer with alcohol prep pad(s) and let the glucometer air dry on a tissue on the medication cart. During the observation, LPN1 stated that she generally allows the glucometer to air dry after she cleans it with the alcohol wipes. At 4:28 PM, LPN1 then performed an accucheck on R21 using the same Assure Prism glucometer. At 4:30 PM, LPN1 obtained the Solimo Disinfecting Wipes (an EPA registered disinfectant) and PDI Sani-Hands and at 4:36 PM LPN1 wiped the used glucometer with a PDI Sani-Hands for 15 seconds; after 15 seconds the glucometer was not visibly wet. During an interview on 10/12/21 at 4:41 PM, LPN1 stated she usually cleans the glucometer with antimicrobial wipes, wets it down for 10-30 seconds, and allows the glucometer to air dry. When asked how long the glucometer needed to remain wet for the product to be effective as a disinfectant, the LPN1 stated she wasn't sure, maybe a minute. LPN1 acknowledged that she used the PDI Sani-Hands for cleaning the glucometer and thought it was a disinfectant wipe. LPN1 stated that no one in the facility had instructed her on how to disinfect the multiuse glucometers between resident use. Review of the product label for PDI Sani-Hands on LPN's medication cart on 10/12/21 at 4:41 PM directs Antiseptic- for handwashing to decrease bacteria on the skin . Active ingredient alcohol 70%. This product is not an EPA registered disinfectant. During an observation on 10/13/21 at 12:12 PM, LPN 2 used the Assure Prism glucometer to check a blood glucose on R67. LPN2 wiped the glucometer for 10 seconds with a Clorox Disinfecting Wipe prior to use and entered the room to perform the accucheck within one minute. When LPN2 finished the accucheck, he wiped the glucometer with a Clorox wipe for five seconds and placed it on a tissue on the medication cart. Within a minute, LPN2 used a tissue and waved over the glucometer to dry it. Continued observation revealed within two minutes, LPN2 gathered the same glucometer used on R67 and performed R20's accucheck. At 12:21 PM, LPN2 wiped the glucometer with a Clorox wipe for five seconds and left it on a tissue on the medication cart to let the glucometer air dry. At 12:23 PM, LPN2 performed R44's accucheck using the same glucometer used on R20. At 12:31 PM, LPN2 wiped the glucometer for six seconds with a Clorox Disinfecting Wipe. At 12:33 PM, LPN performed R48's accucheck using the same glucometer used on R44. During an interview on 10/13/21 at 12:36 PM, LPN2 stated that he cleans the glucometer with a bleach wipe and stated he scrubs the glucometer for 25 seconds and waits for the glucometer to dry; he did not know how long the glucometer was to remain wet. LPN2 acknowledged that he did not ensure that the glucometer remained wet for four minutes prior to use on each resident. LPN2 stated that no one in the facility had instructed him on how to disinfect the multiuse glucometers between resident use. Review of the product label for the Clorox Disinfecting Wipes on LPN2's medication cart on 10/13/21 at 12:36 PM revealed the wipes Kills 99.999% of bacteria, kills cold and flu viruses, kills Staph [bacteria], E coli [bacteria], [CONDITION(S)] [bacteria resistant to antibiotic [CONDITION(S)]], Strep [bacteria]. To use to disinfect hard nonporous surfaces. Wipe surface to be disinfected. Use enough wipes for treated surface to remain visibly wet for 4 minutes. Let surface dry. Further review of the product label for the Clorox Disinfecting Wipes revealed the wipes were effective against [CONDITION(S)] B, [CONDITION(S)], and Human Immunodeficiency Virus ([CONDITION(S)]). Observation on 10/13/21 at 4:00 PM revealed LPN4 gathered an Assure Prism glucometer and put it directly in a small basket on top of opened packets of gauze. Continued observation revealed LPN4 entered R47's room and completed R47's blood glucose check. At 4:05 PM, LPN4 placed the glucometer back into the small basket on top of open gauzes. LPN4 entered the dining room and wiped the glucometer with a [MEDICATION(S)] Alcohol Prep Pad 70% [MEDICATION(S)] Alcohol. Within one-minute LPN4, using the same glucometer used on R47, attempted to perform R27's blood glucose check; however, the surveyor intervened and stopped LPN4. Interview on 10/13/21 at 4:07 PM with LPN4 revealed she normally cleans the multi-use glucometer with the same alcohol prep pads used during the observation. LPN4 stated no one had trained her to use anything different to disinfect the multiuse glucometer. Interview on 10/13/21 at 4:10 PM with the Director of Nursing (DON) revealed it was her expectation LPN4 would have cleaned the glucometer with a bleach wipe and then let it dry for five to 10 minutes. The DON stated LPN4 should have never used an alcohol prep pad to clean the glucometer. The DON also stated a bleach wipe should always be used on glucometers to allow for effective disinfection from blood borne diseases During an interview on 10/13/21 at 4:03 PM, the Infection Preventionist (IP) indicated that the expectation was that glucometers were cleaned with Clorox Bleach Wipes after each use and in between residents according to the manufacturer's product instructions. During an interview on 10/14/21 at 9:30 AM, the Medical Director indicated that his expectation would be that licensed staff follow protocol and sterilize glucometers in between each use, or if residents have their own glucometer that they would also be sterilized after each use. 2. Review of CDC guidance, dated 09/10/21, revealed Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic . Ensure everyone is aware of recommended IPC practices in the facility . Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: . who meets criteria for quarantine or exclusion from work . Review of the Health Attestation Form provided by Infection Preventionist (IP), dated 06/10/20, indicated: Policy: All team members, employed or contracted, pledge to self-monitor and self-report to avoid exposures to communicable disease such as COVID-19 . As part of our protection activities, we ask for these practices to be attested to by your signature. In addition, we will be asking you to submit to having your temperature taken when you report to work . On 10/12 /21 at 3:50 PM, Certified Nursing Assistant (CNA)1 indicated that she did not screen in upon entry today as she was late and did not arrive to the facility until 7:10 AM. CNA1 stated that no one told her to screen for COVID and this was her first time at this facility. CNA1 further indicated that she was fully vaccinated for COVID-19. During an interview on 10/12/21 at approximately 4:10 PM, the IP confirmed that the facility does not have any current staff or residents with COVID-19. The IP further indicated that it is CNA1's first time in the facility and normally when she (the IP) gets into work (around 8:00 AM) she reviews screening with agency staff, but she had not done so with CNA1. During an interview on 10/12/21 at 4:22 PM, the Director of Nursing (DON) indicated that 100% of all staff are required to screen at the door, and it doesn't matter what department they are in or if they are agency, the rules apply to all. The DON indicated that she reviewed the nursing screening logs daily and each department head looks at their own staff as well. On holiday's and weekends the charge nurses are to review the screening logs. The DON did verify that the facility had no system to ensure the logs are reviewed. During this interview, the Administrator asked CNA1 what entrance she used to come into the building. CNA1 stated that the front door was locked, and she pushed the doorbell but didn't hear anything, so she walked around and came in through the laundry room. During an interview on 10/12/21 at 4:40 PM, the Administrator indicated that staff are all educated regarding the requirement to screen at the entrances and at no point in time are staff to enter the building through a door other than a designated entrance.

Based on observations, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure the highest practicable wellbeing for three Residents (Residents #9, 2, and 13) of 20 residents in the survey sample resulting in harm for Resident #9. 1. For Resident #9, the facility staff failed to provide assessment of underlying cause of pain, and failed to administer pain medication timely and effectively, resulting in the hospitalization and surgical removal of a blood clot from leg. 2. For Resident #2 the facility staff failed to implement non-pharmacological interventions prior to administering pain medication. 3. For Resident #13, the facility staff failed to ensure physician's orders were followed. Resident #13 was not administered the ordered 5 p.m. dose of [MEDICATION NAME] Hcl 150 milligram (mg). The findings included: 1. Resident #9 was originally admitted to the facility on [DATE]. Resident #9 was readmitted on [DATE] after a hospital stay, and again readmitted after the most recent hospital stay on 1-2-16. Resident #9's [DIAGNOSES REDACTED]. Resident #9's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 1-12-16. The Resident was coded with a Brief Interview for Mental Status (BIMS) score of 15 points scored in a possible 15 points, indicating no cognitive impairment. The Resident required limited to extensive assistance of one staff member for Activities of Daily Living (ADL's). The Resident was also frequently incontinent of bowel and bladder. Resident #9's Quarterly MDS dated [DATE] after hospitalization , also coded the Resident at area J0100 through J0600 pain management as receiving scheduled pain medication, and receiving as needed pain medication. The document coded that the Resident did not receive non-medication interventions for pain. The document went on to code that the Resident had occasional pain rated at a 3 of 10 in most severe level during the past 5 days, and it had not limited her activities, nor had pain made it hard for her to sleep. Resident #9's Quarterly MDS dated [DATE] prior to hospitalization , coded the Resident at area J0100 through J0600 pain management as receiving scheduled pain medication, and receiving as needed pain medication. The document coded that the Resident did not receive non-medication interventions for pain. The document went on to code that the Resident had occasional pain rated at a 2 of 10 in most severe level during the past 5 days, and it had not limited her activities, nor had pain made it hard for her to sleep. The Resident's pain medications effectively managed her comfort prior to and after hospitalization according to the clinical record and the MDS assessments; however, during this acute illness, the facility staff did not manage Resident #9's pain, nor did they assess for underlying causes and involve the physician timely. Resident #9's physician's orders for December 2015 and Medication Administration/Treatment Administration Records (MAR/TAR) were reviewed and revealed the 3 following pain medication orders; 1. [MEDICATION NAME] ER (extended release) 30 mg (milligrams) routine. Give 1 tablet by mouth every 12 hours at 9:00 a.m., and 9:00 p.m. related to chronic pai[DIAGNOSES REDACTED]. 2. [MEDICATION NAME] (muscle relaxant) give 10 mg by mouth every 8 hours as needed (PRN) related to chronic pai[DIAGNOSES REDACTED]. 3. [MEDICATION NAME] give 10mg by mouth every 6 hours as needed (PRN) related to chronic pai[DIAGNOSES REDACTED]. The Resident was also ordered to have pain monitoring, using a verbal scale of 0 to 10, every shift. That scale follows; 0 as no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 very severe pain. Resident #9's Nursing progress notes were reviewed and revealed the following; It was documented in a Health Change Status Situation, background, assessment, and request (SBAR) nursing note, that on 12-16-15 at 4:29 a.m. Resident #9 was complaining of severe pain. That note is quoted, and is as follows; Situation complaining of pain to lower extremities. Pain rating of 9/10 (very severe). [MEDICATION NAME] 10 mg (milligrams) given at 4:30 a.m. for pain to lower legs. 30 minutes later Resident continuing to complain of pain. Resident started yelling, screaming, and crying. Stated I just want to die. Resident non-compliant with elevating feet while up in wheel chair or up in bed. Attempted to elevate legs with Resident yelling at nurse it hurts. Background [MEDICAL CONDITION], hx of stroke, (Right) Middle Vascular Cerebral Stroke (MVC) post TPA (medicine to dissolve blood clots which cause [MEDICAL CONDITION]) with non-dominant [MEDICAL CONDITIONS](hypertension), Chronic pain in (L) (left) shoulder, SOB (shortness of breath), [MEDICAL CONDITION] of unspecified limb, nicotine dependence, left lower extremity ulcer. Assessment Lying in bed. Left lower extremity with unna boot (special gauze bandage used to treat venous stasis ulcers) in place and elevated on pillow. Resident with [MEDICAL CONDITION] to right lower extremity. Attempted to elevate foot of bed with resident protesting and complaining of pain. Request Increase in pain med frequency from every 6 to every 4 hours. Pain consult and for psyche to follow up with resident regarding behaviors. Review of the clinical record did not evidence these interventions were implemented. Nursing notes were reviewed, and on 12-16-15 the following entries were noted; At 4:32 a.m. the [MEDICATION NAME] was given for pain, and was ineffective. At 5:01 a.m. a new order was received from the doctor for [MEDICATION NAME] 1 mg times 1 dose only. The [MEDICATION NAME] was administered. At 6:54 a.m. a note stating the [MEDICATION NAME] was effective, with pain at a 5/10 (moderate pain) (not fully relieved), was documented, however, at 7:00 a.m. a note was documented by the same nurse stating the Resident was still moaning occasionally, more calm than previously, no further incidents of wanting to die, and this was reported to the oncoming day nurse. At 8:14 a.m. Resident sleeping in chair with head tilted back. At 9:00 a.m. the pain monitoring for routine [MEDICATION NAME] administration revealed pain at 8/10, back to (severe) pain. At 1:20 p.m. the Resident was again administered as needed [MEDICATION NAME] for the Resident ' s stated very severe pain of 10 of 10 (9 hours after the last as needed [MEDICATION NAME] was administered at 4:32 a.m., and it could have been administered at 10:32 a.m. for the complaint of severe pain). At 3:32 p.m. nurses documented (2 hours) after giving the medication at 1:20 p.m. that it was effective. At 9:00 p.m. the pain monitoring for the routine [MEDICATION NAME] administration revealed pain at 10/10 (very severe) again, with no as needed [MEDICATION NAME] given for the seven plus hours from the 1:20 p.m. last administration of [MEDICATION NAME]. No further nursing notes were written about the continued acute bout of pain in the left extremity until 12 hours later, on 12-17-15 at 9:00 a.m. Those notes follow; At 9:00 a.m. the pain monitoring for [MEDICATION NAME] administration revealed pain at 10/10 (very severe). No notes were documented to state if the medication was effective or not. At 3:25 p.m. [MEDICATION NAME] given for pain, 7/10 and documented as effective on the MAR at the same time as given. At 4:47 p.m. the nursing note documented that the pain medication given at 3:25 p.m. was effective. At 9:00 p.m. the pain monitoring for routine [MEDICATION NAME] administration revealed pain at 7/10 (severe), and no further as needed [MEDICATION NAME] was given after the 3:25 p.m. administration until it was given at 3:18 a.m. (12 hours later), on 12-18-15 in the middle of that night. No notes were documented to state if the 9:00 p.m. routine [MEDICATION NAME] was effective. No further nursing notes were written about the pain on 12-17-15 until later that same night after midnight, on 12-18-15 at 3:18 a.m. Those notes follow; 12-18-15: At 3:18 a.m. [MEDICATION NAME] given for pain of 10/10. At 5:31 a.m. nursing notes documented that the pain med was effective, however, one and a half hours later the Resident had to be medicated again due to pain. 6/10, At 7:00 a m. [MEDICATION NAME] was given for pain, 6/10. At 8:21 a.m. the Resident had fallen. At 9:00 a.m. the pain monitoring for routine [MEDICATION NAME] administration revealed pain at 7/10 (severe). At 2:19 p.m. a note said the [MEDICATION NAME] given at 7:00 a.m. was effective; however, at 9:00 a.m. (2 hours after the [MEDICATION NAME]) the Residents pain was at a 7/10 when the routine [MEDICATION NAME] was given. No notes indicated if the [MEDICATION NAME] given at 9:00 a.m. was effective or not. At 4:03 p.m. [MEDICATION NAME] was again given for pain of 8/10. At 7:54 p.m. A nursing note stated the [MEDICATION NAME] that was given at 4:03 p.m., was effective, however, at 8:05 p.m., the doctor, the family of the Resident, and 911 emergency medical services had been called. At 8:05 p.m. A nursing note stated the doctor called the facility with a new order to send the Resident to the hospital. The note stated received new order to send patient to ER (emergency room ) for further evaluation and treatment ., the Resident continues to complain of pain 10/10. No further documentation of any assessment had been done by nursing, or the physician to ascertain as to the cause of the Resident's escalating pain that had continued since 12-16-15 at 4:29 a.m., until 12-18-15 at 8:48 p.m. (approximately 40 hours). The Resident's chronic pain had been well controlled prior to this acute event, according to the clinical record. Facility staff documented an assumption based upon the Request of the SBAR nursing note dated 12-16-15, that A Pain consult, and psyche to follow up with resident regarding behaviors was the problem. Request also included that pain med frequency would be increased from every 6 hours to every 4 hours, however, this was not ordered by the physician or followed up on by facility staff. On 12-18-15 At 8:48 p.m. the nursing note revealed that the Resident is crying and yelling out in pain in room, Resident reports symptoms of sharp pain 10/10 to entire left lower extremity. Skin assessed warm to touch, dressing intact to open area of [MEDICAL CONDITION] with noted mild redness, 2+ [MEDICAL CONDITION] noted, pedal pulse unable to assess. No cyanosis. Resident given [MEDICATION NAME] at 4:03 p.m. and reported mild temporary relief. Resident was also given [MEDICATION NAME] 30 mg as scheduled at 8:00 p.m Resident reports that pain medication has been ineffective. Placed call to on call provider at this time. On 12-18-15 at 8:48 a SBAR note was also completed and follows; Situation Patient yelling out in pain to left lower extremity. [MEDICATION NAME] 10 mg (milligrams) given at 4:03 p.m. in which provided temporary relief. Scheduled [MEDICATION NAME] ER 30 mg given by mouth at 8:00 p.m. as scheduled. Patient continues to yell in pain stating that pain is described as stabbing, and does not radiate. Background Patient with history [MEDICAL CONDITION](stroke) with left side [MEDICAL CONDITIONS](high blood pressure), HLP, [MEDICAL CONDITION], anxiety, [MEDICAL CONDITION] of bilateral lower extremities. Assessment V/S (vital signs) 147/72, pulse 83, respiration 18, Redness noted to lower extremities secondary to [MEDICAL CONDITION]. Patient reports increased pain when extremities are touched. 2+ pedal [MEDICAL CONDITION] noted to left foot, unable to assess pedal pulses and pedal pulses felt to right foot. No cyanosis noted to toes bilaterally. Greater than 2 capillary refill to bilateral extremities. Request PVL (peripheral vascular) studies to rule out [MEDICAL CONDITION] (blood clot). On 12-18-15 at 8:00 p.m. the pain monitoring for the routine [MEDICATION NAME] administration revealed pain at 10/10 (very severe), and the nursing notes at 8:48 p.m. indicated the [MEDICATION NAME] was given at 8:00 p.m. instead of 9:00 p.m., and was not effective. On 12-18-15 at 9:17 p.m. A telephone call was again placed to the doctor's call service, and staff requested a call back. No documentation was found to indicate a call was received from the doctor. At 9:30 p.m. on 12-18-15, emergency medical services arrived to transport the Resident to the hospital. Review of Resident #9's admission hospital records revealed that, Resident #9 was admitted to the hospital on 12-18-15, with a [DIAGNOSES REDACTED]. Upon discharge from the hospital the Resident received discharge [DIAGNOSES REDACTED]. Resident #9 did not return to the facility until 1-2-16 (15 days later). The resident had a history of [REDACTED]. The MAR was reviewed for pain medication administration, the results of the documents follow; On 12-16-15, 12-17-15, and on 12-18-15, the [MEDICATION NAME] that was ordered every 12 hours routinely was given at 9:00 a.m., and 9:00 p.m., with pain monitoring evaluated at those times. The As needed (PRN) [MEDICATION NAME] was only given on 12-18-15 at 7:00 a.m., and was available for administration, however, was not given at any other time. The As needed (PRN) [MEDICATION NAME] was only given on 12-16-15 at 4:32 a.m., and 1:20 p.m., on 12-17-15 at 3:25 p.m., and on 12-18-15 at 3:18 a.m., and at 4:03 p.m. This was documented on the MAR, by the nurses who administered the medications. The [MEDICATION NAME] was available every 6 hours, however, was not given on that schedule. physician progress notes [REDACTED]. The note also stated that the Resident had never used illicit drugs, and was referred by staff for anxiety, agitation, and addiction behaviors. On 3-16-16 at 9:00 a.m., Resident was initially observed in the Resident's room. Resident #9 was alert, and oriented to person, place, time, and situation. The Resident continued to be interviewed at different times throughout the survey. On 3-16-16 at 3:00 p.m. the Resident was again interviewed and asked about her hospitalization , she stated that I hurt so bad for those 2 days before I went, I wanted to die. The Resident further stated she told the staff that, however, they never listened to her, and she had a blood clot they had to remove from her left leg. Resident #9's Pain Care plan was initiated 4-30-15, revised 5-17-15, and last revised on 10-14-15. Resident #9's Pain Care Plan was reviewed and revealed the following pain interventions; Administer medications as ordered. Monitor for effectiveness, and side effects. Anticipate need for pain relief and respond immediately to any complaint of pain. Assess for the appropriateness of non-pharmacological interventions for pain relief (distraction, redirection, positional changes, etc.). Continue to receive services from pain management physician. (None were found in the Clinical record). Assist with ADL's (Activities of Daily Living) as needed by Resident. Monitor for signs of infection. On 3-16-16 at 4:30 PM, at the end of day debrief with surveyors, the RN Regional Director stated (Resident #9) was a Drug seeker, and very manipulative, and could not be believed, or trusted to tell the truth. On 3-16-16 at 4:30 PM, at the end of day debrief, the Administrator, Director of Nursing and Registered Nurse Regional Director were asked for a copy of a pain assessment policy. The policy was received and stated, Residents complaining of pain . are assessed with [REDACTED]. Assessment to find the underlying cause of Resident #9's pain was not completed for 40 hours, staff listed psyche/behaviors, as an underlying cause rather that completing a physical assessment and involving the physician. No non-pharmacological interventions were ever documented as used, and when the DON was asked what non-pharmacologic interventions were used for pain, she could not describe them even after looking at the care plan. On 3-16-16, and 3-17-16, at the end of the day debrief, and exit, the DON and Administrator were notified of the above findings of harm for Resident #9. The facility administration stated they knew there was a problem with pain in the facility, and had identified it previously on 3-3-16 themselves. They presented a plan of correction for the residents with pain issues, however, the plan did not include the problems experienced by Resident #9, as all of those identified in the corrections were males. An Allegation of compliance completion date was given as 3-3-16, regarding the pain plan of correction, however, another incident regarding deficient pain treatment was identified for a second resident during the survey, and was a continuing issue throughout the days of survey. That Resident is identified also in this deficiency as Resident #2. No further information was provided by the facility. Lippincott Manual of Nursing Practice , Eight Edition, page 4 35 and 436, read, in part: [MEDICAL CONDITIONS] is [MEDICAL CONDITION] of deep rather than superficial veins. Two serious complications are [MEDICAL CONDITION] embolism and postphlebiti[DIAGNOSES REDACTED]. Clinical manifestations Clinical features vary with site and length of affected vein. 1. [MEDICAL CONDITION] may occur asymptomatically or may produce severe pain, fever, chills, malaise, and swelling and cyanosis of affected arm or leg. The number one symptom is unilateral limb [MEDICAL CONDITION] in which the onset is sudden. Pain Management Practices, Volume 6, Symptom Management Acute Pain, National Institute for Nursing Research, page 6, read, in part: The primary responsibility for the assessment and management of pain belongs to the nurse. (According to the National Institutes for Health, 1987), the nurse plays a central role in pain management and should coordinate the activities. Sound assessment is necessary for implementation of appropriate pain management interventions. Working Together to relieve your pain, patient information publications, The National Institutes for Health, 1997, read in part: Pain is an individual sensation. Pain exists whenever a person says it does and it feels however a person describes it. A consensus statement from the American Academy of Pain Medicine, 1997, read in part : Like many illnesses that at one time were not well understood, pain and its many manifestations may be poorly treated and seriously underestimated. Inappropriately treated pain seriously compromises patient's quality of life, causing emotional suffering and can contribute to mood disorders such as depression. 2. Resident #2 was admitted to the facility on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Resident #2's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an Assessment Reference Date (ARD) of 12-16-15. The Resident was coded with a Brief Interview for Mental Status (BIMS) score of 4 points scored in a possible 15 points, indicating severe cognitive impairment. The resident required extensive assistance of one staff member for Activities of Daily Living (ADL's). The Resident was also always incontinent of bowel and bladder, and had a stage 4 pressure ulcer. Resident #2 was observed and attempted to be interviewed on 3-16-16 at 1:00 p.m. The Resident was found to be confused, and spoke with off topic answers that did not relate to the questions. Resident #2 had two physician orders for pain medication. Those were as follows; 1. [MEDICATION NAME] ER (extended release) 15 mg (milligrams) routine. Give 1 tablet by mouth every 12 hours at 10:00 a.m., and 10:00 p.m. related to pressure ulcer pain management. 2. [MEDICATION NAME]/[MEDICATION NAME] give 5/325 mg by mouth every 6 hours as needed (PRN) break through pain. The Resident was also ordered to have pain monitoring, using a verbal/non-verbal scale of 0 to 10, every shift. That scale follows; 0 as no pain, 1-3 as mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 very severe pain. The Medication Administration Record (MAR), was reviewed and revealed that the [MEDICATION NAME] was given twice every day for the month of March 2016, as was ordered. The [MEDICATION NAME] PRN medication for break through pain was given on the following days and times; 3-2-16 at 3:32 p.m., no assessment of pain was documented, and no non- pharmacologic interventions were completed. [MEDICATION NAME] was given again at 9:00 p.m. which was 1 hour before the scheduled [MEDICATION NAME] was to be given, and the [MEDICATION NAME] could have been given in this window instead of the [MEDICATION NAME]. The [MEDICATION NAME] was given as well at 10:00 p.m. No assessment for oversedation was completed. 3-3-16 at 5:21 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-5-16 at 4:05 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-8-16 at 3:41 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-9-16 at 4:52 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-11-16 at 5:51 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-14-16 at 6:31 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-15-16 at 3:38 p.m., no assessment of location, or quality of pain was documented, and no non- pharmacologic interventions were completed. 3-16-16 at 9:09 p.m., the daughter stated the Resident was in pain, and Nursing notes state the Resident confirmed it, however, no assessment of pain was documented, and no non- pharmacologic interventions were completed. The [MEDICATION NAME] was given again at 9:00 p.m. which was 1 hour before the scheduled [MEDICATION NAME] was to be given, and the [MEDICATION NAME] could have been given in this window instead of the [MEDICATION NAME]. The [MEDICATION NAME] was given as well at 10:00 p.m. No assessment for oversedation was completed. Review of Resident #2's care plan last revised 12-29-15 revealed the following interventions for pain; Administer Medications as ordered. Monitor for effectiveness, and side effects. Initiated 8-18-14. Anticipate need for pain relief and respond immediately to any complaint of pain. Initiated 8-18-14 Assess for the appropriateness of non-pharmacologic interventions for pain relief (distraction, redirection, positional changes, etc). Initiated 8-18-14 Immediate meeting regarding cohersion of statements from confused resident and request to overmedicate resident from daughter. Initiated 9-8-14. Meeting with daughter to discuss progression of cognitive decline and need for justification of medication administration. Initiated 9-10-14 It is documented that the care plan was not followed, as Nursing notes reveal that Resident #2's daughter was allowed to dictate medication administration on 3-16-16 during the survey, and no nursing assessment of the Resident's pain by nursing was completed. Resident #2 is documented by facility staff to be severely cognitively impaired, and not a good historian, and she was found to be unchanged by surveyor's observations during the survey. On 3-16-16 at 4:30 PM, at the end of day debrief, the Administrator, Director of Nursing and Registered Nurse Regional Director were asked for a copy of a pain assessment policy. The policy was received and stated, Residents complaining of pain . are assessed with [REDACTED]. At the end of day meeting on 3-16-16 11/22/13 the Director of Nursing was asked if the facility provided any non-pharmacological interventions for Resident #2 prior to administering PRN pain medications. The response was that they would be documented in the nursing notes. No further information was provided by the facility regarding Resident #2's pain management. 3. Resident #13 was originally admitted to the facility 2/24/16 and had never been discharged from the facility. The current [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/2/16 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact. On 3/5/16 at 5:05 p.m., during observation of the medication pass and pour Licensed practical nurse (LPN) #21 put 4 medications in the medication cup and administered them to Resident #13. On 3/5/16 at 5:50 p.m. the reconciliation of the medication pass and pour observation with the current physician's orders was completed. The surveyor discovered there were 5 medications which should have been administered during the 5:00 p.m. medication pass. There was a current physician's order for [MEDICATION NAME] Hcl 150 mg tablet, Give 1 tablet by mouth two times per day. The medication was scheduled for administration at 9 a.m. and 5 p.m. [MEDICATION NAME] Hcl is a drug used to reduce stomach acid. Review of the physician's order summary revealed on 2/25/16 an order for [REDACTED]. The clinical record contained no documentation referencing acid reflux symptoms and there was no care plan for the diagnosis. An interview was conducted with Licensed Practical Nurse (LPN) #21 on 3/15/16 at approximately 6:00 p.m. LPN #21 stated the [MEDICATION NAME] was not available to be administered and she did not sign the medication administration record that it was given. LPN #21 further stated she would have to go out to the shed to obtain the medication because over the counter medications are stored in the shed. LPN #21 stated the physician and/or designee was not notified because the medication would be given after it was obtained from the shed. An interview was conducted with the Staff Development Coordinator (SDC) on 3/16/16 at approximately 11:15 a.m. The SDC stated the process for obtaining over the counter medications is daily the nurses assess for the need to restock the medication carts with over the counter medications and a list is completed for the central supply clerk. Weekly a complete audit is performed and if medications are not in the cabinets the central supply clerk goes to the shed to restock the cabinets. The Central supply clerk notifies the Administrator when items in the shed are running low and the Administrator orders approximately a 6 month supply based on the number of residents who has orders for the medication. The facility's policy titled 'Physician's Orders' with a release date of 8/31/15 stated at Procedure #6 Notify attending physicians when issues that arrive with medication administration and or treatments (e.g., patient refuses medication for 3 doses, withholding medications due to patients condition . issues with enteral/[MEDICATION NAME] feedings or medication administration, delayed progression of healing in wound treatment. The above findings were shared with the Administrator, Director of Nursing and Corporate Representative on 3/17/16 at approximately 6:15 p.m. No additional information was provided prior to the survey teams exit. Guidance for nursing standards for the administration of medication was provided by Fundamentals of Nursing, 7th Edition, Potter-Perry, page 705: Professional standards, such as the American Nurses Association's Nursing: Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: The right medication; The right dose;. The right client;. The right route;. The right time;. The right documentation.

Based on observation, staff interview, facility document review, and clinical record review the facility failed to procure, store, prepare and distribute food in a sanitary manner in the main kitchen. Dietary services were observed serving unpasteurized eggs being served with runny yolks and without taking temperatures of the eggs prior to serving. This resulted in Immediate Jeopardy (IJ) (Level 4, Isolated) on 3/13/14 at 9:20 a.m. The findings include: On 3/11/14 at 2:30 p.m during initial tour of the facilities main and only kitchen, unpasteurized eggs were observed in the refrigerator with an open date of 3/9/14. An interview was conducted at this time with the Dietary Manager (DM) about the eggs. The DM verbalized "Those are fresh eggs." The DM went on to state he had recently been hired at the facility (less than a week) and that on Tuesdays and Thursdays dietary cooks breakfast to order and the residents seem to like it. On 3/12/14 this surveyor requested and received food invoices dating from 2/12/14 through 3/12/14. At 2:00 p.m. a call was placed (by this surveyor) to the facility's food vendor to verify that the item code for shelled eggs was in fact unpasteurized (as the item description did not provide this information). The customer service representative verbalized that the item code for shelled eggs were identified as unpasteurized eggs. At 7:15 a.m. on 3/13/14, an observation of breakfast in the main dining room was initiated. Breakfast consisted of cheese omelets, cook to order eggs, bacon, grits, and toast. The omelets and cook to order eggs were being prepared on a griddle located on a table in the dining room. For residents who preferred eggs cooked to order, the cook took two brown eggs, broke them onto the griddle, and broke the yolks with a spatula. After cooking the eggs on one side, the cook flipped the eggs over and cooked them on the other side until the yolks were set (no longer liquid). At 7:35 a.m., the cook prepared two eggs to order for a resident, later identified as Resident #3 in the survey sample. When the plate containing eggs, bacon and toast was served to the resident, he looked at the eggs and said in a voice audible to the surveyor and the cook, "I don't want these. They are dry. I want them over easy." The cook looked at the resident and said, "We can't cook them that way." After approximately two minutes, the cook prepared two eggs over easy (liquid yolks) and placed them on a plate that was served to the resident. The resident took the plate of over easy eggs and placed the eggs on top of the eggs already on his plate. The resident broke the yolks, which were visibly runny, and mixed them in with the other eggs. The resident consumed the "dry" eggs and over easy eggs, along with bacon, toast and a small bowl of grits. The observation of breakfast was completed at approximately 8:10 a.m., when the griddle was unplugged and all cooking apparatus, utensils, and unserved food was returned to the Kitchen. During the observation of breakfast, which lasted approximately 55 minutes, no temperatures of the eggs, including omelets and eggs to order, were taken. At 8:30 a.m. on 3/13/14, the surveyor went to the kitchen and asked the Dietary Manager where the fresh eggs were stored. The Dietary Manager took the surveyor to a reach-in cooler that contained an open container with five trays of brown eggs, with 30 eggs to a tray, for a total of 150 eggs. None of the eggs were marked with a "P" to indicate they were pasteurized. At 8:40 a.m. on 3/13/14, a meeting was held with the survey team, the Dietary Manager and the Registered Dietitian (RD). When asked whether or not the brown eggs used for the eggs to order were pasteurized, the Dietary Manager stated the brown eggs were not pasteurized. The Dietary Manager was also asked if the temperature of the food, particularly the eggs should be taken, and if so, how often. "They should take temperatures every 15 minutes" the Dietary Manager said. The RD, who was present during the preparation and service of the omelets and eggs to order, was asked why the resident was served eggs over easy after being told by the cook that she was unable to cook them that way. "The resident is non-compliant and argumentative" the RD said. "I told (name of the cook) to go ahead and make them for him rather than have him get loud and upset." Resident #3, who was served the eggs over easy, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/6/13, and the most recent Quarterly MDS, with an ARD of 2/20/14, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Throughout the Breakfast observation, the surveyor carried on a conversation with Resident #3. The resident was found to be alert, oriented, well versed with current events, and fully aware of his physical status, including his [MEDICAL TREATMENT] status. When Resident #3 informed the cook he did not want the "dry" eggs he was served, but wanted eggs over easy instead, his voice was firm, but not loud, nor was he argumentative. On 3/13/14 at 9:20 a.m. the survey team held a meeting with the director of nursing (DON) and administrator regarding the finding and to inform the facility that immediate jeopardy was being implemented at this time. On 3/13/14 at 11:40 a.m. the DON and administrator presented a "Performance Improvement Action Plan" that read: Actual problem: Resident served unpasteurized eggs at breakfast meal on 3/14/14. Current measurement/Target: Unpasteurized eggs will not be purchased and or served to the residents. Actions/ Interventions: All unpasteurized eggs disposed of in the trash can. Resident's POA and RP notified of incident and that resident will be monitored for 72 hours for signs and symptoms of salmonella. All dietary staff inserviced on food safety policy (POL 511) not to use unpasteurized eggs for any reason at any time. RD and dietary manager in-serviced on food safety policy (POL 511) not to use or purchase unpasteurized eggs for any reason at any time. Food order eggs will be completed by the dietary manager and/or designee and reviewed by Dietician to validate compliance. Audits of food orders and eggs will be conducted on a weekly basis for 4 weeks, then randomly for 1 quarter. Results of audits to be reported in monthly PI meeting. Target dates 3/13/14 and ongoing. The survey team determined the plan for removal of IJ to be appropriate and lifted IJ at 11:50 a.m. After removal of IJ the survey team set the scope and severity level at 2 widespread. A facility policy was also obtained and read in part "...Food meets the following standards for quality and/or food safety...eggs pasteurized, USDA Grade A..." No other information was provided prior to exit conference on 3/13/14. *State Operation Manual Appendix P - Survey Protocol for Long Term Care revised 4/24/09 defines Level 4 as "immediate jeopardy, a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility." Level 2 is defined as, "noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services."

3. Resident #102 entered the facility 4/16/2012 after a hospitalization . At the time of admission he was was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the nursing notes following admission evidenced the resident was oriented to himself, tried to leave the building, and had some confusion. The resident's Minimum Data Set was not completed at the time of the survey. On 4/25/2012 at 1:30 p.m. Resident #102 complained to the surveyor that his back hurt and he had a hard time getting his pain medication. Review of the clinical record evidenced a 4/18/2012 telephone order from the physician for [MEDICATION NAME] 50 mg (milligrams) one tablet by mouth every 6 hours as needed for pain. The type of pain was not included in the order. Review of the 4/17 and 4/18/2012 nursing notes did not evidence that the resident complained of pain or that the physician was contacted regarding pain for this resident.. Review of the interim care plan developed the day after admission (4/17/2012) and the physician's History and Physical of the same date evidenced the resident had chronic pain or [MEDICAL CONDITION] from his diabetes. The location of the [MEDICAL CONDITION] was not specified. The approaches in the care plan were: monitor signs and symptom of pain to nurse, report changes in pain location/type/frequency/intensity to the physician, pain assessment to be conducted on admission, and notify resident's physician if the resident does not state relief or reduction in pain in one hour. Review of the MAR on 4/25/12 evidenced the resident received a pain pill ([MEDICATION NAME]) at 12:30 PM. and one tablet on 4/24/12 at 10:00 am. The intensity, type/location of the pain was not documented on the back of the MAR or in the nursing notes. On the morning of 4/26/12 the MAR was again reviewed and evidenced the resident had received one additional tablet that morning. The pharmacy blister pack delivered 4/18/2012 containing 60 Ultam tablets was also observed. Seven tablets were missing from the blister pack but only three had been recorded as administered on the MAR. Review of the Narcotics sheet evidenced that the count was correct on 4/26/2012. On the morning of 4/27/2012 the MAR was again reviewed and the blister pack observed. At 9:30 a.m. the medication nurse (LPN #1) on Unit One stated that she had given the resident his [MEDICATION NAME] yesterday and today and had indicated so on both the Narcotics sheet and on the MAR., however she agreed that she had not documented the location/intensity or effectiveness of the prn pain medication and that is part of the protocol for pain management/medications. A count of the [MEDICATION NAME] removed from the blister pack was now nine but only four had been recorded on the MAR. At 10:20 a.m. the Regional nurse consultant was interviewed and stated that the nurses should be documenting type/location/intensity (most typically using a 1-10 scale for pain) of the pain and the effectiveness of the pain medication to effectively manage Resident #102 's pain. Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide care and services for 3 of 11 residents in the survey sample (Resident #107, 110, and 102) to attain or maintain their highest practicable physical well being. 1a. The facility staff failed to thoroughly assess and monitor Resident #107's acute incidental left arm pain for 2 days, subsequently identified as a non-displaced left humerus fracture. 1b. The facility staff failed to implement, monitor and modify pain management for Resident #107's acute incidental left arm pain. 2. The facility staff failed to develop, monitor and modify pain management for Resident #110's bilateral lower extremity contracture pain. 3. The facility failed to assess the effectiveness of the as needed (prn) [MEDICATION NAME] (pain pill) for Resident #102 The findings include: 1a. The facility staff failed to thoroughly assess and monitor Resident #107's acute incidental left arm pain for 2 days, subsequently identified as a non-displaced left humerus fracture. Resident #107 a [AGE] year old was originally admitted to the facility on 8/8/11 with a readmitted [DATE]. [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 3/15/12 evidenced the resident scored an 11 on the BIMS scale (Brief Interview for Mental Status), indicating the resident has moderately impaired cognition. The resident has difficulty communicating some words or finishing thoughts, and misses some part /intent of message but comprehends most conversation. Resident #107 was dependent on one (1) staff for bed mobility, dressing, toileting, personal hygiene, and bathing, and dependent on two (2) staff for transfers, requiring a mechanical lift. The resident has functional limitation with range of motion of the left upper extremity and both lower extremities. Review of the clinical record evidenced a Sick Visit note from the nurse practitioner (NP) dated 4/4/12. The NP documented the following,"Pt's (patients) CNA (certified nurse aide#1) noted 2 days during bathing that pt screamed during bath-movement (sign for with) (L) arm. No known trauma per nurse". The NP examined the resident and documented,"Able to express pain as well as appropriate yes/no answers. Guarding made exam difficult. But pain appears to be (L) shoulder and abduction precipitates severe pain (sign for with) scream, warm to touch, mildly [MEDICAL CONDITION] (swollen)-difficult to assess (due to )contracture's. Under assessment/plan the NP documented," (L) shoulder pain-Give narcotic now ( name of licensed practical nurse #2), (L) upper ext. (extremity) contracture. Dr. (physiatrist) to see. Give narcotic now. Consider X-ray if pain continues. The resident's pain medication ordered on [DATE] was to administer [MEDICATION NAME] 5/500 mg (milligrams) 1 tab by mouth every 4 hours as needed for mild to moderate pain and [MEDICATION NAME] 5/325 mg 2 tabs by mouth every 4 hours as needed for severe pain. On 4/25/12 at 3:15 P.M., CNA#1 was interviewed. She stated she had taken care of Resident #107 on Friday (3/30/12) and he did not exhibit any pain during night time (HS) care. On Monday (4/2/12) as she was taking the resident's shirt off he hollered out in pain. She indicated this was not normal for the resident .She stated she went and told RN#1, "Something was wrong with Mr. (name of resident )". She stated RN#1 came in and "checked him out". When asked to demonstrate how RN#1 "checked" the resident out, the CNA touched her left forearm from the elbow down to the left hand. She was asked if the nurse raised the resident's left arm in the same manner as she did when the resident hollered out in pain, she could not recall. She stated the resident was asked,"How did this happen? (injury)", the resident stated he did not know. The resident was asked if he "bumped" it and again stated he did not know. CNA#1 stated on Tuesday (4/3/12) during HS care the resident "Acted like he was in pain...hollering...I asked him if he was alright and he said they gave me something". The CNA stated, "I assumed they had taken care of whatever the problem was (of the left arm)". She stated,"He acted like it hurt". She stated, "I was trying to talk to the nurse about it (RN#1), telling him "He (Resident #107) was still in pain". On Wednesday (4/4/12) CNA#1 stated when she did her first rounds while changing the resident she noted he was in pain. She stated she knew "something wasn't right". When another nurse (orientee)came in to obtain the resident's blood sugar Resident #107 was "making noise...something was wrong with his arm". The CNA stated she went to find the nurse (LPN#2) assigned to care for the resident to inform her. The nurse was at the nursing station on the phone. The NP was at the desk at the same time and asked what the concern was. The CNA stated she was reluctant to tell the NP of Resident #107's pain before speaking with the charge nurse first. The NP assured her it was okay to tell her. The CNA told the NP of the resident's pain during HS care for the last 2 nights and today. The NP assessed the resident as aforementioned in the Sick Visit notes dated 4/4/12. CNA#1 stated the NP told her," She was glad I said something...I wanted to make sure my residents are taken care of". On 4/26/12 at 3:17 P.M., RN#1 was interviewed. He stated on 4/2/12 CNA #1 approached him stating, "Hey (name of nurse), I need you to come here (Resident #107) is in pain...she was given care...I asked him if he was in pain and he said, "No". RN#1 stated,"There was no swelling, no trauma, no change in movement...I moved it (left arm) as much as I could...I moved it a little bit (left arm)...it was as it normally was". The nurse was asked if he raised the resident's left arm up as it would have been during removal of his shirt during HS care and stated he did not. The nurse demonstrated how he assessed the resident's left arm, by palpating from the left elbow down to the hand and bringing the forearm forward approximately 2-3 inches from the resident's chest area. He did not touch the resident's left upper arm, left shoulder or assess for ROM of the left upper arm for changes or pain. The nurse stated he did not document this assessment as there was no change in condition identified. When asked if CNA#1 informed him of the resident's left arm pain on 4/3/12 he stated, "I don't think so...I can't quite recollect". The clinical record failed to evidence RN#1 assessed the resident for left arm pain on 4/3/12. On 4/25/12 at approximately 3:30 P.M., LPN#2 assigned to care for Resident #107 on 4/4/12 was interviewed. She stated, "I wasn't directly involved....I wasn't his nurse...I remember the CNA telling the NP...it was late in the evening". On 4/27/12 at 9:50 A.M., LPN#2 was interviewed a second time. This time she stated on 4/4/12 she was orientating a new employee. LPN#2 was assigned to care for Resident #107. The new employee left early, and she had to take over passing the 9 PM medications. She recalled CNA#1 informing the NP of Resident #107's pain. She stated the NP told her she would assess the resident. LPN#2 stated, "By the time I left I don't think she had gotten to assess the resident". When asked if she assessed the resident herself when she was made aware of Resident #107's pain, she stated, "No". When asked if she had administered the resident any medication for pain she stated, "If I had given him anything for pain I would have written it on the MAR (medication administration record.) The MAR did not evidence pain medication was administered. On Thursday 4/5/12 at 4:15 PM, the 3PM-11PM RN (registered nurse) nursing supervisor documented in the Resident Progress Notes the following, "Resident complained of (L) shoulder pain during transfer from wheelchair to bed, restricted ROM (range of motion) to left arm and shoulder, complain of pain on ROM to left shoulder and arm. Contracture noted to (L) arm. (Name of physician) notified. Resident medicated with (2) [MEDICATION NAME] 5-325 and to continue to closely monitor." A physician order [REDACTED]. On 4/26/12 at 3:45 P.M., the 3PM-11PM RN supervisor was interviewed. He stated he was called to the room by CNA#1. He stated, "I came upstairs and CNA#1 and CNA#9 stated they were moving the patient...CNA#1 told me he was complaining of pain to the left arm...I assessed the patient...he (Resident #107) was saying he was in pain...I could not see any injury...at that time (name of attending physician) was here...because of his cognition I asked the Dr. to check his pain". The X-ray results were received and reported to the physician on 4/06/12 at midnight. The X-ray evidenced an non-displaced [MEDICAL CONDITION] neck of the left humerus. The resident was sent to the emergency room for evaluation. The resident returned to the facility with new orders for a left arm immobilizer, ice packs to the left arm as needed three times a day as needed, and to elevate the left arm on pillows to reduce swelling. The nursing staff failed to conduct a thorough assessment and monitor Resident #107's status change resulting in acute left shoulder pain for 3 days, 4/2, 4/3 and 4/4/12. 1b. The facility staff failed to implement, monitor and modify pain management for Resident #107 following a significant status change resulting in acute incidental left arm pain. The facility identified and care planned on 3/2/12 the resident has discomfort when moving the left arm due to contracture. One of the interventions listed was to pre-medicate for comfort as indicated. The resident's pain medication ordered on [DATE] was to administer [MEDICATION NAME] 5/500 mg (milligrams) 1 tab by mouth every 4 hours as needed for mild to moderate pain and [MEDICATION NAME] 5/325 mg 2 tabs by mouth every 4 hours as needed for severe pain. CNA#1 reported to the nursing staff Resident #107 was experiencing a status change resulting in acute left arm pain on 4/2, 4/3 and 4/4/12. The April 2012 MAR's failed to evidence Resident #107 was medicated for pain on 4/2, 4/3 or 4/4/12. Review of the MAR evidenced a pain monitor section to be documented every shift. The nursing staff documented the resident did not have any pain on 4/2, 4/3 and 4/4/12. Even after it was identified by the NP that the resident had "severe" pain on 4/4/12, the facility staff failed to assess, monitor and treat Resident #107's pain. The April 2012 MAR's failed to evidence the facility staff modified the resident's pain management for the acute left arm pain until it was identified as a fracture on 4/06/12 (4 days after the presentation of acute pain.) The MAR failed to evidence LPN#2 administered Resident #107 pain medication as directed/documented in the NP Sick Visit note dated 4/4/12. The NP described the resident's pain as "severe". On 4/06/12 the X-ray evidenced the resident had a left humerus fracture at which time the physician changed the resident's pain medication regimen. A new order was received to administer [MEDICATION NAME] 5/325 mg 2 tabs every 6 hours x 8 doses then PRN (as needed) as ordered (above). On 4/11/12 the resident was assessed by the physiatrist/ pain management physician who changed the resident's pain medication to [MEDICATION NAME] 10 mg 1 tab by mouth every 12 hours for intractable left shoulder pain. On 4/27/12 At 11:45 P.M., the attending physician and the DDCO (District Director of Clinical Operations) requested a meeting with the survey team. A review of the findings for Resident #107 was shared. The attending physician stated,"Part of the problem is education, residents with chronic [MEDICAL CONDITION] have a higher risk for fracture, my mistake for not letting them know that". The attending physicians response to the nursing assessment conducted by RN#1 on 4/2/12 was"I would have wanted the assessment to have been differently...the assessment wasn't complete". She stated she would have obtained an x-ray on Wednesday (4/4/12), instead of waiting as indicated by the NP on 4/4/12. The physician reviewed the X-ray results and based on the findings could not determine if the fracture was acute (injury occurred 24-48 hours) or subacute (72 hours or later). She stated the fracture could very likely have been present on Monday 4/2/12. The nursing staff's failure to medicate and monitor the resident for acute pain on 4/2, 4/3 and 4/4/12 was reviewed, the physician's response was,"I have nothing". The FRI (Facility Reportable Incident) and subsequent facility investigation of the resident's injury of unknown origin (fracture) was reviewed, the cause was undetermined. During the survey days the resident was observed in bed with the left arm immobilizer in use. The resident denied having any pain and stated he bumped his arm of the side rail. 2. The facility staff failed to effectively develop, monitor and modify pain management for Resident #110's bilateral lower extremity contracture pain. Resident #110 was a [AGE] year old originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the current MDS (Minimum Data Set) an annual with an assessment reference date of 2/17/12 assessed the resident as having severely impaired cognition. Resident #110 was dependent on staff for all activities of daily living (ADL's) to include, bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The resident required mechanical lift for transfers. Under section J 0100 pain management it was identified the resident was receiving scheduled pain medication., the pain assessment interview was not conducted. There were no indicators (i.e., non-verbal, vocal, facial expressions or protective body movements or posture) of pain or possible pain in the past 5 days. The quarterly nursing assessment dated [DATE] was reviewed. In the pain section the staff indicated the resident was unable to verbalize pain. The staff was directed to use form TL 6121-02 PAINAD scale, and score the pain level. The pain score was left blank. A pain score could not be found in the clinical record. Review of the comprehensive plan of care dated 2/21/12 identified the resident had contracture's of the left elbow, wrist, both lower extremities and left hand. The goal set did not address effective pain management. One of the approaches listed was to pre-medicate for comfort as indicated (see MAR). Review of the physician order [REDACTED]. pain management. The original order date was 11/25/09. The resident was also ordered to receive [MEDICATION NAME] 5/500 mg 1 tab every 4 hours as needed (PRN) for pain. Review of the physical therapy evaluation dated 3/08/12 evidenced the following documentation under pain,"pt (patient) grimaces & moans (sign for with) all attempts to range LE's (lower extremities)". The resident was evaluated for contracture management and treatment. The reason for the therapy referral was, "to address worsening L's (lower extremity) contracture's interfering with perineal care and overall comfort". Review of the therapy daily modality note with narrative notes from 3/26/12-4/27/12 evidenced documentation of the resident's response as follows: 3/26/12- modality-ultrasound-grimacing with min. (minimal) pain-pt given pain meds 6 am per nsg (nursing) 4/3/12-modality-diathermy-pain with stretching-nsg provided 6 am pain meds 4/6/12-modality- ultrasound- with stretching pt (sign for with) min. pain 4/9/12-modality-diathermy-pain with stretching, 6 am pain meds given 4/10/12-modality-ultrasound-pain with stretching 4/11/12-modality-diathermy-grimacing with pain stretching 4/12/12-modality-diathermy-minimal pain with stretching 4/17/12-modality-diathermy-grimacing with pain-pain meds given per nsg 4/18/12-modality-diathermy-grimacing with pain-stretching 4/19/12-modality-diathermy-grimacing with pain minimal-stretching 4/20/12-modality-pain with stretching 4/22/12 -modality-ultrasound-grimacing secondary to pain-pt grimaces and verbalizes pain 4/23/12-modality-diathermy-grimacing secondary to pain 4/24/12-modality-diathermy-grimacing secondary to pain On 4/25/12 at 9:05 A.M., the physical therapy assistant (PTA) was in the resident's room and had just completed the resident's last diathermy treatment. The PTA was asked about the resident's pain during the treatment. She stated, "Pain, absolutely, when I do minimal stretching she'll yell out or push against it". She stated the resident was non-verbal. The PTA stated, "I asked the nurse about pain medication after the first session". She stated the nurse had informed her the resident was receiving scheduled pain medication at 6 AM every morning. The nurse stated the resident, "Could not have pain medication again until 10 AM". The PTA stated she would "Usually treat the resident around 8:30 AM". She stated when using diathermy the treatment would last for approximately 20 minutes for each leg, and then stretching afterwards. On 4/26/12 at 9:40 A.M., resident #110 was observed receiving a complete bed bath by CNA#4. The resident was heard yelling out in pain twice when the CNA was attempting to put pants on the resident. The resident was heard moaning lowly with repositioning and fidgeting her right hand on the mattress surface. The CNA was asked if the resident was in pain, she stated,"She is always in pain". She indicated the resident has increase in pain during movement/manipulation of the lower extremities. On 4/26/12 at 3:45 P.M., the evening shift CNA#3 caring for Resident #110 was interviewed. She stated it was difficult to provide incontinent care for the resident due to her contractures stating, "It is hard to open her legs". She stated the resident did not, "seem to be in pain....can't say I remember her yelling...she does have some discomfort when I take her shirt off." She described the pain as minimal. Review of the April 2012 MAR's evidenced the resident was administered [MEDICATION NAME] 5/500 mg every morning at 6 AM, once at 6:40 AM on 4/11, at 6:30 AM and 5:30 PM on 4/21, and 6:30 AM on 4/26/12. There was no other evidence of the resident receiving PRN pain medications for April. The facility nursing staff failed to modify the administration time of the Q AM pain medication closer to the time of the contracture management treatment and morning ADL's to ensure maximal effectiveness. Review of the every (Q) shift pain monitoring on the April MAR's indicated the resident was not in pain at anytime. The resident's daily pain with the PTA during treatment and during care per CNA#4 was not captured on this pain monitoring tool. On 4/26/12 at approximately 4:30 PM., the above findings were shared with the administrator and the DDCO. On 4/27/12 At 11:45 P.M., the attending physician and the DDCO (District Director of Clinical Operations) requested a meeting with the survey team. The attending physician stated she had spoken with the physiatrist last evening about Resident #110's pain medication. He informed her the pain medication ([MEDICATION NAME]) peaks at 2 hours and last's for 4 hours, stating the resident should have been "covered". The resident's pain medication was changed on 4/26/12 to administer [MEDICATION NAME] 5/500 mg twice a day scheduled at 8 AM & 8 PM.

Based on observation, staff interview, and clinical record review, facility staff failed to administer pain medication in a manner to prevent pain and promote comfort during a dressing change on a Stage IV Pressure Ulcer containing gross contamination with liquid stool, for Resident #3,one of 19 residents in the survey sample. The findings include: Resident #3 was an [AGE] year old admitted to the facility on [DATE] S/P (status [REDACTED]. [DIAGNOSES REDACTED]. Resident # 3 had a known history of fistula development. The MDS (Minimum Data Set), done as a significant change with assessment reference date of 12/3/11, coded Resident# 3 as a 13 out of 15 on the BIMS (Brief Interview of Mental Status) both understanding others and being understood. Resident # 3 was coded as totally dependent in bed mobility and transferring, toileting and personal hygiene. The resident was coded as always incontinent in bowel and bladder control. Pain was coded as frequently present. Resident was coded as at risk for developing skin breakdown. On the significant change assessment, Resident # 3 was coded as having a Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling - NPUAP http://www.npuap.org/pr2.htm) not coded on the previous MDS. On 2/23/12 at 10:00 am through 11:00 am this surveyor observed a dressing change on a Stage IV Pressure Ulcer on the sacral area. Prior to entering the resident's room at 10:00 am, the Medication Nurse told the Wound Nurse she had medicated the resident for pain "around 45 minutes ago". Upon entering the room, the Wound Nurse asked the resident how her pain was. The resident responded that it was "a little better". After setting up a clean field on the over-bed table and arranging the products, the Wound Nurse and CNA(Certified Nursing Assistant) #1 positioned the resident and removed the resident's brief to find a small amount of semi-formed stool in the rectal area and the dressing on the sacral area soaked with liquid brown stool. Upon removing the dressing, the wound was also observed to be filled with liquid brown stool, totally obscuring the wound bed. Touching the sides of the wound resulted in stool gushing from the undermined area. The Wound Nurse stated she had never seen the wound "like this before". The Wound Nurse began to clean the wound using a small bottle of wound cleaner and wiping the center of the wound bed with several 4x4's. She discarded the 4x4s and picked up several new 4x4, wiping the center and outside edges of the wound bed. During the cleaning of the wound bed, Resident # 3 was crying out "Oh, Ohoo, Oh my God" and "Oh Honey". The Wound Nurse and the CNA stated we will be finished in a little while. The Wound Nurse continued to try and clean the wound for for an additional 5 minutes. The Wound Nurse used a cotton tipped applicator to clean the undermined area and then packed the undermined area. When asked after the procedure about the resident's pain, the Wound Nurse stated she should have "stopped and called the Physician for additional pain medication". When asked if the resident might have had more pain than usual based on the need to clean the wound, the Wound Nurse stated "Yes". Review of Resident # 3's February MAR (Medication Administration Record) for the day shift, when dressing changes were done, revealed Resident # 3 rated her pain as either 'severe discomfort' or 'excruciating pain' in 17 of 23 opportunities for the month. Review of Resident #3's Physician order [REDACTED]. A second order read: [MEDICATION NAME] ES 1 (by mouth) every 4 hours prn (when ever necessary) for b/t (break through )pain ". According to review of the MAR, Resident #3 received both medications at 9:00 am on 2/23/12, prior to the beginning of the dressing change. Review of the Weekly Pressure Ulcer Report for 2/21/12, completed by the Wound Nurse, described the sacral pressure ulcer as 4.9 x 3.6 x 2.7. Review of the Clinical Record included a Wound Care Specialist Evaluation report, dated 2/21/12 revealed the Physician Assessment : " Stool in wound upon examination. Opening 6 oclock of .2 [MEDICAL CONDITION] cm likely fistula to colon as determined by contamination of cotton tip applicator upon probing. Another opening of .2 x .2 c, at 5 o'clock probed to coccyx of 2.7..." Review of Resident # 3's Physician order [REDACTED]. According to the U.S. Department of Health and Human Services Clinical Practice Guideline Number 3 titled Pressure Ulcers in Adults: Prediction and Prevention page 31 reads the following: "Because Pain may be evoked or may be especially acute during dressing changes and debriedment, the care giver should try to prevent such discomfort or take steps to relieve it". On 2/24/12 at 11:00 am the Director of Nursing, Regional Clinical Director and Unit Manager of 2nd Floor were presented with the above information. When asked, the Unit Manager agreed the Wound Nurse should have stopped the procedure and called the Physician for Pain Relief and a different order for Wound Cleaning.

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to provide care and services for 3 of 11 residents in the survey sample (Resident #107, 110, and 102) to attain or maintain their highest practicable physical well being. 1a. The facility staff failed to thoroughly assess and monitor Resident #107's acute incidental left arm pain for 2 days, subsequently identified as a non-displaced left humerus fracture. 1b. The facility staff failed to implement, monitor and modify pain management for Resident #107's acute incidental left arm pain. 2. The facility staff failed to develop, monitor and modify pain management for Resident #110's bilateral lower extremity contracture pain. 3. The facility failed to assess the effectiveness of the as needed (prn) [MEDICATION NAME] (pain pill) for Resident #102 The findings include: 1a. The facility staff failed to thoroughly assess and monitor Resident #107's acute incidental left arm pain for 2 days, subsequently identified as a non-displaced left humerus fracture. Resident #107 a [AGE] year old was originally admitted to the facility on 8/8/11 with a readmitted [DATE]. [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a quarterly with an assessment reference date of 3/15/12 evidenced the resident scored an 11 on the BIMS scale (Brief Interview for Mental Status), indicating the resident has moderately impaired cognition. The resident has difficulty communicating some words or finishing thoughts, and misses some part /intent of message but comprehends most conversation. Resident #107 was dependent on one (1) staff for bed mobility, dressing, toileting, personal hygiene, and bathing, and dependent on two (2) staff for transfers, requiring a mechanical lift. The resident has functional limitation with range of motion of the left upper extremity and both lower extremities. Review of the clinical record evidenced a Sick Visit note from the nurse practitioner (NP) dated 4/4/12. The NP documented the following,"Pt's (patients) CNA (certified nurse aide#1) noted 2 days during bathing that pt screamed during bath-movement (sign for with) (L) arm. No known trauma per nurse". The NP examined the resident and documented,"Able to express pain as well as appropriate yes/no answers. Guarding made exam difficult. But pain appears to be (L) shoulder and abduction precipitates severe pain (sign for with) scream, warm to touch, mildly [MEDICAL CONDITION] (swollen)-difficult to assess (due to )contracture's. Under assessment/plan the NP documented," (L) shoulder pain-Give narcotic now ( name of licensed practical nurse #2), (L) upper ext. (extremity) contracture. Dr. (physiatrist) to see. Give narcotic now. Consider X-ray if pain continues. The resident's pain medication ordered on [DATE] was to administer [MEDICATION NAME] 5/500 mg (milligrams) 1 tab by mouth every 4 hours as needed for mild to moderate pain and [MEDICATION NAME] 5/325 mg 2 tabs by mouth every 4 hours as needed for severe pain. On 4/25/12 at 3:15 P.M., CNA#1 was interviewed. She stated she had taken care of Resident #107 on Friday (3/30/12) and he did not exhibit any pain during night time (HS) care. On Monday (4/2/12) as she was taking the resident's shirt off he hollered out in pain. She indicated this was not normal for the resident .She stated she went and told RN#1, "Something was wrong with Mr. (name of resident )". She stated RN#1 came in and "checked him out". When asked to demonstrate how RN#1 "checked" the resident out, the CNA touched her left forearm from the elbow down to the left hand. She was asked if the nurse raised the resident's left arm in the same manner as she did when the resident hollered out in pain, she could not recall. She stated the resident was asked,"How did this happen? (injury)", the resident stated he did not know. The resident was asked if he "bumped" it and again stated he did not know. CNA#1 stated on Tuesday (4/3/12) during HS care the resident "Acted like he was in pain...hollering...I asked him if he was alright and he said they gave me something". The CNA stated, "I assumed they had taken care of whatever the problem was (of the left arm)". She stated,"He acted like it hurt". She stated, "I was trying to talk to the nurse about it (RN#1), telling him "He (Resident #107) was still in pain". On Wednesday (4/4/12) CNA#1 stated when she did her first rounds while changing the resident she noted he was in pain. She stated she knew "something wasn't right". When another nurse (orientee)came in to obtain the resident's blood sugar Resident #107 was "making noise...something was wrong with his arm". The CNA stated she went to find the nurse (LPN#2) assigned to care for the resident to inform her. The nurse was at the nursing station on the phone. The NP was at the desk at the same time and asked what the concern was. The CNA stated she was reluctant to tell the NP of Resident #107's pain before speaking with the charge nurse first. The NP assured her it was okay to tell her. The CNA told the NP of the resident's pain during HS care for the last 2 nights and today. The NP assessed the resident as aforementioned in the Sick Visit notes dated 4/4/12. CNA#1 stated the NP told her," She was glad I said something...I wanted to make sure my residents are taken care of". On 4/26/12 at 3:17 P.M., RN#1 was interviewed. He stated on 4/2/12 CNA #1 approached him stating, "Hey (name of nurse), I need you to come here (Resident #107) is in pain...she was given care...I asked him if he was in pain and he said, "No". RN#1 stated,"There was no swelling, no trauma, no change in movement...I moved it (left arm) as much as I could...I moved it a little bit (left arm)...it was as it normally was". The nurse was asked if he raised the resident's left arm up as it would have been during removal of his shirt during HS care and stated he did not. The nurse demonstrated how he assessed the resident's left arm, by palpating from the left elbow down to the hand and bringing the forearm forward approximately 2-3 inches from the resident's chest area. He did not touch the resident's left upper arm, left shoulder or assess for ROM of the left upper arm for changes or pain. The nurse stated he did not document this assessment as there was no change in condition identified. When asked if CNA#1 informed him of the resident's left arm pain on 4/3/12 he stated, "I don't think so...I can't quite recollect". The clinical record failed to evidence RN#1 assessed the resident for left arm pain on 4/3/12. On 4/25/12 at approximately 3:30 P.M., LPN#2 assigned to care for Resident #107 on 4/4/12 was interviewed. She stated, "I wasn't directly involved....I wasn't his nurse...I remember the CNA telling the NP...it was late in the evening". On 4/27/12 at 9:50 A.M., LPN#2 was interviewed a second time. This time she stated on 4/4/12 she was orientating a new employee. LPN#2 was assigned to care for Resident #107. The new employee left early, and she had to take over passing the 9 PM medications. She recalled CNA#1 informing the NP of Resident #107's pain. She stated the NP told her she would assess the resident. LPN#2 stated, "By the time I left I don't think she had gotten to assess the resident". When asked if she assessed the resident herself when she was made aware of Resident #107's pain, she stated, "No". When asked if she had administered the resident any medication for pain she stated, "If I had given him anything for pain I would have written it on the MAR (medication administration record.) The MAR did not evidence pain medication was administered. On Thursday 4/5/12 at 4:15 PM, the 3PM-11PM RN (registered nurse) nursing supervisor documented in the Resident Progress Notes the following, "Resident complained of (L) shoulder pain during transfer from wheelchair to bed, restricted ROM (range of motion) to left arm and shoulder, complain of pain on ROM to left shoulder and arm. Contracture noted to (L) arm. (Name of physician) notified. Resident medicated with (2) [MEDICATION NAME] 5-325 and to continue to closely monitor." A physician order [REDACTED]. On 4/26/12 at 3:45 P.M., the 3PM-11PM RN supervisor was interviewed. He stated he was called to the room by CNA#1. He stated, "I came upstairs and CNA#1 and CNA#9 stated they were moving the patient...CNA#1 told me he was complaining of pain to the left arm...I assessed the patient...he (Resident #107) was saying he was in pain...I could not see any injury...at that time (name of attending physician) was here...because of his cognition I asked the Dr. to check his pain". The X-ray results were received and reported to the physician on 4/06/12 at midnight. The X-ray evidenced an non-displaced [MEDICAL CONDITION] neck of the left humerus. The resident was sent to the emergency room for evaluation. The resident returned to the facility with new orders for a left arm immobilizer, ice packs to the left arm as needed three times a day as needed, and to elevate the left arm on pillows to reduce swelling. The nursing staff failed to conduct a thorough assessment and monitor Resident #107's status change resulting in acute left shoulder pain for 3 days, 4/2, 4/3 and 4/4/12. 1b. The facility staff failed to implement, monitor and modify pain management for Resident #107 following a significant status change resulting in acute incidental left arm pain. The facility identified and care planned on 3/2/12 the resident has discomfort when moving the left arm due to contracture. One of the interventions listed was to pre-medicate for comfort as indicated. The resident's pain medication ordered on [DATE] was to administer [MEDICATION NAME] 5/500 mg (milligrams) 1 tab by mouth every 4 hours as needed for mild to moderate pain and [MEDICATION NAME] 5/325 mg 2 tabs by mouth every 4 hours as needed for severe pain. CNA#1 reported to the nursing staff Resident #107 was experiencing a status change resulting in acute left arm pain on 4/2, 4/3 and 4/4/12. The April 2012 MAR's failed to evidence Resident #107 was medicated for pain on 4/2, 4/3 or 4/4/12. Review of the MAR evidenced a pain monitor section to be documented every shift. The nursing staff documented the resident did not have any pain on 4/2, 4/3 and 4/4/12. Even after it was identified by the NP that the resident had "severe" pain on 4/4/12, the facility staff failed to assess, monitor and treat Resident #107's pain. The April 2012 MAR's failed to evidence the facility staff modified the resident's pain management for the acute left arm pain until it was identified as a fracture on 4/06/12 (4 days after the presentation of acute pain.) The MAR failed to evidence LPN#2 administered Resident #107 pain medication as directed/documented in the NP Sick Visit note dated 4/4/12. The NP described the resident's pain as "severe". On 4/06/12 the X-ray evidenced the resident had a left humerus fracture at which time the physician changed the resident's pain medication regimen. A new order was received to administer [MEDICATION NAME] 5/325 mg 2 tabs every 6 hours x 8 doses then PRN (as needed) as ordered (above). On 4/11/12 the resident was assessed by the physiatrist/ pain management physician who changed the resident's pain medication to [MEDICATION NAME] 10 mg 1 tab by mouth every 12 hours for intractable left shoulder pain. On 4/27/12 At 11:45 P.M., the attending physician and the DDCO (District Director of Clinical Operations) requested a meeting with the survey team. A review of the findings for Resident #107 was shared. The attending physician stated,"Part of the problem is education, residents with chronic [MEDICAL CONDITION] have a higher risk for fracture, my mistake for not letting them know that". The attending physicians response to the nursing assessment conducted by RN#1 on 4/2/12 was"I would have wanted the assessment to have been differently...the assessment wasn't complete". She stated she would have obtained an x-ray on Wednesday (4/4/12), instead of waiting as indicated by the NP on 4/4/12. The physician reviewed the X-ray results and based on the findings could not determine if the fracture was acute (injury occurred 24-48 hours) or subacute (72 hours or later). She stated the fracture could very likely have been present on Monday 4/2/12. The nursing staff's failure to medicate and monitor the resident for acute pain on 4/2, 4/3 and 4/4/12 was reviewed, the physician's response was,"I have nothing". The FRI (Facility Reportable Incident) and subsequent facility investigation of the resident's injury of unknown origin (fracture) was reviewed, the cause was undetermined. During the survey days the resident was observed in bed with the left arm immobilizer in use. The resident denied having any pain and stated he bumped his arm of the side rail. 2. The facility staff failed to effectively develop, monitor and modify pain management for Resident #110's bilateral lower extremity contracture pain. Resident #110 was a [AGE] year old originally admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the current MDS (Minimum Data Set) an annual with an assessment reference date of 2/17/12 assessed the resident as having severely impaired cognition. Resident #110 was dependent on staff for all activities of daily living (ADL's) to include, bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The resident required mechanical lift for transfers. Under section J 0100 pain management it was identified the resident was receiving scheduled pain medication., the pain assessment interview was not conducted. There were no indicators (i.e., non-verbal, vocal, facial expressions or protective body movements or posture) of pain or possible pain in the past 5 days. The quarterly nursing assessment dated [DATE] was reviewed. In the pain section the staff indicated the resident was unable to verbalize pain. The staff was directed to use form TL 6121-02 PAINAD scale, and score the pain level. The pain score was left blank. A pain score could not be found in the clinical record. Review of the comprehensive plan of care dated 2/21/12 identified the resident had contracture's of the left elbow, wrist, both lower extremities and left hand. The goal set did not address effective pain management. One of the approaches listed was to pre-medicate for comfort as indicated (see MAR). Review of the physician order [REDACTED]. pain management. The original order date was 11/25/09. The resident was also ordered to receive [MEDICATION NAME] 5/500 mg 1 tab every 4 hours as needed (PRN) for pain. Review of the physical therapy evaluation dated 3/08/12 evidenced the following documentation under pain,"pt (patient) grimaces & moans (sign for with) all attempts to range LE's (lower extremities)". The resident was evaluated for contracture management and treatment. The reason for the therapy referral was, "to address worsening L's (lower extremity) contracture's interfering with perineal care and overall comfort". Review of the therapy daily modality note with narrative notes from 3/26/12-4/27/12 evidenced documentation of the resident's response as follows: 3/26/12- modality-ultrasound-grimacing with min. (minimal) pain-pt given pain meds 6 am per nsg (nursing) 4/3/12-modality-diathermy-pain with stretching-nsg provided 6 am pain meds 4/6/12-modality- ultrasound- with stretching pt (sign for with) min. pain 4/9/12-modality-diathermy-pain with stretching, 6 am pain meds given 4/10/12-modality-ultrasound-pain with stretching 4/11/12-modality-diathermy-grimacing with pain stretching 4/12/12-modality-diathermy-minimal pain with stretching 4/17/12-modality-diathermy-grimacing with pain-pain meds given per nsg 4/18/12-modality-diathermy-grimacing with pain-stretching 4/19/12-modality-diathermy-grimacing with pain minimal-stretching 4/20/12-modality-pain with stretching 4/22/12 -modality-ultrasound-grimacing secondary to pain-pt grimaces and verbalizes pain 4/23/12-modality-diathermy-grimacing secondary to pain 4/24/12-modality-diathermy-grimacing secondary to pain On 4/25/12 at 9:05 A.M., the physical therapy assistant (PTA) was in the resident's room and had just completed the resident's last diathermy treatment. The PTA was asked about the resident's pain during the treatment. She stated, "Pain, absolutely, when I do minimal stretching she'll yell out or push against it". She stated the resident was non-verbal. The PTA stated, "I asked the nurse about pain medication after the first session". She stated the nurse had informed her the resident was receiving scheduled pain medication at 6 AM every morning. The nurse stated the resident, "Could not have pain medication again until 10 AM". The PTA stated she would "Usually treat the resident around 8:30 AM". She stated when using diathermy the treatment would last for approximately 20 minutes for each leg, and then stretching afterwards. On 4/26/12 at 9:40 A.M., resident #110 was observed receiving a complete bed bath by CNA#4. The resident was heard yelling out in pain twice when the CNA was attempting to put pants on the resident. The resident was heard moaning lowly with repositioning and fidgeting her right hand on the mattress surface. The CNA was asked if the resident was in pain, she stated,"She is always in pain". She indicated the resident has increase in pain during movement/manipulation of the lower extremities. On 4/26/12 at 3:45 P.M., the evening shift CNA#3 caring for Resident #110 was interviewed. She stated it was difficult to provide incontinent care for the resident due to her contractures stating, "It is hard to open her legs". She stated the resident did not, "seem to be in pain....can't say I remember her yelling...she does have some discomfort when I take her shirt off." She described the pain as minimal. Review of the April 2012 MAR's evidenced the resident was administered [MEDICATION NAME] 5/500 mg every morning at 6 AM, once at 6:40 AM on 4/11, at 6:30 AM and 5:30 PM on 4/21, and 6:30 AM on 4/26/12. There was no other evidence of the resident receiving PRN pain medications for April. The facility nursing staff failed to modify the administration time of the Q AM pain medication closer to the time of the contracture management treatment and morning ADL's to ensure maximal effectiveness. Review of the every (Q) shift pain monitoring on the April MAR's indicated the resident was not in pain at anytime. The resident's daily pain with the PTA during treatment and during care per CNA#4 was not captured on this pain monitoring tool. On 4/26/12 at approximately 4:30 PM., the above findings were shared with the administrator and the DDCO. On 4/27/12 At 11:45 P.M., the attending physician and the DDCO (District Director of Clinical Operations) requested a meeting with the survey team. The attending physician stated she had spoken with the physiatrist last evening about Resident #110's pain medication. He informed her the pain medication ([MEDICATION NAME]) peaks at 2 hours and last's for 4 hours, stating the resident should have been "covered". The resident's pain medication was changed on 4/26/12 to administer [MEDICATION NAME] 5/500 mg twice a day scheduled at 8 AM & 8 PM. 3. Resident #102 entered the facility 4/16/2012 after a hospitalization . At the time of admission he was was [AGE] years old and had [DIAGNOSES REDACTED]. Review of the nursing notes following admission evidenced the resident was oriented to himself, tried to leave the building, and had some confusion. The resident's Minimum Data Set was not completed at the time of the survey. On 4/25/2012 at 1:30 p.m. Resident #102 complained to the surveyor that his back hurt and he had a hard time getting his pain medication. Review of the clinical record evidenced a 4/18/2012 telephone order from the physician for [MEDICATION NAME] 50 mg (milligrams) one tablet by mouth every 6 hours as needed for pain. The type of pain was not included in the order. Review of the 4/17 and 4/18/2012 nursing notes did not evidence that the resident complained of pain. Review of the interim care plan developed the day after admission (4/17/2012) and the physician's History and Physical of the same date evidenced the resident had chronic pain or [MEDICAL CONDITION] from his diabetes. The location of the [MEDICAL CONDITION] was not specified. The approaches in the care plan were: monitor signs and symptom of pain to nurse, report changes in pain location/type/frequency/intensity to the physician, pain assessment to be conducted on admission, and notify resident's physician if the resident does not state relief or reduction in pain in one hour. Review of the MAR on 4/25/12 evidenced the resident received a pain pill ([MEDICATION NAME]) at 12:30 PM. and one tablet on 4/24/12 at 10:00 am. The intensity, type/location of the pain was not documented on the back of the MAR or in the nursing notes. On the morning of 4/26/12 the MAR was again reviewed and evidenced the resident had received one additional tablet that morning. The pharmacy blister pack delivered 4/18/2012 containing 60 Ultam tablets was also observed. Seven tablets were missing from the blister pack but only three had been recorded as administered on the MAR. Review of the Narcotics sheet evidenced that the count was correct on 4/26/2012. On the morning of 4/27/2012 the MAR was again reviewed and the blister pack observed. At 9:30 a.m. the medication nurse (LPN #1) on Unit One stated that she had given the resident his [MEDICATION NAME] yesterday and today and had indicated so on both the Narcotics sheet and on the MAR., however she agreed that she had not documented the location/intensity or effectiveness of the prn pain medication and that is part of the protocol for pain management/medications. A count of the [MEDICATION NAME] removed from the blister pack was now nine but only four had been recorded on the MAR. At 10:20 a.m. the Regional nurse consultant was interviewed and stated that the nurses should be documenting type/location/intensity (most typically using a 1-10 scale for pain) of the pain and the effectiveness of the pain medication to effectively manage Resident #102 's pain.

Based on observation, staff interview, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to ensure 2 of 19 residents (Resident #3 and Resident #1) in the survey sample received the proper care and services to prevent infection and promote healing of pressure ulcers. The findings include: 1a. The facility staff failed to assess and treat Resident #3's sacral area for skin breakdown prior to the identification of an unstagable sacral pressure ulcer, measured as 3.8 x 3 with 80 % eschar, despite the presence of redness and significant pain. Resident #3 was a [AGE] year old admitted to the facility on [DATE] S/P (status [REDACTED]. [DIAGNOSES REDACTED]. Resident # 3 had a history of [REDACTED]. The MDS (Minimum Data Set), done as a significant change with Assessment Reference Date (ARD) of [DATE], coded Resident# 3 as a 13 out of 15 on the BIMS (Brief Interview of Mental Status) both understanding others and being understood. Resident # 3 was coded as totally dependent in bed mobility, transfering, toileting and personal hygiene. The resident was coded as always incontinent in bowel and bladder control. Pain was coded as frequently present. Resident was coded as at risk for developing skin breakdown. On the significant change assessment, Resident # 3 was coded as having a Stage IV sacral pressure ulcer, not coded on the previous MDS. Review of Resident # 3's Nurses Notes revealed an entry at 6:00 am on [DATE] that read "Diaphoretic, constantly complaining of pain in the tail bone. Pain medication administered as needed with minimal effect". Review of the CNA (Certified Nursing Assistant) Flow Record for November, 2011 revealed a CNA entry on [DATE]that read: "Patient Buttocks- Bright Red in color. She acts as if in extreme pain when cleanse(d) area and repositioning her. Reported to nurse". On [DATE] the weekly skin assessment stated "No open areas, buttocks red". An entry on the CNA Flow Record on [DATE] by the CNA read : "Patient clean(ed) and reposition(d) every two hours. Patient in extreme pain. Reported to Nurse. Area on Buttock appears to be breaking down". On [DATE] on the CNA Flow Record an entry read: "Patient is in a lot of pain in her sacral area. She continues to have loose BMs. Patient has been cleaned. Turned and positioned every two hours." Review of the Nurses Notes on [DATE] and [DATE], do not indicate any further assessment or interventions of the sacral area or referral to the wound care nurse. Review of Resident # 3's Nurses Notes revealed an entry on [DATE] at 10:00 am that read: "Called to resident's room to assess area on sacrum. On assessment, noted resident to have an unstagable area on sacrum 3.8 x 3 cm. 80 % necrotic tissue. Edges irregular. No s/s (signs and symptoms) of infection. RN (Registered Nurse) to notify family. (Name of Physician's Assistant) notified. Treatment in place". On [DATE] at 11:30 am, following the observation of a dressing change on Resident # 3's sacral wound, the Wound Nurse stated she was working nights in November when Resident # 3's pressure ulcer was identified. She stated she remembered the wound as being 80 % covered with "dark eschar" . The Wound Nurse stated Resident # 3 had chronic loose stools since she had been admitted and recalled that Resident # 3 began to decline in late November. When asked about the responsibility of reporting skin changes she stated the CNA should report any skin changes. She stated it was the Nurses' responsibility to assess and report to the Wound Nurse any changes. On [DATE] at 11:00 am the Regional Clinical Director, the Director of Nursing and the Unit Manager of 2nd Floor were presented with the above information. When asked, the Unit Manager stated the CNAs were expected to report any changes to the Nurse on a daily basis and the Nurse should assess and notify the Wound Nurse as necessary. When asked if the unstageable wound should have been found earlier, the Unit Manager stated the wound should have been identified earlier . 1b. The facility staff failed to properly clean a Stage IV Sacral Pressure Ulcer when it was found grossly contaminated with liquid brown stool, believed to related to a fistula from the colon to the wound. On [DATE] at 10:00 am through 11:00 am this surveyor observed a dressing change on a Stage IV Pressure Ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling - NPUAP http://www.npuap.org/pr2.htm) on the sacral area. After setting up a clean field on the over-bed table and arranging the products, the Wound Nurse and CNA #1 positioned the resident and removed the resident's brief to find the dressing on the sacral area soaked with liquid brown stool and a small amount of semi-formed stool in the rectal area. Upon removing the dressing, the wound was observed to be filled with liquid brown stool, totally obscuring the wound bed. Touching the sides of the wound resulted in stool gushing from the undermined area. The Wound Nurse stated she had never seen the wound "like this before". The Wound Nurse began to clean the wound using a small bottle of wound cleaner and wiping the center of the wound bed with several 4x4's. She discarded the 4x4s and picked up several new 4x4, wiping the center and outside edges of the wound bed, returning to the center of the wound bed again with the same 4x4s. The Wound Nurse used a cotton tipped applicator to clean the undermined area. The wound continued to have a film of stool covering the wound bed. The Wound Nurse then applied the dressing as ordered. On [DATE] at 11:30 am when asked after the procedure about the cleaning of the wound, the Wound Nurse stated she should have "stopped and called the Physician" for a new order to clean the wound more effectively. Review of the Weekly Pressure Ulcer Report for [DATE], completed by the Wound Nurse described the sacral pressure ulcer as 4.9 x 3.6 x 2.7. Review of the Clinical Record included a Wound Care Specialist Evaluation report, dated [DATE] revealed the Physician Assessment : " Stool in wound upon examination. Opening 6 oclock of .2 [MEDICAL CONDITION] cm likely fistula to colon as determined by contamination of cotton tip applicator upon probing. Another opening of .2 x .2 c, at 5 o'clock probed to coccyx of 2.7..." Review of Resident # 3's Physician order [REDACTED]. A new Physician order [REDACTED]. On [DATE] at 11:00 am the Regional Clinical Director, the Director of Nursing and the Unit Manager of 2nd Floor were presented with the above information. When asked the Unit Manager agreed, the Wound Nurse should have stopped the procedure and called the Physician for Pain Relief and an order for [REDACTED]. 2. The facility staff failed to assess the nutritional needs related to the development of pressure ulcer for Resident #1. Resident #1 was originally admitted on [DATE] to the nursing facility with [DIAGNOSES REDACTED]. The resident was discharged to the local hospital on [DATE] because of Altered Mental Status (AMS) and readmitted on [DATE] with a Stage II pressure ulcer. Resident #1 was again discharged to the hospital on [DATE] due to AMS and readmitted to the nursing home on [DATE] with a Stage III-IV unstageable pressure ulcer and a feeding tube. A Stage II pressure ulcer is a partial thickness skin loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. A Stage III pressure ulcer is a full thickness tissue loss with possible slough, undermining and /or tunneling. A Stage IV pressure ulcer is a full thickness loss with exposed bone, tendon or muscle. Slough and eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. An unstageable pressure ulcer is coverage of wound bed by slough and/or eschar and stage of wound is not known (Agency for Health Care Policy and Research (AHCPR) Quick reference guide 1992). The 5-day Minimum Data Set (MDS) assessment dated [DATE] did not code the resident with pressure ulcers, but assessed at risk for them. The 5-day MDS dated [DATE] coded the resident with 1 Stage II pressure ulcer and nutrition or hydration intervention to manage skin problems. The care plan dated [DATE] indicated Resident #1 had actual alteration in skin integrity, Stage II sacral pressure ulcer. The goal of the staff was the wound would be free of slough, necrotic tissue and would have evidence of healing. Some of the goals the staff would use to accomplish this goal included the Registered Dietician (RD) would monitor and evaluate nutritional intake, condition of the wound and make recommendations as indicated. The care plan dated [DATE] indicated the resident had an unstageable left and right sacral pressure ulcer with surrounding Deep Tissue Injury (DTI). Bilateral heel DTI was also noted on the care plan. The goal of the staff was the wound would be free of slough, necrotic tissue and would have evidence of healing. Some of the goals the staff would use to accomplish this goal included the Registered Dietician (RD) would monitor and evaluate nutritional intake, condition of the wound and make recommendations as indicated. Upon review of the clinical record, there were no dietary recommendations made by the RD with regard to the initial Stage II or Stage III-IV unstageable pressure ulcer. According to the Weekly Pressure Ulcer BWAT report dated [DATE], the Stage II pressure ulcer measured 2.2 centimeters (cm) x 1.2 x 0.1 cm. According to the same report dated [DATE], the Stage II pressure ulcer increased in size and measured 6.0 cm x 2.0 x 0.1 cm. The nurses notes from [DATE] and meal intake records indicated the resident was not eating or drinking well (less than (<) 50 %, <25% and refusing the meal). An interview was conducted with the RD on [DATE] at 12:15 pm. She stated she did dietary reviews on all residents within 7 days of admission and if they had any pressure ulcers, she wanted to know within the first 3 days or as soon as possible so she could make special nutritional recommendations to support wound healing. She stated she depended on the wound care nurse to inform her of pressure ulcers at any time, but was not made aware Resident #1 had any ulcers until this writers inquiry on [DATE]. She stated if she had known the resident had a Stage II, she wound have requested labs (pre-[MEDICATION NAME], sodium level, renal level and a complete metabolic panel), extra calories and fluids, as well as protein supplements. She further said, in that the wound did not show improvement, was getting larger and the resident's intake was poor, she would have added further vitamin supplementation: Vitamin C, A and Zinc. A re-evaluation of energy, protein and fluid needs would have been re-assessed using the Harris-Benedict equation with injury factor. The RD provided actual calculations of the resident's calories, protein and fluids needs based on existing pressure ulcers. She also provided the guidelines she used to determine medical nutrition therapy for wounds. An interview was conducted with the the First floor Registered Nurse (RN) Unit Manager on [DATE] at 12:50 pm. He confirmed the resident was admitted on [DATE] with no areas; on [DATE] with a Stage II that did increase significantly in size and on [DATE], the wound was a Stage III-IV with necrotic tissue and surrounding DTI. The Unit Manager stated the resident had a PICC line when he was admitted [DATE], but was only used for IV antibiotics. On [DATE] at 1:00 pm, the wound care nurse, LPN#1, stated the resident was admitted on [DATE] with a Stage II sacral wound, went to the hospital on [DATE] and was readmitted on [DATE] with the wound progressed to a Stage III-IV unstageable wound surrounded by DTI on both buttocks. She stated she made the RD aware of the resident's pressure ulcers when he was first admitted on [DATE] and on [DATE]. She provided a pressure ulcer log dated [DATE] with Resident #1's wound listed on it with measurements, and stated she gave a copy to the RD. She stated the log and running list of residents with pressure sores were sent to the Director of Nursing (DON), Administrator, First floor Unit Manager, Minimum Data Set (MDS) nurse coordinator, RD, Data Entry person, and the facility's two attending physicians. LPN #1 and the RD were interviewed together on [DATE] at 1:20 pm. The RD looked at the pressure ulcer log and stated, "I see the resident's name on the log, I guess I missed it!" LPN #1 said to the RD, "I talked to you about his (Resident #1) wounds, but you have so much on your plate you probably forgot we talked about it." The RD responded, "I do not remember any discussion about his wounds." LPN #1 could not explain why there was no follow-up with the RD in light of the resident having a pressure ulcer that tripled in size and no initial or additional dietary recommendations to aid in would healing. On [DATE] at 3:30 pm, an interview was conducted with the DON, Division Director of Clinical Operations (DDCO) and the First floor Unit Manager RN #2. They stated there was a Standards of Care meeting every Thursday and they would check to see if her signature was on the document indicating her attendance. The DDCO stated these meetings took place with interdisciplinary care team to discuss resident issues/problems to include pressure ulcers. The DON stated, "All care plan meetings have a sign in sheet, but the wound care nurse or Unit Manager did not have to wait for Thursday's Standard of Care meeting or the care plan meeting to address care needs. We could have also consulted the wound care physician when the wound increased in size". The group stated they expected and relied on the RD to have recommendations for wound healing per facility policy and she was a part of the interdisciplinary team. On [DATE] at 9:30 am, the Standards of Care Review form for Resident #1 dated [DATE] identified all of his problems addressed in the meeting to include the pressure ulcer. The RD's signature was not among the interdisciplinary team to indicate her attendance. It was noticed by this writer, added information, such as a PEG tube and Foley as an intervention as of [DATE] and that the resident's wound was an unstageable sacrum upon the original admission of [DATE], all of which the resident did not have until his return on [DATE]. On [DATE] at 1:15 pm, the DON stated she added the extra information when she looked at the form the evening of [DATE], but shouldn't have. On [DATE] at 11:10 am, a pressure ulcer dressing change was observed performed by wound care nurse LPN #1. The sacral area wound bed was observed with thick yellow slough surrounded by large dark purple areas (DTI) to include both buttock regions.