Every finding on record at Bethany on 42ND

Based on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 3 of 9 sampled residents (Resident #28, #55 and #95) observed during cares. Failure to practice infection control standards related to hand hygiene and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Hand Hygiene occurred on 04/30/25. This policy, revised February 2021, stated, . Hand Hygiene table . Soap and Water or Alcohol Based Hand Rub . Before applying and after removing personal protective equipment (PPE), including gloves . After assisting with personal body function . elimination . Review of the facility policy titled Infection Control - Enhanced Barrier Precautions occurred on 05/01/25. This policy, revised January 2025, stated, . Enhanced barrier precautions will be implemented for residents with the following . Wounds . High-contact resident care activities include . Wound care, any skin opening requiring a dressing. - Observation on 04/28/25 at 1:36 p.m. showed two certified nurse aides (CNAs) (#2 and #3) assisted Resident #28 with perineal care. The CNA (#2) performed perineal care, changed gloves, applied a clean brief, assisted the resident up in bed, and adjusted the resident's clothing and blankets. The CNA (#2) failed to perform hand hygiene after removing gloves. - Observation on 04/28/25 at 3:27 p.m. showed two CNAs (#4 and #5) assisted Resident #55 with perineal care. The CNA (#4) performed perineal care after an incontinent bowel movement, changed gloves, applied a clean brief, assisted the resident up in bed, adjusted the resident's blankets, lowered the bed and changed gloves. The CNA (#4) collected the garbage and exited the room. The CNA (#4) failed to perform hand hygiene after removing gloves and before exiting the room. - Review of Resident #95's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified the resident receives dialysis. The current care plan stated, . [Resident #95] is on Enhanced Barrier Precautions for presence of right chest port and wound. An observation on 04/29/25 at 8:25 a.m. showed a nurse (#6) entered Resident #95's room, applied gloves, and provided wound care. The nurse (#6) failed to follow EBP and apply a gown during high contact wound care. 27221

42397 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Resident #6, #9 and #51) and two supplemental residents (Resident #44 and #85). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised October 2023, pages A-30 thru A-32, . A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Review of Resident #44's medical record occurred all days of survey. A Level 1 PASRR, dated 08/07/23, stated, . You meet PASRR inclusion criteria for Serious Mental Illness . Resident #44's Admission MDS dated [DATE] identified diagnoses of manic depression (bipolar disorder). Facility staff coded item A1500: Is the resident currently considered by the state level II PASRR process to have a serious mental illness . as no. During an interview on 03/13/24 at 10:55 a.m. two administrative staff (#2 and #3) confirmed staff failed to code Resident #44's admission MDS correctly. SECTION J: FALLS The Long-Term Care Facility RAI Manual, revised October 2023, page J-37, states, . If this is not the first assessment . the review period is from the day after the ARD [assessment reference date] of the last MDS assessment to the ARD of the current assessment. Determine the number of falls that occurred since . prior assessment . and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. - Review of Resident #9's medical record occurred all days of survey. The medical record identified a fall with head laceration on 02/03/24. Resident #9's quarterly MDS, dated [DATE], identified no falls since previous assessment. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2023, pages N-1, and N-6 to N-8 stated, Section N Medications . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., [for example] aspirin/extended release . ) was taken by the resident at any time during the 7-day observation period . - Review of Resident #6's medical record occurred all days of survey. Physician's orders included aspirin 81 milligrams (mg) daily, initiated on 07/28/23. The quarterly MDS, dated [DATE], showed staff coded aspirin as an anticoagulant (blood thinner) rather than an antiplatelet medication. - Review of Resident #51's medical record occurred on all days of survey. Physician's orders included aspirin 81 mg daily, initiated on 08/08/23. The quarterly MDS, dated [DATE], showed staff coded aspirin as an anticoagulant and antiplatelet medication. - Review of Resident #85's medical record occurred on 03/12/24. Physician's orders included aspirin 81 milligrams (mg) daily, initiated on 01/29/24. The quarterly MDS, dated [DATE], showed staff coded aspirin as an anticoagulant (blood thinner) rather than an antiplatelet medication. During an interview on 03/14/24 9:45 a.m., an administrative nurse (#1) confirmed staff failed to code Resident #6, #9, #51, and #85's MDSs correctly.

42397 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure timely electronic data submission of required Minimum Data Sets (MDS) assessments for 1 of 1 supplemental residents (Resident #32) and one closed record (Resident #30). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.18.11), page 2-34 stated, . The MDS must be transmitted (submitted and accepted into iQIES [Internet Quality Improvement and Evaluation System]) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). and page 5-1, stated, Transmitting MDS Data. All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS [Center for Medicare and Medicaid Services] Internet Quality Improvement and Evaluation System . Required MDS records are those assessments and tracking records that are mandated under OBRA [Omnibus Budget Reconciliation Act] . - Review of Resident #30's medical record occurred on 03/13/24 and showed a discharge MDS dated [DATE]. - Review of Resident #32's medical record occurred on 03/13/24 and showed a quarterly MDS dated [DATE]. During a phone interview on 03/14/24 at 8:16 a.m., an administrative nurse (#1) stated staff submitted Resident #30 and #32's MDS and confirmed the MDSs were not accepted by CMS. The facility failed to ensure CMS accepted the submitted assessments.

Based on observation, review of manufacture instructions, review of facility sanitizer logs, and staff interview, the facility failed to prepare, store, and serve food under sanitary conditions in 1 of 1 kitchen (main kitchen) and 2 of 4 kitchenettes (Cottonwood and Sterling House). Failure to monitor the quaternary (quat) sanitizer concentration and follow facility guidelines for quat concentration procedure may result in unsafe preparation of food and foodborne illness. Findings include: Review of the manufacturer instructions for Smart Power Sink and Surface Cleaner Sanitizer posted above the kitchen dishwasher sinks, stated, EPA-registered cleaner sanitizer for pre-cleaned use on hard, non-porous food prep surfaces and wares, kills foodborne organisms . it is a no-rinse sanitizer that is effective across a dilution range of 0.27 to 0.55 oz.[ounce] per gallon of water. Sanitization Range Testing: Testing solution should be at or above room temperature: 65F [Fahrenheit]. Withdraw a test strip from the canister. Dip test strip for 5 seconds in test solution. Shake off excess solution. Compare colors after 10 seconds with colors on the test strip canister to determine concentration (oz/gal) [ounces/gallon] . Testing solution should be between 272-700 ppm [parts per million] DDBSA [dodecylbenzene sulfonic acid] . Review of the Facility Sanitizer Daily Test Strip Log stated, . Test strip must be between 272-700 ppm. If it is out of range, test again. If second test is still out of range, notify the supervisor. The staff failed to record the specific concentration of the sanitizer mix on the logs. Observation of the main kitchen on 03/27/23 at 12:00 p.m. with two directors of dining and nutrition (#1 and #2), and identified a red sanitizer bucket by the kitchen prep area. Using a test strip, staff obtained a reading of 848 (high) of the solution. Staff tested a second red sanitizer bucket located in the dishwasher area with a reading of 848 (high). On 03/28/23 at 10:40 a.m., an assistant director of dining services (#4) tested the two sanitizer buckets located in the main kitchen prep areas. Both buckets registered at 848. The assistant director of dining services (#4) confirmed the concentrations were high and not safe to use. Observations on 03/29/23 at 1:30 p.m. with two directors of dining services and nutrition (#1 and #3) in the facility kitchenettes and the main kitchen, showed staff obtained strip test readings of the sanitizer buckets that identified the following: * Cottonwood Kitchen: Sanitizer solution reading 848 (high) * Sterling House: Sanitizer solution reading 848 (high). The director of dining services and nutrition (#1), remixed and retested the solution, and obtained a second reading of 848 (high).

Based on observation, review of facility policy, and resident interviews, the facility failed to serve foods at palatable temperatures for 2 of 8 units (Meadowlark Lane and Crestwood). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition. Findings include: Review of the facility policy titled Service of Food occurred on 03/30/23. This policy, revised December 2021, stated, 1. Hot foods will be held until service at 135 degrees F. [Fahrenheit] or above. 2. Hot foods should be at least 120-130 degrees F. when presented to the residents. Interviews on the afternoon of 03/27/23 identified the following: *Resident #51 - The food is often cold when staff deliver it to her room *Resident #66 - The food is not always hot when it's delivered to the room *Resident #68 - The food is not hot especially breakfast food, sausages, pancakes, and waffles. Sometimes it is so cold I cannot eat it. *Resident #79 - The food is usually not hot. *Resident #96 - By the time staff deliver food (to the room), it is cold. During an interview on the morning of 03/28/23, Resident #40 stated, Sometimes it's lukewarm, sometimes it's cold [the food]. Rarely is it hot enough. Observation on 03/29/23 at 8:29 a.m. showed a dietary assistant (#11) dished up food for residents. The steam table items did not have lids covering the food and when requested to check the temperature of the sausage patties the dietary assistant removed approximately six sausage patties and placed them on a plate. The sausage temperature showed 93 degrees F. 28611

Based on record review, review of a professional reference, and staff interview, the facility failed to ensure a resident remained free from significant medication errors for 1 supplemental resident (Resident #95) reviewed for dialysis. Failure to administer medications according to the practitioner's order and report frequently missed doses to the practitioner, may inhibit the effectiveness of the medications and cause subtherapeutic levels. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 816, stated, Because the purpose of most drug therapy is to maintain a constant drug level in the body, repeated doses are required to maintain that level. Another dose is given in order to maintain therapeutic levels. If the client does not receive another dose of the drug . the concentration steadily decreases. Pages 838-841, about medication administration, stated, Performance . Safety . All medications . 8. Administer the medication at the correct time. Report significant deviations from normal to the primary care provider. Review of Resident #95's medical record occurred on all days of survey. Diagnoses included diabetes, chronic atrial fibrillation, and pain. During an interview on 03/29/23 at 12:05 p.m., a nurse (#15) stated Resident #95's morning meds are skipped due to the resident being at dialysis. The medication administration records showed the following: - January 2023: Staff failed to complete the 7:00 a.m. accu checks (a test for blood sugar levels) and failed to administer the following 8:00 a.m. medications: acetaminophen (ordered twice a day for pain), apixaban (ordered twice a day for atrial fibrillation) carboxymethylcellulose sodium (eye drops ordered twice a day for dry eyes), and metoprolol tartrate (ordered twice a day for atrial fibrillation) on 11 dialysis days. - February 2023: Staff failed to administer the 8:00 a.m. nutritional supplement (ordered 02/14/23) on 2 dialysis days and the acetaminophen, apixaban, carboxymethylcellulose sodium, and metoprolol tartrate on 11 dialysis days. - March 2023: Staff failed to administer the 8:00 a.m. nutritional supplement on 5 dialysis days (discontinued 03/23/23) and failed to administer the following medications: glipizide (once a day for diabetes, ordered 03/01/23), acetaminophen, apixaban, and carboxymethylcellulose sodium on 10 dialysis days. During the months of January, February, and March 2023, Resident #95 missed 32 doses of pain medication, eye drops, and a medication for atrial fibrillation, 22 doses of another medication for atrial fibrillation, 10 doses of diabetic medication, 11 blood sugar checks, and seven servings of nutritional supplements. The medical record lacked documentation of notification to the provider of these missed doses of medications. On the afternoon of 03/30/23, administrative staff (#7) identified it is not the facility practice for residents to miss medications on dialysis days.

Based on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), the facility failed to complete a Minimum Data Set (MDS) that accurately reflected the residents' status for 4 of 4 sampled residents (Resident #18, #38, #63, and #64) and 1 supplemental resident (Resident #55) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately code the MDS may negatively affect the development of a comprehensive care plan and the care provided to the residents. Findings include: The Long-Term Care Facility RAI Manual, revised October 2019, page A22-A23, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . Review the Level I PASRR form to determine whether a Level II PASRR was required. Review the PASRR report provided by the State if Level II screening was required. Code 0, no: . if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening, or Level II screening determined that the resident does not have a serious MI [mental illness] . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. - Review of Resident #18's medical record occurred on all days of survey and identified a level 2 PASRR completed on 01/08/21 with a diagnosis of bipolar disorder. The significant change MDS, dated [DATE] failed to identify the Level 2 PASRR and serious mental illness. - Review of Resident #38's medical record occurred on all days of survey and identified a Level 2 PASRR completed on 04/19/21 with a diagnosis of major depression. The annual MDS, dated [DATE], failed to identify the Level 2 PASRR and serious mental illness. - Review of Resident #55's medical record occurred on all days of survey and identified a Level 2 PASRR completed on 10/09/17 with a diagnosis of major depressive disorder. The annual MDS, dated [DATE], failed to identify the Level 2 PASRR and serious mental illness. - Review of Resident #63's medical record occurred on all days of survey and identified a level 2 PASRR completed on 04/02/20 with a diagnosis of schizophrenia, paranoid type. The significant change MDS, dated [DATE], failed to identify the Level 2 PASRR and serious mental illness. - Review of Resident #64's medical record occurred on all days of survey and identified a Level 2 PASRR completed on 04/22/22 with a diagnosis of schizophrenia and anxiety disorder. The significant change MDS, dated [DATE], failed to identify the Level 2 PASRR and serious mental illness. 37620 47896

Based on resident and family interviews and facility policy, the facility failed to provide care in a manner that maintains or enhances resident dignity for 7 of 7 (Resident A, B, C, D, E, F, and G) confidential sampled resident interviews and 3 confidential family interviews. Failure to answer call lights promptly, provide care in a dignified manner, and treat residents respectfully does not enhance the resident's quality of life and may result in decreased self-esteem, incontinence, and skin breakdown. Findings include: Review of the facility policy titled Dignity occurred on 03/30/23. This policy, revised January 2018, stated, It is the practice of this facility to protect and promote residents 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 resident's individuality. Respond to requests for assistance in a timely manner. Groom and dress residents according to resident preference. Speak respectfully to residents . Review of the facility policy titled Routine Care occurred on 03/30/23. This policy, revised December 2018, stated, . Answer call lights promptly . During a resident interview on the afternoon of 03/27/23, Resident A referred to a daytime certified nurse aide (CNA) as a bully. Resident A could not recall the CNAs name. Resident A also voiced concerns that it takes at least 20 minutes for staff to answer the call light and at times staff walk by the call light. During an interview on 03/27/23 at 12:58 p.m., Resident B reported there is a CNA that is really rough on their arms when the CNA gets the resident ready in the morning and at night. Resident B also reported that staff do not let the resident choose what they want to wear. During a resident interview on the afternoon of 03/27/23, Resident C reported One of the morning workers gets mad at me, sometimes she does not dress me, and she makes me cry. The resident later reported One day when she did help me I told her my pants were too tight and she made me wear them. During a resident interview on 03/28/23 at 1:55 p.m., Resident D reported a few months ago, a CNA would take their knuckles and dig them into the resident's side and back when repositioning or changing the resident. Resident D stated they would tell the CNA to stop but the CNA wouldn't. Resident D also stated a CNA entered the resident's room and yelled at the resident, calling them old .fat .and lays in bed all the time. - During an interview on the afternoon of 03/27/23, Resident E stated he/she waits for the call light to be answered, usually in the evenings and on weekends. Resident E stated, Sometimes it's 30-35 minutes. For example- last night after supper I had to use the commode. I turned on my light and waited for 20 minutes. My CNA came in and turned it off, said she'd be right back but never came back. So then I waited another 30 minutes and turned it on again. A different CNA came in and took my supper tray, and said she'd find someone to help. No one ever came back. So I turned it on a third time and waited another 30 minutes. Finally my CNA did come in and answer the light, she came back within 10-15 minutes with another person and the Hoyer [full body mechanical lift]. But all told, it was like an hour and a half from the time I put my light on until I actually got help to the commode. Resident E further identified staff are sometimes rough with cares and stated, Would I call it abuse, no. But rough handling? Definitely. It's like I'm not even a person, I'm just a body. - During an interview on 03/27/23 at 2:50 p.m., Resident F stated It often takes an hour for my light to be answered. - During an interview on the afternoon of 03/27/23, Resident G stated staff will often answer the call light, shut it off, and not help or come back. - During a confidential interview on the afternoon of 03/27/23, a family member (AA) stated she has been in the resident room with the call light on for 45 minutes. - During a confidential family interview on 03/27/23 at 1:17 p.m., a family member (BB) reported that staff is quick and rough with the resident in the morning and staff does not allow the resident to choose their own outfit. - During a confidential family interview on the afternoon of 03/29/23, a family member (CC) voiced concerns of staff pulling on the resident arms during cares, being gruff, and not very nice. The family member stated while on the phone they overheard staff saying, Now what do you want? and when the resident requested to use the bathroom staff said No you don't, you just went. Failure to provide care in a dignified manner and interact respectfully with the residents is a violation of their rights and may result in emotional/physical harm and a decreased quality of life. 28611 37620 47896

Based on observation and review of facility policy, the facility failed to follow infection control practices for 4 of 14 sampled residents (Residents #19, #37, #58, and #93) observed during personal cares. Failure to follow infection control practices has the potential for transmission of communicable diseases and infections to residents, staff, and visitors. Findings include: Review of the facility policy titled Hand Hygiene occurred on 03/27/23. This policy, revised February 2021, stated, . Hand Hygiene Table . Before applying and after removing personal protective equipment (PPE) including gloves . after assistance with personal body functions . - Observation on 03/27/23 at 3:32 p.m. showed two certified nurse aides (CNAs) (#13 and #14) donned gloves and provided perineal care for Resident #93. The CNA (#13) cleansed the rectal area of stool using a wet wipe. The CNA (#13) removed her gloves and without performing hand hygiene, the CNA (#13) applied a clean brief, turned the resident from side to side to change the bed sheet, and changed the resident's shirt. The CNA (#13) failed to perform hand hygiene after removing the soiled gloves and before completing other tasks. - Observation on 03/27/23 at 4:01 p.m. showed a CNA (#8) donned gloves and provided perineal care for Resident #19. The CNA (#8) cleansed the rectal area of stool using a wet wipe. Without removing gloves, the CNA (#8) placed a clean brief, applied ointment to the resident's buttocks and groin, pulled up the resident's pants, placed the transfer sling under the resident, and relocated the resident's wheelchair. The CNA (#8) failed to remove the soiled gloves and complete hand hygiene before touching other surfaces. 37620 - Observation on 03/29/23 at 8:19 a.m. showed a CNA (#18) assisted Resident #37 to the bathroom. The CNA donned gloves and provided perineal care. Without removing the gloves, the CNA placed a gait belt around the resident's waist, assisted the resident to stand, placed a new brief, and pulled up the resident's pants. The CNA then placed the resident's call light pendant around Resident #37's neck and removed the gait belt before removing her gloves. Without performing hand hygiene, the CNA donned new gloves and combed the resident's hair. The CNA failed to remove her soiled gloves and perform hand hygiene after perineal care and before performing other tasks. 28611 47896 - Observation on 03/27/23 at 4:02 p.m. showed CNAs (#16 and #17) donned gloves and transferred Resident #58 into the wheelchair, discarded their gloves, and CNA (#17) failed to perform hand hygiene upon exiting the resident's room. 13101

Based on record review, review of facility policy, and resident and family interview, the facility failed to report alleged violations of misappropriation of resident property to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #5 and #51) with reports of missing items. Failure to report allegations and submit investigation results placed all residents at risk for misappropriation of property. Findings include: Review of the facility policy titled Reporting Alleged Abuse and Neglect Violations occurred on 03/30/23. This undated policy stated, . All alleged violations involving abuse, neglect, exploitation or mistreatment must be reported immediately. This includes injury of unknown source and misappropriation of resident property. If the alleged violation does not involve abuse or does not involve serious bodily injury it must be reported no later than 24 hours after the allegation is made. The alleged violations must be reported to . other officials (including to the state survey agency and adult protective services where state law provides jurisdiction in long term care facilities) in accordance with state law through established procedures. - During an interview on 03/28/23 at 9:41 a.m., Resident #5 stated [I] had some perfume stolen. Now I keep it in the locked drawer. The perfume cost $150.00 and they won't replace it. The facility initiated a Loss Report Form for the perfume on 02/05/22. A progress note from social services on 02/17/22 at 4:47 p.m., stated Late Entry: Note text: SS [social services] checked in with [Resident #5] on this date. [Resident #5] voiced she bought new perfume and came today. SS provided education to [Resident #5] in depth on keeping her items of value in her drawer locked and keeping the key on her. [Resident #5] voiced she understood this and planned to keep her perfume in her locked drawer. - During an interview on the afternoon of 03/27/23, Resident #51 stated she had a new cell phone from her sister. She placed it on the overbed table when she went to bed one night, and when she woke up it was gone. Resident #51 stated, Now I keep it right here [indicating along side her body]. She identified she told a social services staff member, and stated, We looked everywhere for it but couldn't find it. Resident #51 stated facility staff told her they would not replace her phone. During a phone interview on the morning of 03/29/23, Resident #51's family member stated Resident #51 reported her phone went missing during the night. Resident #51's family member stated this happened about a month ago. A Loss Report Form, dated 02/23/23, identified staff attempted to find the phone, but lacked evidence of reporting the incident as possible misappropriation of resident property. A nurse's note, dated 03/02/23, stated, . SS spoke with [Resident #51's family] about the loss report for [Resident #51's] phone and confirmed the phone had not been found. SS also provided [Resident #51's family] is always welcome to call the nurses station and ask to speak with [Resident #51]. The facility failed to report the alleged misappropriation of property within 24 hours and submit the findings of the investigation within five days to the State Survey Agency. 13101

Based on record review, resident and staff interview, the facility failed to ensure 2 of 2 sampled residents (Resident #51 and #57) reviewed for restorative therapy received the services developed by the therapy staff. Failure to consistently provide restorative nursing/therapy services may adversely affect the residents' abilities to maintain their range of motion (ROM), balance, strength, and mobility. Findings include: - During an interview on 03/27/23 at 3:10 p.m. Resident #57 stated, Look at my hands. I can't even open them. Resident #57 reported he/she had not received therapy. Review of Resident #57's medical record occurred on all days of survey. The current care plan stated, . requires a restorative program to maintain or improve functional ROM. At times (resident) may refuse the ROM program. Functional ROM will be maintained or improved to highest practicable level of function. PROM [passive range of motion] up to 4 x Week [four times a week], PROM to UE [upper extremity] and LE [lower extremity] . The quarterly minimum data set (MDS), dated [DATE], identified upper extremity impairment on one side. A Functional ROM Plan of Care, dated 11/07/22, identified PROM to LE 4 times a week and PROM to UE 4 times a week. Review of provider progress notes identified the following: * 01/12/23 . left hand contracture with decreased ROM, pain and decreased functional use of left hand. * 01/12/23 . Dupytren Contracture left hand chronic problem, now causing more pain. * 01/19/23 . secondary discharge diagnosis . Dupytrens contracture of left hand . Review of the restorative nursing documentation, dated 01/05/23 -03/30/23 identified staff provided passive range of motion (PROM) 10 times during the 12 week period with one refusal documented on March 20, 2023. The facility failed to provide restorative therapy services four times a week to Resident #57. During an interview the morning of 03/30/23, a restorative CNA (#8) confirmed resident #57 was on a restorative program. - During an interview on the afternoon of 03/27/23, Resident #51 stated, I was supposed to have therapy this whole last week. A lady stopped in one day when I was in the bathroom but she never came back. Hopefully they will try again this week. Review of Resident #51's medical record occurred on all days of survey. The current care plan stated, . requires restorative program to maintain or improve functional ROM. refuses RNP [restorative nursing program] at times . NURSING REHAB: AROM [active range of motion] up to 3X Week: LE, Supine (lying on back) Exercises 10 Reps [repetitions] . LE Seated Exercises 2# [pounds] Wts [weights] Red Thera Band 10 Reps or UE Exercises 2# Wt Dowel Exercises . A Functional ROM Plan of Care, dated 03/10/23, identified upper and lower extremity exercises three times per week. The medical record lacked evidence of restorative nursing provided or refused by the resident for the week of March 19-25, 2023. During an interview on 03/30/23 at 11:20 a.m., an MDS Coordinator (#9) confirmed restorative staff focus on the 6 day a week residents and get to the others when they are able. 28611

Based on observation, record review, review of the facility policy, and staff interview, the facility failed to provide proper respiratory care consistent with standards of practice and physician's orders for 3 of 8 sampled residents (Resident #86, #92 and #164) and 3 supplemental residents (Resident #16, #38 and #72) receiving oxygen therapy. Failure to administer oxygen as ordered, document oxygen use, and change oxygen tubing per facility policy may complicate the residents' respiratory status. Findings include: Review of the policy titled SKILLED - ADMINISTRATION OF OXYGEN occurred on 01/05/22. This policy, revised February 2019, stated, . Oxygen should be administered under orders of the provider . Set the flow meter to the rate ordered by the physician . Review of the facility form titled Oxygen Checklist stated, . Every Friday NOC [night], change . tubing (including tubing on tanks). - Review of Resident #16's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 12/18/21, stated, . Oxygen 2 L [liters] NC [nasal cannula] PRN [as needed] for SOB [shortness of breath] . Observation on 01/04/22 at 10:39 a.m. showed Resident #16's oxygen tubing/nasal cannula labeled 11/12 (indicating the date the staff changed the tubing). The facility failed to change the oxygen tubing/nasal cannula per policy. - Review of Resident #38's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 01/21/20, stated, Oxygen 2 L via NC three times a day. Call [providers name] if sats [oxygen saturation levels] drop below 90%. Observation on 01/04/22 at 10:36 a.m. showed Resident #38 seated in a wheelchair in her room wearing oxygen via nasal cannula and the oxygen flow meter set at 4 L (not 2 L as ordered). The facility failed to follow Resident #38's physician's order for 2 L of oxygen. - Review of Resident #72's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 08/18/21, stated, Oxygen 1.5 L as needed for comfort . Observations on 01/03/22 at 1:26 p.m. and 01/04/22 at 8:40 a.m. showed Resident #72 sitting in a wheelchair wearing oxygen via NC and the oxygen flow meter set at 2 L (not 1.5 L as ordered). The TAR, dated January 1-5, 2022, lacked documentation of Resident #72's oxygen use on January 3-4, 2022. - Review of Resident #86's medical record occurred on all days of survey. A physician's order, dated 03/13/19, stated, Nurse: O2 [oxygen] continuous @ (at) 2 Liters NC-SOB. An observation on 01/06/22 at 8:25 a.m., showed Resident #86's oxygen tubing, from the room oxygen system, dated 12/11 indicating the date staff changed the tubing. Staff failed to change the oxygen tubing weekly as per policy. - Review of Resident #92's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's order, dated 11/30/21, stated, Oxygen 3 L via NC as needed for comfort. Observations showed the following: * Resident #92 wore a nasal cannula on all days of survey. The oxygen tubing attached to the humidifier/bubbler showed a date of 12/11 (the date staff last changed the tubing.) * On 01/05/22 at 12:20 p.m., Resident #92 wore a nasal cannula with the flow meter set at 2.5 L. Observation showed staff failed to set the oxygen flow rate at 3 L as ordered by her physician. The TAR, dated January 1-5, 2022, identified staff failed to document Resident #92's continuous use of oxygen throughout the survey. The Oxygen Checklist, dated 12/01/21-01/05/22, identified staff checked the humidifier/bubbler, filled it with distilled water, and changed the bubbler/tubing every Friday night. Observation showed staff failed to change the tubing after Saturday, December 11th. During an interview on 01/06/22 at 9:00 a.m., a managerial nurse (#3) reported, Resident #92's oxygen] order was changed to continuously yesterday. [It was] as-needed before. - Review of Resident #164's medical record occurred on all days of survey. A physician's order, dated 12/18/21, stated, Nurse: Oxygen at 2-4L PRN via Nasal Cannula. Refer to care pathway for guidelines. as needed for DYSPNEA [difficult breathing]. Observations made on all days of survey showed Resident #164 wore oxygen continuously. Review of the TAR on 01/05/22 at 5:30 p.m., showed nursing staff failed to sign off Resident #164's oxygen use January 3-5, 2022.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED 02/02/20 Based on observation, resident interview, and record review, the facility failed to ensure appropriate care and services to manage symptoms of [CONDITION(S)] (fluid retention) for 1 of 1 sampled residents (Resident #43) with order for leg wraps. Failure to ensure timely and consistent implementation of leg wraps may result in worsening [CONDITION(S)] and increased pain. Findings include: During an interview on 01/03/22 at 2:20 p.m., Resident #43 stated, sometimes staff wrap my legs and other times they do not. The resident complained of leg pain related to the [CONDITION(S)]. Review of Resident #43's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current care plan identified, . [CONDITION(S)] to their bilateral lower extremities. Observations during the following dates and times identified no ace wraps present: * 01/03/22 at 2:20 p.m. * 01/04/22 at 10:04 a.m. * 01/04/22 at 2:00 p.m * 01/05/22 at 10:00 a.m. * 01/05/22 at 12:00 p.m

Based on observation, record review, review of facility policy, and resident/staff interviews, the facility failed to provide reasonable accommodation of needs regarding call lights for 2 of 4 sampled residents (Resident #8 and #53) utilizing an alternative soft-touch call light. Failure to assess the residents' ability to effectively use alternative soft-touch call lights and/or place the soft-touch call lights within the residents' reach may result in an inability to call for help, discomfort, incontinence, and/or skin breakdown. Findings include: Review of the facility policy titled Routine Care occurred on 01/06/22. This policy, revised January 2018, stated, . Each of the following is part of the routine care provided by care givers . Each item is based on the abilities of the resident to participate in their care and needs based on physical and mental limitations. Call light within reach when resident is in room . - During an interview on 01/03/22 at 3:51 p.m., when asked questions pertaining to call lights/response times, Resident #8 stated, I have a call light around my neck, but it is hard to push. I don't have fine motor skills, so they gave me the other one [soft-touch call light]. I have another call light down there [hanging from the bed rail], but I can't reach it. Sometimes I can't push that either. Sometimes they reposition me and the call light is underneath me and I have to try to pull it out. Observation at the time of the interview showed Resident #8 lying in bed with a call light pendant around her neck and a soft-touch call light hanging from the left bed rail, approximately two inches from the floor and not within Resident #8's reach. Review of Resident #8's medical record occurred on all days of survey. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #8 as cognitively intact and totally dependent on two or more persons for bed mobility. Observation on 01/04/22 at 11:10 a.m. showed a certified nursing assistant (#1) assisted Resident #8 to reposition in bed. Resident #8 wore a call light pendant and the soft-touch call light continued to hang from the left bed rail, approximately four inches from the floor and not within Resident #8's reach. During an interview on 01/06/22 at 11:44 a.m., when discussing Resident #8's concerns regarding her ability to access a call light, an administrative nurse (#2) acknowledged, The [soft-touch call light] was a preference of hers. - Review of Resident #53's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified the resident required total assistance with bed mobility, transfer, dressing, eating, toileting and personal hygiene. Observations and interviews of Resident #53 showed the following: * 01/03/22 at 2:33 p.m., resting in bed and a soft-touch call light set on the pillow adjacent to the resident's face. When asked how she asks for help when needed, the resident stated, With the soft call light on my pillow and further stated, I can't get to it [the call light] most of the time. The resident stated she is unable to raise both arms, needs to yell for help, and when she yells, is told, [Resident's name] don't yell. You'll wake everyone up. * 01/04/22 at 8:57 a.m., seated in a wheelchair in her room and a call light pendant hanging around her neck. When asked to demonstrate use of the call light pendant, the resident unsuccessfully attempted to raise both arms, and stated she cannot use the call light pendant. * 01/04/22 at 12:24 p.m., lying in bed with the soft-touch call light next to her left cheek. When asked to demonstrate her ability to turn on the soft-touch call light, the resident was unable to turn her head far enough to activate the light. The resident stated, Even if they [facility staff] put it [the soft-touch call light] in my hands, I can't turn it on, and the resident expressed concern about not being able to get help without yelling. When asked to demonstrate her ability to grasp/pinch with both hands, the resident was unable to close her fingers enough to turn on a call light.

Based on observation, record review, review of facility policy, and resident/staff interviews the facility failed to provide activities of daily living (ADL) assistance for 7 of 25 sampled residents (Resident #2, #34, #38, #63, #107, #158, and #159) who required staff assistance for toileting/check and change. Failure to provide assistance in a timely manner to residents who cannot independently carry out ADL's may result in poor grooming/hygiene and decreased self-esteem. Findings include: Review of the facility policy, revised on 12/16 titled Bladder Management occurred on 02/06/2020. This policy stated, . Scheduled/Habit Toileting: A behavior technique that calls for scheduled toileting at regular intervals on a planned basis to match the resident's voiding habits or needs . Check and Change: Involves checking the resident's dry/wet status at regular intervals and using incontinence devices and products per manufacturer's recommendations. Identified by 'CC' on ADL (Activities of Daily Living) sheet . - Review of Resident #2's medical record occurred on all days of survey. The quarterly Minimum Data Set (MDS), dated [DATE], identified Resident #2 required total (dependent) assistance of two staff for toileting, and the resident was always incontinent of bowel and bladder. The resident's current care plan stated, . (Resident #2) has incontinent episodes due to TBI [MEDICAL CONDITION] bladder, medication use, impaired cognition and decreased mobility. Refer to ADL sheet for toileting schedule/plan. (Resident #2) requires assist with ADL's related to history of MVA (motor vehicle accident), TBI, cognitive deficit, aphonia, and left side spastic [MEDICAL CONDITION] . Resident #2's ADL sheet stated, . Check and Change every 2 hours . The skin assessment, dated 01/31/20, identified reddened areas to groin. The toileting log, dated (MONTH) 29 through (MONTH) 4, 2020, identified fourteen occasions where staff failed to check and change Resident #2 as care planned. The log showed gaps of approximately 2.5 to 9 hours. - Review of Resident #34's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance for toileting, was on a current toileting program, and was frequently incontinent. The current care plan identified, . (Resident #34) has potential for incontinent episodes due to limited mobility and medication use . Refer to ADL sheet for toileting schedule/plan . The current care card identified, . TOILETING . S = Scheduled Q (every) 2 HRS (hours) . The Bladder Assessment, dated 12/09/19, identified, Habit time to remain in effect due to decreased incontinence episodes. On 02/05/20 at 8:26 a.m., Resident #34 indicated/wrote that he had to wait twice 1/2 hour for the night nurse and pointed to the bathroom. The toileting log, dated (MONTH) 30 through (MONTH) 5, 2020, identified twenty four occasions where staff failed to toilet Resident #34 as care planned. The log showed gaps of approximately 2.5 to 15 hours. - Review of Resident #38's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified Resident #38 required total (dependent) assistance of two staff for toileting, and the resident was always incontinent of bowel and bladder. The resident's care plan stated, . (Resident #38) has a dx (diagnosis) of urinary incontinence and hypertonicy of bladder. Refer to ADL sheet for toileting schedule/plan. (Resident #38) requires assist with ADL's d/t (due to) dx of [MEDICAL CONDITION], dementia . Resident #38's ADL sheet stated, . Check and change every two hours . The toileting log, dated (MONTH) 29 through (MONTH) 4, 2020, identified fourteen occasions where staff failed to check and change Resident #38 as care planned. The log showed gaps of approximately 2.5 to 10 hours. - Review of Resident #63's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance for toileting and was frequently incontinent. The current care plan identified, . (Resident #63) is incontinent of bladder at times d/t (due/to) impaired mobility, dx of dementia . Refer to ADL sheet for toileting schedule/plan . The current care card identified, . TOILETING . S = Scheduled Q (every) 2 HRS (hours) . The toileting log, dated (MONTH) 30 through (MONTH) 5, 2020, identified eighteen occasions where staff failed to toilet Resident #63 as care planned (none of which were due to Resident #63 refusing cares). The log showed gaps of approximately 3 to 11.25 hours. - Review of Resident #107's medical record occurred on all days of survey. The annual MDS, dated [DATE], identified Resident #107 required total (dependent) assistance of two staff for toileting, and the resident was always incontinent of bowel and frequently incontinent of bladder. The resident's care plan stated, . (Resident #107) is incontinent due to decreased mobility, dementia and hypertonic bladder. Refer to ADL sheet for toileting schedule/plan. (Resident #107) requires assist with ADL's due to dementia and [MEDICAL CONDITIONS] . Resident #107's ADL sheet stated, . Check and Change every two hours . The skin assessment, dated 01/30/20, identified redness to coccyx. The toileting log, dated (MONTH) 29 through (MONTH) 4, 2020, identified nine occasions where staff failed to check and change Resident #107 as care planned. The log showed gaps of approximately 2.5 to 8 hours. - Review of Resident #158's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance from two persons for toileting and always incontinent. The current care plan identified, . (Resident #158) has incontinence related to dementia or [MEDICAL CONDITION] . Refer to ADL sheet for toileting schedule . The current care card also identified, . CC = Check and Change Q 2 HRS . The Skin Assessment, dated 02/06/20, identified, . blanchable redness to perineal area - tx (treatment) applied . The toileting log, dated (MONTH) 30 through (MONTH) 5, 2020, identified twenty eight occasions where staff failed to toilet Resident #158 as care planned. The log showed gaps of approximately 2.5 to 11.75 hours. - Review of Resident #159's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The current care plan identified, . (Resident #159) has potential for incontinent episodes due to decreased mobility . Refer to ADL sheet for toileting schedule/plan . The current care card identified, . TOILETING . S = Scheduled Q 2 HRS . The toileting log, dated (MONTH) 30 through (MONTH) 5, 2020, identified eighteen occasions where staff failed to toilet Resident #159 as care planned (none of which were due to Resident #159 refusing cares). The log showed gaps of approximately 2.5 to 11.25 hours. During an interview on 02/06/20 at 9:20 a.m., a managerial nurse (#2) stated she expected staff to follow each resident's toileting schedule and/or check and change as indicated on the care plan and ADL sheet. During an interview on 02/06/20 at 11:45 a.m., a managerial nurse (#1) stated, If a resident is care-planned to be repositioned or toileted every 1-2 hours, staff should follow the resident's care plan.

Based on facility policy, record review, observation, and staff interviews, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 7 of 25 sampled residents (Resident #2, #37, #38, #49, #82, #107, and #158) requiring staff assistance for repositioning. Failure to consistently provide assistance with repositioning may result in pain/discomfort or skin breakdown. Findings include: Review of facility policy titled Turning and Positioning Program occurred on 02/06/20. This policy, revised (MONTH) 2013, stated, . To provide pressure relief, maintain skin integrity, prevent pressure ulcers . Unit nurse will notify the unit clerk to enter the appropriate tasks in P[NAME] (plan of care) for the corresponding care plan . (and) will add the additions and/or changes to the ADL (activities of daily living) care sheet . - Review of Resident #2's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], identified the resident required extensive assistance for bed mobility and total (dependent) assist for transfers and was at risk of developing pressure ulcers. The current care plan identified, . (Resident #2) is at risk for developing pressure ulcer due to . decreased sensory perception, moisture, decreased activity, decreased mobility . Turn and reposition every 2 hours and prn (as needed) . The current care card also identified, . T2 = TURN 2 HOURS . The Skin Assessment, dated 01/31/20, identified, . redden (sic) areas to groin . The repositioning log, dated (MONTH) 29 through (MONTH) 4, 2020, identified eighteen occasions where staff failed to reposition Resident #2 as care planned. The log showed gaps of approximately 2.5 to 9.5 hours. - Review of Resident #37's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The significant change MDS, dated [DATE], identified the resident required extensive assistance for bed mobility/transfers, had a history of [REDACTED]. The current care plan identified, . (Resident #37) is at risk for developing a pressure ulcer due to: moisture, decreased activity, decreased mobility, friction/sheer . T/R (turning/repositioning) every 2 hours due to history of skin breakdown . The current care card also identified, . T2 = TURN 2 HOURS . The repositioning log, dated (MONTH) 30 through (MONTH) 5, 2020, identified thirteen occasions where staff failed to reposition Resident #37 as care planned. The log showed gaps of approximately 2.5 to 8 hours. - Review of Resident 38's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance for bed mobility and total (dependent) assist for transfers and was at risk of developing pressure ulcers. The current care plan identified, . (Resident #38) is at risk for developing pressure ulcer due to . decreased mobility, incontinence of bowel and bladder, and history of refusals of cares/assistance, history of pressure ulcers . Turn and repo (reposition) at 2 hours . The current care card also identified, . T2 = TURN 2 HOURS . The repositioning log, dated (MONTH) 29 through (MONTH) 4, 2020, identified fifteen occasions where staff failed to reposition Resident #38 as care planned. The log showed gaps of approximately 2.5 to 9.5 hours. - Review of Resident #49's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The current care plan identified, . AT RISK - PRESSURE ULCER - HIGH RISK: (Resident #49) is at high risk for Skin Breakdown related to limited mobility, scoliosis, hx (history) of pressure ulcers . He also has a history of refusing turning and repositioning . Turn and repo q (every) 2 hr (hours) and PRN . The current care card also identified, . T2 = TURN 2 HOURS . The repositioning log, dated (MONTH) 30 through (MONTH) 5, 2020, identified eighteen occasions where staff failed to reposition Resident #49 as care-planned (none of which were due to Resident #49 refusing cares). The log showed gaps of approximately 2.5 to 6 hours. - Review of Resident #82's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance from two persons for bed mobility/transfers, received Hospice care, and was at risk of developing pressure ulcers. The current care plan identified, . (Resident #82) is at risk for developing a pressure ulcer due to decreased sensory perception, moisture, decreased activity, decreased mobility, nutrition . At risk for pressure ulcer: turning/repositioning program determined by tissue tolerance assessment . The current care card identified, . T2 = TURN 2 HOURS . The repositioning log, dated (MONTH) 30 through (MONTH) 5, 2020, identified seventeen occasions where staff failed to reposition Resident #82 as care planned. The log showed gaps of approximately 2.5 to 7.75 hours. - Review of Resident #107's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The annual MDS, dated [DATE], identified the resident required extensive assistance for bed mobility and total (dependent) assist for transfers and was at risk of developing pressure ulcers. The current care plan identified, . (Resident #107) is at risk for developing pressure ulcer due to . hx of pressure ulcers, decreased mobility, bowel and bladder incontinence . Continue T/R every 2 hours and prn . The current care card also identified, . T2 = TURN 2 HOURS . - Observations on 02/04/20 showed Resident #107 in the following positions: * 8:38 a.m. - In the bed on her back with a pillow on each side of her. * 11:27 a.m. - In the bed on her back with a pillow on each side of her. - Observations on 02/06/20 showed Resident #107 in the following positions: * 8:14 a.m. - In the bed on her back, with no pillows used for positioning. Two pillows noted in the recliner beside the bed. * 12:50 p.m. - In the bed on her back, with no pillows used for positioning. Two pillows noted in the recliner beside the bed. The Skin Assessment, dated 01/30/20, identified, . redness to coccyx . The repositioning log, dated (MONTH) 29 through (MONTH) 4, 2020, identified twelve occasions where staff failed to reposition Resident #107 as care planned. The log showed gaps of approximately 2.5 to 9 hours. - Review of Resident #158's medical record occurred on all days of survey, and identified [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], identified the resident required extensive assistance from two persons for bed mobility/transfers and was at risk of developing pressure ulcers. The current care plan identified, . (Resident #158) is at risk for developing a pressure ulcer due to moisture, decreased activity, decreased mobility, nutrition . TTA (Tissue Tolerance Assessment) completed 01/29/20. Redness noted after 1 hour. Turn/reposition q 1 hour . The current care card also identified, . T1 = TURN EVERY HOUR . The Skin Assessment, dated 02/06/20, identified, . blanchable redness to perineal area - tx (treatment) applied . The repositioning log, dated (MONTH) 30 through (MONTH) 5, 2020, identified twenty three occasions where staff failed to reposition Resident #158 as care planned. The log showed gaps of approximately 1.5 to 5 hours. During an interview on 02/06/20 at 11:45 a.m., a managerial nurse (#1) stated, If a resident is care-planned to be repositioned or toileted every 1-2 hours, staff should follow the resident's care-plan. During an interview on 02/06/20 at 12:44 a.m., a managerial nurse (#2) stated, If a resident is care-planned to be repositioned every 2 hours, staff should follow the resident's care-plan.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 01/24/2019 Based on observation, review of facility policy, and staff interview the facility failed to label and document refused medications located in 1 of 4 medication carts (First floor, Dakota Plains), observed during medication storage review. Failure to ensure refused medications are properly labeled increased the risk of residents receiving the wrong medications. Findings include: Review of the policy titled Medication Administration - General Guidelines occurred on 02/05/20. This policy, revised (MONTH) 2019, stated, B. Administration: 4) The person who prepares the dose for administration is the person who administers the dose. 5) If resident refuses medication leave it in the top drawer of the medication cart, label with resident initials. Complete a refusal of care note. Observation on 02/05/20 at 4:55 p.m. showed an unlabeled medication cup in the top drawer of the medication cart with unknown amount of pills in a dark brown solution. The staff nurse (#4) stated she is unaware of who the medication is for and the nurse whom she took over from must have put the medication cup in the drawer. She stated she would report it to her nurse manager. The nurse who placed the medication cup in the medication cart drawer failed to label the medication cup with the resident's initials and to document in the electronic medication record the resident's refusal. During an interview on the morning of 02/06/20 an administrative nurse (#3) stated she expected staff to label refused medication, put it in the top drawer of the medication cart and document it in the electronic medication record.

Based on observation, record review, and staff interview, the facility failed to ensure accurate labeling of medications for 1 of 10 residents (Resident #96) observed during medication pass. Failure to relabel an insulin pen following an order change may result in Resident #96 receiving too much/little insulin and/or having a negative reaction. Findings include: Review of Resident #96's medical record occurred on 01/24/19. The current physician orders [REDACTED]. Observation on 01/24/19 at 8:50 a.m. showed Resident #96's [MEDICATION NAME] Flex Pen with a label that read 4 units three times per day. When asked if the [MEDICATION NAME] label was correct, the nurse (#1) responded, Yes, he gets that in the a.m., noon, and evening. When asked how staff are informed of an order change, he pointed to a print out with hand written notes and stated, You come in early to go thru the MAR (medication administration record). We also receive a clinical alert listing report that is prepared by the night shift of changes, and we are notified at report. During an interview on 01/24/19 at 9:00 a.m., when asked how medication labels are updated following an order change, a pharmacist (#2) stated, Nursing can bring (the insulin pen) down and we will relabel the pen. The nurses know they can bring the medication to us for relabel and they should (do so.) The [MEDICATION NAME] Pen failed to contain a label reflecting the correct dosage or a sticker referring staff to the eMAR (electronic medication administration record)/order (regarding the) dosage change.

Based on record review and review of professional reference, the facility failed to follow professional standards of practice regarding physician's orders for 1 of 23 sampled residents (Resident #10). Failure to carry out physician's orders regarding [MEDICAL CONDITION] medications may result in inadequate monitoring and adverse drug effects related to their use. Findings include: Berman, Snyder, and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th ed., Pearson Education, Inc., Massachusetts, page 68, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #10's medical record occurred on February 27-28, 2018. [DIAGNOSES REDACTED]. A faxed Provider Notification of [MEDICAL CONDITION] Drug Gradual Dose Reduction (GDR), signed by the provider on 10/16/17, stated, . [MEDICATION NAME] (an antidepressant) 25 mg (milligrams) PO (by mouth) HS (bedtime) for [MEDICAL CONDITION] . (decreased) 7/12/17 . Tolerated last GDR well. Does spend a lot of time in bed. Continue (with) GDR? . The provider responded, last seen 4-25-17. Please schedule. A second provider notification, signed on 01/09/18, stated, . [MEDICATION NAME] 25 mg PO @ HS for [MEDICAL CONDITION] . (decreased) 7/12/17 . Did well (with) recent GDR. Continue? . The provider responded, last seen 4-25-17. Please schedule. A nurse's note, dated 01/10/18, stated, . (Resident #10) is due for a GDR for Trazadone (sic) 25 mg. GDR is not accepted by (provider's name) at this time. (Resident #10) was last seen in April so Provider is requesting a new appointment be scheduled before any changes are made. The record lacked evidence of follow-up regarding the provider's requests for an appointment.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.15), and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 of 23 sampled residents (Resident #103). Failure to ensure Section N (Medications) of Resident #103's MDS accurately reflected his current status/needs, has the potential to affect the accurate development of his comprehensive care plan and the care provided. Findings include: The Long-Term Care Facility RAI User's Manual, revised October 2017, page N-7 stated, . N0410E, Anticoagulant (e.g. (example given), [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Review of Resident #103's medical record occurred on all days of survey. Review of the resident's Significant Change MDS, dated [DATE], showed Resident #103 received an anticoagulant medication every day of the 7-day look-back period. The February electronic Medication Administration Record [REDACTED]. During an interview on 02/07/18 at 12:08 p.m., an MDS Coordinator (#5) agreed she failed to accurately code Section N of the MDS.

Based on observation, review of facility policies, and resident/staff interviews, the facility failed to provide the necessary care and services to maintain the highest practicable psychosocial well-being for 1 of 21 sampled residents (Resident #5). Failure to ensure staff provided the necessary care and services in a timely manner when responding to Resident #5's call lights resulted in bowel incontinence and caused her psychosocial harm. Findings include: Review of the facility policy titled Call Light - Use . occurred on 02/04/16. This document, revised April 2015, stated, . Once a resident activates the system . a message is immediately sent to all designated staff carrying an I-touch (call light system). If the staff within the household is unable to answer the call light in a reasonable amount of time, the system provides them with the ability to escalate the call to other staff members. This majority of the staff working in skilled care will have an I-touch while working and have the ability to respond accordingly. Resident alerts through the call system will automatically clear when it senses that a staff member is in a close proximity . to the resident for 10 seconds. During an interview on 02/04/16 at 10:15 a.m., two administrative staff members (#7 and #8) confirmed the resident's call light automatically clears as soon as a staff member enters the resident's room. They also reported they are unable to determine whether or not the staff member actually provided cares after entering the room. - During the initial tour on 02/01/16 at 11:25 a.m., Resident #5, later identified by the facility as interviewable, volunteered, (The facility) is definitely short-staffed. She reported having to wait an average of 15-20 minutes for staff to respond to her call light, and then went on to describe one particular episode during which she waited approximately 35-45 minutes for staff assistance. She stated, (I was) so upset! No one came! I pooped in my pants. - During the group interview on 02/01/16 at 4:00 p.m., when asked if staff respond to call lights in a timely manner, Resident #5 elaborated on the statements she made during the initial tour. In front of seven of her peers, Resident #5 described the incident that had occurred approximately two weeks prior. She reported self-transferring to the bathroom, after waiting 25 minutes for assistance. She was unable to get (to the bathroom) fast enough which resulted in a big mess (bowel movement (BM)). She went on to say a male CNA (certified nursing assistant) entered her room, observed the mess, and exited the room in search of gloves. Resident #5 noted there were gloves present in the bathroom, and reported the male CNA never came back (to her room). Several minutes later, a female CNA entered her room and provided the needed cares. Resident #5 reported the incident to the female CNA. She described the incident as horrible. (The female CNA failed to report the incident as possible neglect.) - During an interview on 02/02/16 at 9:35 a.m., when asked if staff respond to call lights in a timely manner, Resident #5 elaborated on the statements she made during the initial tour and the group interview. She reported self-transferring to the bathroom, after waiting 25 minutes for assistance. She stated, By the time I got there, I pooped all over, (even on the) floor. I was crying. If they got here in time, it wouldn't have happened. She went on to say the (male) CNA entered her room, saw the poop, and exited the room in search of gloves. Resident #5 noted there were gloves present in the bathroom, and reported the (male) CNA never came back. Several minutes later, another (female) CNA entered her room and stated, I thought (the male CNA) had helped (you). Resident #5 said she started crying again. It was humiliating . horrible! In closing, Resident #5 stated, They got after me for not waiting. What am I supposed to do? Review of Resident #5's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The admission Minimal Data Set (MDS), dated [DATE], identified extensive assistance of two or more people required for transfers, toileting, and personal hygiene. An MDS Summary, dated 01/21/16, stated, . (Resident #5) was . incontinent of bowel x 1 during the reference period. The facility staff's failure to provide the necessary care and services to Resident #5 in a timely manner placed her at risk for falls while she attempted to self-transfer to the bathroom and resulted in her episode of bowel incontinence and increased her risk of skin irritation. Staff failed to report the incident to supervisory staff as possible neglect. Resident #5 repeated her story three times to different members of the survey team and in front of her peers, describing her persistent feelings of humiliation. - During an interview on 02/01/16 at 4:13 p.m., when asked if staff respond to call lights in a timely manner, Resident #7, identified by the facility as interviewable, responded, When I do need help, it can be (a) 15-45 minute . wait to use the bathroom. When they didn't come, then I take my walker and go to (the) bathroom myself. - During an interview on 02/01/16 at 5:00 p.m., when asked if staff respond to call lights in a timely manner, Resident #6, identified by the facility as interviewable, responded, (It takes staff a) long time to answer call lights. He reported being incontinent of bowel/bladder while waiting for help.

1. Based on record review, observation, review of facility policy, and family interview, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 sampled resident (Resident #2) who experienced uncontrolled pain and 1 closed record resident (Resident #14) who experienced un-relieved chest pain. Failure to evaluate and re-assess pain and implement pain management interventions for Resident #2 and #14 resulted in the residents experiencing prolonged episodes of pain. Findings include: Review of facility policy, "PAIN ASSESSMENT" occurred on 01/27/11. This policy, dated August 2009, stated, ". . . PROCEDURE: 1. Ask the resident to describe his/her pain. 2. Ask the resident to identify which "Box" or "Number" of pain level best describes his/her pain. 3. Provide pain relief modalities as outlined in the resident's care plan. 4. After a suitable time frame (dependent on the modality used), evaluate the effect of the pain relief modality by repeating 1 and 2 above. 5. Document results, including any pain relief modalities used. 6. PRN (as needed) pain medications may be ordered initially to determine if a pattern or specific schedule would be appropriate. 7. If a pattern is identified scheduling pain medications should be considered. . . ." Review of Resident #2's medical record occurred on January 24-27, 2011. The record identified an admission date of [DATE] and medical [DIAGNOSES REDACTED]. Review of Resident #2's hospital discharge summary, dated 01/12/11, stated, ". . . 1. Acute compression fracture of T12 confirmed . . . underwent vertbroplasty. . . . still having a fair amount of pain. We tried [MEDICATION NAME], which caused confusion, [MEDICATION NAME], which did not give enough pain control, and then we will start her on a [MEDICATION NAME]. . . ." Medications ordered for Resident #2 on admission for pain included [MEDICATION NAME] 200 milligrams (mg) per day, [MEDICATION NAME] 12.5 microgram (mcg) patch to skin every 72 hours, Tylenol 650 mg every 4 hours PRN, and [MEDICATION NAME] ([MEDICATION NAME]) 50 mg 1-2 tablets (tabs) every 6 hours PRN. The physician also ordered [MEDICATION NAME] 0.5 mg PRN on admission for anxiety. Resident #2's care plan for pain, initiated 01/16/11, stated ". . . experiences pain frequently related to recent vertebroplasty of the T12 spine and pressure ulcer to left achilles tendon. . . . Interventions: . . . Assess c/o (complaints of) pain promptly and administer medication as appropriate. . . . Assess for non-verbal signs of pain (grimacing, moaning, guarding, diaphoresis, etc.) Medications as ordered. Monitor (resident's) response to pain management regularly. . ." Resident #2's care plan for mood and behavior, initiated 01/21/11, stated, "Trouble falling or staying asleep & (and) yelling out & restlessness. . . . Interventions: Assess for unmet physical/psychosocial needs (pain . . .)" Resident #2's Progress Notes and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 01/13/11 *3:55 p.m. - ". . . Verbally stated 10/10 (pain level of 10 on a scale of 1-10) lower back pain. . . . PRN [MEDICATION NAME] administered as ordered at 0700 (7:00 a.m.) per her request. Continued to c/o 5/10 pain but refused to have anything else. . . ." MAR: [MEDICATION NAME] - 1:55 a.m. [MEDICATION NAME] 2 tabs - 6:56 a.m. and 10:02 p.m. 01/14/11 *12:53 a.m. - Nurses Note - Pain: LLE (left lower extremity). Verbalization of pain to area, rubbing and holding leg. . . [MEDICATION NAME] 2 tabs. . . . stated she is feeling better . . . " *1:02 a.m. - ". . . seemed very anxious. (family members) suggested to have [MEDICATION NAME] scheduled due to her anxiety. . . . also c/o pain to LLE. . . ." MAR: [MEDICATION NAME] - 3:55 p.m. [MEDICATION NAME] 2 tabs - 12:22 a.m. 01/15/11 *07:06 a.m. - "Pain: lower back - pain rating scale of 8/10, grimacing with movement, decreased bed mobility noted. . . PRN [MEDICATION NAME] administered . . . at 0300 (3:00 a.m.). Response: post administration, . . . stated that she felt relief with pain rated a 5/10 but she further stated that she didn't feel she would be able to fall back asleep and requested medication that would alleviate anxious symtoms (sic) and assist her to sleep. PRN [MEDICATION NAME] administered . . ." *12:00 noon - "Having pain in her left ankle. Wincing, verbal complaints . . . [MEDICATION NAME] administered . . ." * 4:00 p.m. - "Type of Fall: . . . unattended. Time of fall: 1045 (10:45 a.m.) . . . found on her back approximately 3-4 feet from her chair. Large bump on back of head. . . Fax sent to providor (sic). . . ." *11:34 p.m. - "Pain - Left LE (lower extremity). Verbally stated 'ouch . . .' Verbally stated 8/10 pain. . . . PRN Ulram (sic) administered . . . at 1939 (7:39 p.m.). . ." MAR: [MEDICATION NAME] - 3:38 a.m. and 7:21 p.m. [MEDICATION NAME] 2 tabs - 3:04 a.m., 12:04 p.m. and 7:39 p.m. 01/16/11 A Pain Assessment for Resident #2, dated 01/16/11, identified the following: "Current orders - [MEDICATION NAME], Tylenol PRN, [MEDICATION NAME] PRN. . . . Non-Pharmacological Interventions - repositioned, warm blanket, elevate leg. . . Frequency of Pain - daily. . . Are you requesting medication change/additions at this time: No. Is the resident having pain - Yes - on scheduled pain medications . . ." *4:01 a.m. - ". . . she did complain of mild back pain just now in which [MEDICATION NAME] was administered . . ." *5:28 a.m. - "lower back. . . . pain rating scale 8/10, grimacing with repositioning, stated, "it's not that bad' . . ." *12:29 p.m. - ". . . still c/o back pain at this time." *1:17 p.m. - ". . . has been having back pain which she rates 9/10. She does not show any signs of accute (sic) distress . . . but is moving in her chair very frequently. [MEDICATION NAME] was administered with little effect. Talked to (family member), regarding above. . . ." *1:22 p.m. - "Pain: upper back. . . . moving in her chair frequently trying to reposition. She states her pain is 9/10 . . . [MEDICATION NAME] did not seem to be effective in relieving pain. Will continue to monitor and try other interventions." *5:48 p.m. - "(Resident) c/o 8/10 pain to lower back this shift. (Resident) stated that the [MEDICATION NAME] she has ordered for PRN pain is ineffective. (Resident's family member) suggested to writer to see if there is anything else that we could get ordered for her to help with pain. Writer called on-call and received order to increase [MEDICATION NAME] to 25 mcg/hr every 3 days and [MEDICATION NAME] 5/325 mg every 4 hours PRN. (Resident) . . . with an ice pack to back. Will continue to monitor and treat pain accordingly." Facility staff did not call the physician regarding Resident #2's pain until the family suggested to call for something to help with her pain. MAR: [MEDICATION NAME] - *6:56 p.m. [MEDICATION NAME] 2 tabs - 3:50 a.m., 10:04 a.m., and *6:56 p.m. *[MEDICATION NAME] given at the same time as the [MEDICATION NAME] 01/17/11 *1:43 a.m. - "Back pain. Verbalization of 8/10 pain. . . ." *3:09 a.m. - "lower back and abdominal pain. . . . pain rating scale of 8/10, holding abdomen with repositioning, grimacing and squinting with movement, states, 'I think I better take something before it gets worse'. . ." *5:33 a.m. - Location of Pain: LLE venous ulcer . . . pain rating scale of 10/10, grimacing with movement/repositioning. . . PRN [MEDICATION NAME] administered . . . per request. Response: current time is (5:30 a.m.) . . . soundly sleeping. . ." *6:43 a.m. - "(Resident) has been restless since administration of [MEDICATION NAME] around (4:00 a.m.). She did state that she was feeling anxious. . . . PRN [MEDICATION NAME] administered . . ." *8:56 a.m. - ". . . c/o 10/10 pain to area upon dressing change. . . ." *12:49 p.m. - ". . . She c/o pain to her LLE. . . *1:03 p.m. - "Location of Pain: lower back. . . was grimacing, stating she was in pain and request a pain pill. . . ." *4:10 p.m. - "Location of Pain: Left lower leg. . . . Verbally stated 10/10 pain to left lower leg. . . . [MEDICATION NAME] administered . . . Response: Stated relief of 5/10 one hour after administration. . . ." MAR: [MEDICATION NAME] - 5:50 a.m., *1:30 a.m., and 5:15 p.m. [MEDICATION NAME] 2 tabs - 1:18 a.m., 9:04 a.m. and 7:39 p.m. [MEDICATION NAME] - 4:07 a.m. and *1:30 p.m. *[MEDICATION NAME] given at the same time as the [MEDICATION NAME] 01/18/11 *1:26 a.m. - "Location of Pain: Unable to specify where pain is located, very restless at this time. . . . Resident is very restless and unable to settle. Unable to tell writer where she is having pain. . . . PRN [MEDICATION NAME] . . . Response: Has calmed down some but is continuing to say that she's having pain. *6:57 a.m. - "Location of Pain: Back and left leg. . . . Resident stated 'my back hurts, oh my back hurts so bad, so does my leg.' Writer asked her to rate her pain using 0-5 scale, unable to follow direction. She just kept telling the writer how bad it hurt. . . . PRN [MEDICATION NAME], 2 tabs administered. Response: Still very restless, unable to settle down at this time." *7:00 a.m. - "[MEDICAL CONDITION] medication in Use: [MEDICATION NAME]. [DIAGNOSES REDACTED]. . Behaviors or symptoms being treated: Unable to settle, has been up all night very restless stating that she is in pain. Administered pain medications x2 this early morning, not proven to be effective. Unable to calm her anxiety. . . In summary, this medication has not proven to be effective for this resident at this time. She is still awake and having anxiety." *4:08 p.m. - "Location of Pain: Back and Left leg. . . . Wincing, frequent repositioning, states having pain. . . . [MEDICATION NAME] and [MEDICATION NAME] administered. Response: Pain medications do not seem to be effective at this time. Requesting to have pain medications scheduled." *8:43 p.m. - "Location of Pain: Complained of back pain and leg pain. Asked resident to rate and resident continued to voice 'Its just horrible' (at) (3:00 p.m.) and again at (4:00 p.m.). . . . Facial grimacing, Curling body inward, Calling out for help and grabbing at lower back and left lower extremity. . . . PRN [MEDICATION NAME] given at (3:00 p.m.) and PRN [MEDICATION NAME] 2 tabs given at (4:00 p.m.) after [MEDICATION NAME] still not noted to be effective. Response: At (7:00 p.m.) resident seem much more relaxed and did not have complaints of pain . . . " MAR: [MEDICATION NAME] - 5:16 a.m. and 9:30 a.m. [MEDICATION NAME] 2 tabs - 2:47 a.m., 3:56 p.m. [MEDICATION NAME] - 12:31 a.m., 10:06 a.m., and 2:50 p.m. 01/19/11 *1:54 a.m. - "Location of Pain: Unable to say where she is having pain. . . . tossing and turning in bed groaning, saying "God, please help me I hurt" . . . PRN [MEDICATION NAME]. Response: No effect on (resident) at this time, also states that she's feeling itchy." *4:46 a.m. - ". . . is extremely restless this evening and into the early morning. She is complaining of pain, unable to verbalize where this pain is located however. She keeps saying 'God, please help me' . . . PRN medications including [MEDICATION NAME] for pain, [MEDICATION NAME] for anxiety and [MEDICATION NAME] for continued pain, all of which seem to be ineffective. . . Unable to settle at this point, she has not slept at all during this shift. Will continue with interventions and medications to try to give her comfort . . ." *7:18 p.m. - "[MEDICATION NAME] . . . helped provide relief after [MEDICATION NAME]." *7:19 p.m. - "[MEDICATION NAME] . . . did seem to provide some relief as resident was not c/o pain as much." *10:33 p.m. - "Location of Pain: Lower left leg and back (at) (8:30 p.m.). . . Facial grimacing and restlessness. . . . PRN [MEDICATION NAME] . . . Response: Noted to be slightly effective at (9:30 p.m.). Resident in room resting but still tossing at times and calling out occasionally but is not calling out in pain at this time." MAR: [MEDICATION NAME] - *1:03 a.m. and 3:53 p.m. [MEDICATION NAME] 2 tabs - 2:26 a.m., 10:04 a.m. [MEDICATION NAME] - *1:03 a.m., 8:42 a.m. and 8:32 p.m. *[MEDICATION NAME] given at the same time as the [MEDICATION NAME] 01/20/11 *6:19 a.m. - "Unable to explain where pain is located, (resident) was lying in her bed repeating 'Oh god, please help me' . . . She was moving around in her bed, not listening to reassurance and direction given by staff, unredirectable and irritable. Administered PRN [MEDICATION NAME] . . . PRN [MEDICATION NAME]. . ." *7:41 p.m. - "Location of Pain: Lower back and shoulders. . . . (Resident) is moaning, grimacing, and c/o pain. . . . can not really rate her pain when ask (sic), she just states her back hurts. . . . [MEDICATION NAME]. Response: . . . did not stop moaning." MAR: [MEDICATION NAME] - *12:47 a.m., *10:05 a.m. and 6:30 p.m. [MEDICATION NAME] 2 tabs - *12:47 a.m. and 5:27 p.m. [MEDICATION NAME] - *10:05 a.m. [MEDICATION NAME] given at the same time as the [MEDICATION NAME] and [MEDICATION NAME] 01/21/11 *6:52 a.m. - "Behavior noted/What was observed: Upon entering (resident's) room at (5:15 a.m.) . . . she was crying out that 'I just can't catch my breath' and rocking back and forth in her bed. . . . Interventions: PRN [MEDICATION NAME] . . . and PRN [MEDICATION NAME] . . ." *10:57 a.m. - "Daughter . . . called this AM requesting to have pain medications scheduled and to 'throw out the Tylenol' She stated her mother is generally stoic and does not complain of pain. Since she has been complaining of pain, family would like that under control. Action: Call placed to (name of physician) nurse with above info. . . ." *11:51 a.m. - MDS (Minimum Data Set) Summary- ". . . During pain interview (resident) c/o moderate back pain. Currently medications are being adjusted and include a 25 mcg [MEDICATION NAME], and PRN [MEDICATION NAME] and [MEDICATION NAME]. . . . Will request that physician schedule [MEDICATION NAME] or [MEDICATION NAME] for better pain management. Recent vertebroplasty noted. . . ." *4:18 p.m. - ". . . has a necrotic tissue pressure wound to left achilles tendon and continues to c/o severe pain. Fax sent to provider requesting a change in [MEDICATION NAME] per daughter (name) request." Facility staff did not call the physician regarding Resident #2's pain until the family suggested they call for a change in [MEDICATION NAME]. MAR: [MEDICATION NAME] - *6:02 a.m. and 6:39 p.m. [MEDICATION NAME] 2 tabs - *6:02 a.m. *[MEDICATION NAME] given at the same time as the [MEDICATION NAME] 01/22/11 *4:10 p.m. - "Left achilles teneon (sic) wound . . . (Resident) has complained of pain to area and PRN [MEDICATION NAME] were administered . . . and appear to be ineffective. In contact with physician regarding pain control. . . ." *4:37 p.m. - "Order: [MEDICATION NAME] Patch 37 mcg/hour . . . Topical: Change every 72 hours. . . Notification: Daughter (name) notified of above orders as she called asking about them. She would like staff to monitor her pain level and update provider if it does not appear effective." *5:11 p.m. - "Location of Pain: Lower back and left LE. . . . Very anxious, unable to redirect, continuously states 'help me, I hurt'. . . PRN [MEDICATION NAME] administered . . . Response: [MEDICATION NAME] does not appear effective as she continues to complain of pain. Will continue to monitor." MAR indicated [REDACTED] *7:25 p.m. - Location of pain: lower back. . . . grimacing, and crying out stating she was in pain. . . . [MEDICATION NAME]. Response: (Resident) is quite (sic) not c/o pain." The MAR indicated [REDACTED]. MAR: [MEDICATION NAME] - *1:35 p.m. and 10:55 p.m. [MEDICATION NAME] 2 tabs - 12:48 a.m. and 4:07 p.m. [MEDICATION NAME] - *1:35 p.m. *[MEDICATION NAME] administered at the same time as the [MEDICATION NAME]. 01/23/11 *8:42 a.m. - ". . . LLE dressing was changed this AM. . . complained of pain during procedure. . . ." *10:29 a.m. - "Location of Pain: Lower Back. . . . was grimacing and moaning her back hurt. . . Pharmacologic interventions used for relief: [MEDICATION NAME] (sic). Response: sleeping" *2:00 p.m. - "Left achilles tendon . . . (Resident) complained of pain to area and received PRN [MEDICATION NAME]. . . ." *2:08 p.m. - "Location of Pain: Lower back. . . . c/o pain in her lower back. . . Pharmacologic interventions used for relief: [MEDICATION NAME]. Response: resting." *11:36 p.m. - "Location of Pain: Low back. . . . Verbalization of 7/10 pain, slow movements, facial grimacing. . . ." MAR: [MEDICATION NAME] - *9:16 a.m. and *10:37 p.m. [MEDICATION NAME] 2 tabs - 12:27 p.m. and *10:37 p.m. [MEDICATION NAME] - *9:16 a.m. and 3:25 p.m. *[MEDICATION NAME] administered at the same time as the [MEDICATION NAME] and [MEDICATION NAME] 01/24/11 *2:49 a.m. - ". . . PRN [MEDICATION NAME] and [MEDICATION NAME] for increase restless (sic), repeating "God please help me" and complaints of back pain. . . . PRN [MEDICATION NAME] and [MEDICATION NAME] seem to be effective, as been resting comfortable in her recliner . . ." *6:56 a.m. - "Location of Pain: Legs bilaterally and both shoulders. . . . States that she hurts really bad, repeating 'oh God, please help me, I hurt' fidgeting in bed. Unable to relax and sit still. . . . PRN [MEDICATION NAME] . . . Response: States that it still hurts but it does feel better." *8:36 a.m. - "Dressing was changed to left achilles. . . . some discomfort noted. . . ." *5:00 p.m. (Late Entry) - "Behavior noted/What was observed: Repetitive verbalization - 'what's wrong, something must be wrong, where are my kids, God help me' Very anxious and restless. . . . [MEDICATION NAME] and pain medication given. . . ." *8:05 p.m. - "Location of Pain: Lower back. . . . (Resident) was grimacing, moaning and c/o lower back pain . . . Pharmacologic interventions . . . [MEDICATION NAME]. Response: resting." MAR: [MEDICATION NAME] - *4:45 p.m. and *11:06 p.m. [MEDICATION NAME] 2 tabs - 5:38 a.m., *4:45 p.m. and *11:06 p.m. Tylenol 650 mg - 8:36 a. m. *[MEDICATION NAME] administered at the same time as the [MEDICATION NAME] 01/25/11 *1:37 a.m. - "Location of Pain: Back pain. . . . Facial grimacing, and the patient saying 'Oh it hurts' repeatedly, demonstrated anxious behaviors . . . [MEDICATION NAME] . . . and [MEDICATION NAME] . . . were administered at (11:06 p.m.) for pain and anxious manifestations exhibited. Response: Patient appears to be sleeping comfortably at this time." *5:34 a.m. - "Location of Pain: Patient verbalizes she has generalized pain. . . verbalized she hurts repeatedly. . . . [MEDICATION NAME] 5/325 was administered . . . Response: Pt (patient) appears to be sleeping . . ." *12:58 p.m. - "[MEDICATION NAME] . . . resident was less restless and c/o pain much less." MAR: [MEDICATION NAME] - *10:46 p.m. Tylenol 650 mg - 7:30 a.m., 1:02 p.m. and *10:45 p.m. [MEDICATION NAME] 2 tabs - 8:05 p.m. [MEDICATION NAME] - 3:17 a.m. *[MEDICATION NAME] given at the same time as the Tylenol Observation of staff toileting Resident #2 occurred at 10:30 a.m. on 01/25/11. Resident #2 complained of left leg pain and back pain throughout the entire observation, saying "it hurts so bad" and requesting to have her back rubbed. Observation of toileting on 01/26/11 at 7:45 a.m. showed Resident #2 complaining of back pain, and saying "God help me, God help me." At 8:30 a.m., a nurse (#3) changed the dressing on resident's left leg. Resident #2 was weepy and complained of back pain and leg pain during the procedure. During interview, on 01/27/11 at 8:30 a.m., Resident #14's family member (#1) stated she is concerned about her mother's pain and wants to get this controlled so that she will be comfortable. The family member stated she wants her mother to have pain medications on a scheduled basis because otherwise the pain goes on too long and gets out of control. The family member stated "Tylenol is worthless" when staff give it to her mother for pain. She also stated she did not want her mother to have [MEDICATION NAME], as it makes her confused. The family member stated her mother's recent MRI (01/26/11) indicated her back is "screwed up again" and thinks that it happened when her mother fell . A "Nursing Narrative" dated 01/26/11 at 5:26 p.m. stated, "[MEDICATION NAME] radiology called regarding earlier MRI performed and stated that (resident) does have a compression fracture in her upper spine. They are going to contact the daughter and discuss options and then get back to us with the decision. Resident #2's family expressed concern about pain control on 01/16/11 and 01/21/11 and requested that changes be made to get the resident's pain under control. On 01/16/11, the physician added another PRN pain medication ([MEDICATION NAME]) and increased the dosage of the [MEDICATION NAME] to 25 mcg. On 01/22/11, the physician increased the [MEDICATION NAME] dosage to 37 mcg. Despite these medication changes, Resident #2 continued to experience uncontrolled pain and required various PRN medications (Tylenol, [MEDICATION NAME]) every day. In addition, on 12 separate occasions, facility staff administered [MEDICATION NAME] for anxiety at the same time as they administered pain medications, making it difficult to determine the effectiveness of each of these medications. Failure to comprehensively assess the resident's pain to determine patterns and effectiveness of interventions resulted in Resident #2 experiencing uncontrolled pain and discomfort. - Review of Resident #14's closed record occurred on 01/27/11. The record identified the facility admitted Resident #14 on 10/26/10 after hospitalization for a [MEDICAL CONDITION] infarction (MI) and [MEDICAL CONDITION]. Review of the hospital discharge summary identified the physician discussed the resident's cardiac function with the patient and family and it was decided to treat her with medical management. Resident #14's Progress Notes identified the following: 10/31/10 *2:37 a.m. - Nurses Note - "States that she is having chest pain. Offered reassurance and 1:1 time. Administered 1300 mg of APAP (Tylenol) and 2L of O2 (oxygen) per nasal canual (sic). At (3:00 a.m.) (name of resident) stated that she was feeling better but the pain was still there. . . ." *6:53 a.m. - Nurses Note - ". . . was experiencing some mild chest pain throughout the night. She states that this has been happening quite frequently during the night. . . . Note left for provider. Awaiting response." *10:36 p.m. - Nurses Note - "(name of resident) c/o (complains of) chest pain, . . . denied being SOB (short of breath) . . . did not want to go to ER (emergency room ), ask for Tylenol. Will have next shift monitor." 11/01/10 *1:13 a.m. - Nurses Note - "(name of resident) continues to complain of chest pain the (sic) is consistent. Does not want to go to the ER tomorrow. Note left for provider to follow up. Administered oxygen at 2L/min (liters per minute) via nasal cannual (sic). . . . Will continue to monitor." *1:17 a.m. - Nurses Note - "At (12:45 a.m.) (resident) stated that there is no relief from the chest pain that she is having." *7:06 a.m. - Nurses Notes - "(Resident) was having episode of nausea and vomiting. 1 large emesis, 2 small ones an (sic) felt nauseated for the rest of the night. Low grade fever, 99.0. Left note for provider. . . ." *7:31 p.m. - Nurses Note - Family Communication - "Daughter . . . came to visit (resident) today and was concerned with (resident's) chest pain during the night. At her request, called on call physician to obtain an order for [REDACTED]. She is happy that we took the time to get the order." 11/02/10 *12:40 p.m. - Nurses Note - Lab - " . . . Contacted PA (physician's assistant) regarding the results. The PA state that she (the resident) most likely has had another [MEDICAL CONDITION] . . . " 11/08/10 *7:58 a.m. - Nurses Notes - "Location of Pain: Chest pain. . . . stated her chest hut (sic), . . . rated her pain at a 6 on scale of 0-10. . . head of bed raised, (resident) was resposition (sic), was advise (sic) to rest. Tylenol . . . Response: feeling a little better. *8:07 a.m. - "At (7:00 a.m.) (resident) c/o chest pain vitals . . . P (pulse) 115 R (respirations) 22 . . . Tylenol was given and (resident) was started on 1.5 L of O2." *8:29 a.m. - "Data: (Resident's) daughter called and stated that she will be transferring her mother to (name of another skilled nursing facility) at noon today. . . ." *10:40 a.m. - (Telephone Order) - "Order: To send (resident) to ER (emergency room ) per family request . . . Reason for Order: Chest pain . . . *10:44 a.m. - "Transfer to ER. . . ." Resident #14 experienced chest pain that was not relieved by Tylenol on 10/31/10, 11/01/10, and again on 11/08/10. Facility staff failed to comprehensively assess this resident's complaint of chest pain. Failing to assess the resident's pain, notify the physician, and then implement the appropriate treatment may have resulted in Resident #14 experiencing another [MEDICAL CONDITION]. 2. Based on record review, family interview, and staff interview, the facility failed to ensure the provision of care and services for 1 of 1 sampled resident (Resident #2) regarding follow-up of a wound specimen culture and sensitivity result and 1 of 1 closed record resident (Resident #14) regarding prompt attainment of an ordered lab specimen. Failure to provide the care and services related to prompt attainment of lab specimens and prompt follow-up regarding lab results resulted in a delay of antibiotic treatment for [REDACTED]. Findings include: Review of the medical record, on all days of survey, identified the facility admitted Resident #2 on 01/12/11 after discharge from the hospital. Resident #2's medical [DIAGNOSES REDACTED]. Review of Resident #2's hospital discharge summary, dated 01/12/11, stated, ". . . 6. Left leg ulcer. . . . She did have a culture of her wound, which did grow some Pseudomonas, sensitivities are pending. . . . Contact (name of physician) . . . when the sensitivities of the left leg culture come back. . . ." Resident #2's hospital discharge "New Prescriptions" form stated, "When sensitivities on culture of L (left) leg available, call (name of physician) at (name of clinic) for antibiotic orders." Review of Resident #2's Progress Notes identified the following: 01/13/11 *3:28 p.m. - "Dressing changed to left achilles tendon . . . Area has necrotic tissue noted throughout with small yellow/green sloughing tissue in the middle. Noxious odor noted. . . . states she was having pain to that area during the dressing change. . . ." 01/16/11 *1:11 p.m. - "Data: reported by previous staff member that daughter brought forth concerns that her mother should be treated with IV (intravenous) antibiotics for her left leg ulcer. Writer observed in H&P (history and physical) in chart from (name of hospital) that they had obtained a culture but were awaiting the sensitivities report. Action: Writer phoned (name of hospital) lab and had them fax over the results of the C&S (culture and sensitivity) report . . . . Action: noted and faxed to (clinic name) will have day shift staff call on-call MD (medical doctor) in the AM to see if they would like to initiate antibiotic treatment. . . ." Review of the C&S report identified the culture sensitivities were available on 01/13/11. 01/17/11 *8:56 a.m. - ". . . The dressing to (resident's) left achilles tendon was changed . . . Moderate amount of brown drainage noted . . . Necrotic tissue around sloughing tissue. . . . c/o 10/10 pain to area . . . ." *1:27 p.m. - ". . . Dressing changed to LLE. Site is necrotic and sloughing. Moderate odor noted. Moderate amount of drainage and sloughing noted . . ." 01/18/11 *1:13 p.m. - "Order: [MEDICATION NAME] 300 mg PO (by mouth) QID (four times a day) x 10 days. [MEDICATION NAME] 3.375 mg IV q (every) 6 hours x 10 days. . . ." *4:47 p.m. - "Type of Wound: Vascular. Location: Left achilles. Size: 5cm (centimeters) x7 cm. Stage: Unstageable . . . Most severe tissue type: Eschar. Drainage: Moderate amount of brownish drainage noted. Odor: mild odor noted. . . ." 01/21/11 *4:18 p.m. - "(Resident) has a necrotic tissue pressure wound to left achilles tendon and continues to c/o severe pain. . . . Strong noxious odor to wound with moderate drainage noted. . . . Location/Type of Infection: Pseudomonas to left achilles tendon. . . ." During interview, on 01/27/11 at 8:30 a.m., Resident #2's family member (#1) stated her mother had an infection in her foot prior to admission to the nursing facility and "she was supposed to be on antibiotics for her leg." The family member stated "the ball got dropped" and her mother didn't get started on antibiotics until 01/18/10 (five days after the culture sensitivities were available). - Review of Resident #14's closed record, on 01/27/11, revealed the facility admitted the resident on 10/26/10. Resident #14's care plan, initiated 10/27/10, stated ". . . has altered urinary elimination pattern related to . . . Hx (history) of incontinence. . . . leaks urine when she sneezes or coughs and she also has urgency. . . . utilizes [MEDICATION NAME] (a medication used to treat overactive bladder symptoms of urinary frequency, urgency, and incontinence.) . . . Interventions: . . . Monitor for signs of infection. . . ." Review of Resident #14's admission Minimum Data Set, dated dated [DATE], identified the resident as occasionally incontinent of urine and required extensive assistance of one staff member for toilet use and transfers. Resident #14's Nursing Progress Notes identified the following: 11/01/10 *7:06 a.m. - "Data: (Resident) was having episodes of nausea and vomiting. . . . felt nauseated for the rest of the night. Low grade fever, 99.0. . . . Note left for provider." *7:27 p.m. - "Order: . . . UA/UC (urine analysis/urine culture) . . ." 11/02/10 *11:29 p.m. - "Data: (Resident's) daughter called this AM inquiring about the labs that were ordered yesterday. She also had concerns that (resident) told her . . . that nobody has been in to assist with cares. . . ." 11/03/10 Review of laboratory results identified the following: *3:59 p.m. - Urine specimen collected *8:50 p.m. - Urine specimen received in the lab *9:08 p.m. - Urinalysis results reported. *10:31 p.m. - Nurses Note - "Data: UA Received. Clarity - Cloudy, [MEDICATION NAME] - Positive . . . Action: Waiting for UC results. Response: UC pending for results." 11/05/10 *11:23 p.m. - "Data: . . . Urine Culture results: Isolate . . . [DIAGNOSES REDACTED] pneumoniae . . . Response: New orders received for antibiotics." *12:07 p.m. - "Order: Keflex 500 mg PO BID (twice a day) for 10 days. . . . Reason for Order: UTI (urinary tract infection). . . " During interviews, the morning of 01/27/11, two administrative nurses (#1 and #2) stated they did not know why it took staff approximately 20 hours after it was ordered to collect the urine sample for Resident #14. Resident #2's Pseudomonas infection and Resident #14's urinary tract infection required antibiotic treatment. Failure of staff to promptly follow up on laboratory test results for Resident #2 and failure to promptly collect a lab specimen for Resident #14 resulted in a delay of antibiotic treatment for [REDACTED]. Delay in treatment may have also contributed to the increased pain experienced by Resident #2. 3. Based on record review, review of facility policy and procedure, review of professional references, and staff interview, the facility failed to ensure the provision of necessary care and services for 4 of 4 sampled diabetic residents (Resident #3, #7, #12, and #13) regarding high and low blood glucose parameters and when to contact a physician. Failure to establish high and low blood glucose parameters and when to contact a physician placed all diabetic residents at risk and limited the physicians' ability to ensure the quality of care. Findings include: "Managing Diabetes