Every finding on record at Burnett Medical Center

Based on interview and record review, the facility failed to ensure each resident's care plan is reviewed and revised based on the resident's needs and preferences. This occurred for 6 of 9 sampled residents (R) whose care plans were reviewed (R3, R4, R5, R6, R7, R8) for sleeping hour preferences. R3, R4, R5, R6, R7, and R8 preferred to be allowed to sleep during the night without being woken up during sleeping hours and their care plans were not updated by 6/12/26 as indicated by the facility investigation of incontinence care and resident preferences.Findings include:On 06/29/26 at 11:04 AM, Surveyor reviewed the facility reported incident investigation wherein it was alleged R3, R4, R5, R6, R7 and R8 did not receive incontinence care during the night shift from Certified Nursing Assistant (CNA) C on 05/29/26. On 06/29/26 at 9:49 AM, Surveyors interviewed R3 regarding receiving assistance with incontinence care. R3 stated he had no concerns and uses the bathroom independently. On 06/29/26 at 10:08 AM, Surveyors interviewed R6 regarding receiving assistance with incontinence care and reported no concerns and staff answer call light within 5 minutes. On 06/29/26, R4 was not available for interview, and R5, R7 and R8 were not interviewable. On 06/29/26 at 1:16 PM, Surveyor interviewed family representative for R7 who stated was made aware of concerns and stated facility was on top of it immediately and is not aware of any further concerns. On 06/29/26 at 1:23 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E regarding R7 being reported to have increased redness due to urine incontinence. LPN E stated was not aware of any skin issues with R7. On 06/29/26 at 2:50 PM, Surveyor interviewed CNA D regarding incident of concerns of lack of incontinence care submitted to state agency. CNA D indicated receiving education and expectations of completing incontinence care for residents and not aware of any further expectations. On 06/29/26 at 3:00 PM, Surveyors interviewed R9 regarding receiving assistance with incontinence care and R9 reported no concerns. On 06/29/26 at 3:10 PM, Surveyor interviewed CNA G regarding incident of concerns of lack of incontinence care to residents. CNA G indicated receiving education and expectations of completing incontinence care for residents and not aware of any further expectations.Review of licensed staff schedules from 05/17/26 through 06/13/26 notes that Certified Nursing Assistant (CNA) C no longer works at facility. Review of resident care plans indicate that R3, R4, R5, R6, R7 and R8 had no changes made to their care plans as indicated by the facility's prevention plan of the residents who have a preference to stay sleeping during hours of sleep have been identified and preferences will be entered into care plans by 06/12/26. On 06/29/26 at 2:04 PM, Surveyor interviewed Director of Nursing (DON) B regarding investigation and prevention plan the residents who have a preference to stay sleeping during hours of sleep have been identified and preferences will be entered into care plans by 06/12/26. DON B stated the task of finding out preference for incontinence care during hours of sleep was delegated to the 3rd shift staff and it hasn't been completed yet.

Based on interview and record review, the facility did not conduct a thorough investigation of abuse and neglect for 1 of 9 sampled residents (R)(R9). The facility failed to conduct a thorough investigation by not interviewing other residents to ensure no other residents may have been affected by staff verbal abuse.The facility policy, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last reviewed 03/15/22, states under section F(a). Procedures must be in place to provide the resident with a safe, protected environment during the investigation .iv. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identity and immediate clinical interventions necessary. On 05/21/26, the facility reported to state agency an allegation of verbal abuse by Registered Nurse (RN) H towards R9 who reported that, [RN H] was mean to me last night. The facility initiated and completed an investigation immediately. On 06/29/26, Surveyor reviewed the facility's investigation of events and noted the facility failed to interview other residents to ensure no other residents may have been affected by staff verbal abuse. On 06/29/26 at 3:00 PM, Surveyor conducted an interview with R9. R9 was alert and responsive. Surveyor asked R9 about the incident with RN H. R9 stated they could not remember the incident. When asked about care concerns, R9 stated there were no concerns and spoke with praise of the staff. R9 stated they had sometimes argued with RN H but they got along and the alleged incident was my fault . I don't know how to explain it . I go off the rails, if you know what I mean. R9 proceeded to share about experiencing anxiety and that they sometimes had episodes. R9 then recalled the staff helped find a glass during the night of the reported incident and they could not remember RN H being mean. When asked about concerns or staff, R9 stated there were no complaints and staff were responsive. On 06/29/26 at 2:04 PM, Surveyor interviewed Director of Nursing (DON) B regarding investigation and asked DON B if any other residents were interviewed who may have had potential negative interactions with RN H. DON B stated no other residents were interviewed regarding this investigation.

Based on observation, interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 of 3 residents (R) reviewed (R1).On 03/22/26, the facility was made aware of R1's allegation of abuse by staff. The facility did not complete a full body assessment of R1, complete interviews with staff and other residents to ensure a thorough investigation into the allegation. This is evidenced by: Facility policy titled, Abuse, neglect, Mistreatment and Misappropriation of Resident Property, with revised date of 07/10/25, states in part: The facility will immediately begin a thorough investigation of any reported incident, collect information that corroborates or disproves the incident and document the findings for the incident.Collecting and preserving physical and documentary evidence.interviewing the alleged perpetrator.Identifying and interviewing other staff or resident in the immediate area at the time of the incident who may have witnessed what occurred. Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident.Injuries present including a resident assessment.R1 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, type 2 diabetes mellitus, emphysema, bipolar disorder, depression, and generalized anxiety. Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 3/15, indicating severe cognitive impairment, behaviors of inattention fluctuate, and a PHQ-9 score of 5, meaning mild depression.R1's progress note dated 03/22/26 documented .At 0115, writer responded and observed resident attempting to stand unassisted next to bed. Writer and CNA guided resident to a safe seated position. Resident made repeated accusations toward staff, stating, You're beating me. and used profane language. Staff provided reassurance that care was for resident's safety and attempted to de-escalation by reducing stimulation and giving resident space. Resident continued yelling, kicking, and making accusations toward staff .Writer notified DON (Director of Nursing) at 0250 to report incident and resident's statements/behavior. DON acknowledged report and stated she would follow-up with resident on Monday.On 04/29/26 at 8:45 AM, Surveyor observed R1 in his wheelchair in the dining room during breakfast and R1 appeared calm. R1 did not show signs of physical abuse. On 04/29/26 at 9:10 AM, Surveyor interviewed R2 regarding abuse by staff or if R2 has observed staff abusing other residents. R2 denied being abused by staff and felt safe in the facility. R2 had no concerns about abuse. R2's Power of Attorney (POA) was present during interview with R2. R2's POA stated they had no concerns about abuse by staff. On 4/29/26 at 9:40 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D about resident abuse. Surveyor asked CNA D if CNA D had knowledge of R1's allegation of abuse. Surveyor asked CNA D what CNA D would do if CNA D witnessed abuse occurring in the facility. CNA D replied that CNA D had no knowledge of abuse occurring in the facility and would report to charge nurse and Director of Nursing (DON) immediately. Surveyor asked CNA D regarding abuse education. CNA D stated CNA D receives abuse education as needed and yearly.On 04/29/26 at 9:57 AM, Surveyor observed R1 in his wheelchair in the dining room during activities and R1 appeared calm.On 04/29/26 at 11:28AM, Surveyor interviewed R3 regarding abuse by staff or if R3 observed staff abusing other residents. R3 denied being abused by staff and felt safe in the facility. R3 had no concerns about any type of abuse.On 04/29/26 at 12:00 PM, Surveyor observed R1 in his wheelchair in the dining room during lunch and R1 was calm and interactions with staff were appropriate.On 04/29/26 at 12:03 PM, Surveyor interviewed CNA E about resident abuse. Surveyor asked CNA E if CNA E had knowledge of R1's allegation of abuse. Surveyor asked CNA E what CNA E would do if CNA E witnessed abuse occurring in the facility. CNA E stated having no knowledge of abuse occurring in the facility and would report to charge nurse and DON immediately. CNA E stated CNA E receives abuse education as needed and yearly.On 04/29/26 at 12:10 PM, Surveyor interviewed R4 and R4's spouse regarding abuse by staff or if R4 or R4's spouse observed staff abusing other residents. R4 and R4's spouse denied R4 being abused by staff and felt safe in the facility. R4 and R4's spouse had no concerns about any type of abuse. On 04/29/26 at 12:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN) F about resident abuse. Surveyor asked LPN F if LPN F had knowledge of R1's allegation of abuse. Surveyor asked LPN F what LPN F would do if LPN F witnessed abuse occurring in the facility. LPN F stated having no knowledge of abuse occurring in the facility and would report to charge nurse and DON immediately. LPN F stated LPN F receives abuse education as needed and yearly.Surveyor reviewed R1's medical record; there is no evidence documented in R1's medical record of a skin assessment on R1 after R1 alleged abuse occurred by staff. There is no documentation regarding an investigation of the allegation in R1's record.On 04/29/26 at 2:33 PM, Surveyor interviewed DON B about investigating R1's allegation of abuse by staff. DON B stated DON B interviewed R1 on Monday [3/23/26] and R1 recanted R1's statement. R1 stated staff did not hurt R1 and R1 wanted to be left alone. DON B stated no other interviews were conducted with other residents or staff only the written statements from the staff involved. After speaking with R1 it was determined the allegation did not occur.

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the State Agency and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1).On 03/22/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to the State Agency (SA) or to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Abuse, neglect, Mistreatment and Misappropriation of Resident Property, with revised date of 07/10/25, states: G. Reporting and Response Components.The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.to the administrator of the facility and the DQA in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility.R1 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, type 2 diabetes mellitus, emphysema, bipolar disorder, depression, and generalized anxiety. Minimum Data Set, dated [DATE] documented a Brief Interview for Mental status (BIMS) score of 3/15, indicating severe cognitive impairment, behaviors of inattention fluctuate, and a PHQ-9 score of 5, meaning mild depression.R1's progress note dated 03/22/26 documented .At 0115, writer responded and observed resident attempting to stand unassisted next to bed. Writer and CNA guided resident to a safe seated position. Resident made repeated accusations toward staff, stating, You're beating me. and used profane language. Staff provided reassurance that care was for resident's safety and attempted to de-escalate by reducing stimulation and giving resident space. Resident continued yelling, kicking, and making accusations toward staff .Writer notified DON (Director of Nursing) at 0250 to report incident and resident's statements/behavior. DON acknowledged report and stated she would follow-up with resident on Monday.On 04/29/26 at 12:31 PM, Surveyor interviewed Registered Nurse (RN) C about R1's abuse allegation. RN C stated R1 was agitated and tried to ensure R1 was safe when R1 was trying to self-transfer. R1 started making allegations of staff beating R1. RN C stated she immediately reported the incident to DON B and wrote out statements and had staff write statements. RN C stated RN C and the Certified Nursing Assistants (CNA)s continued to work the remainder of their shift.On 04/29/26 at 2:33 PM, Surveyor interviewed DON B regarding R1's allegation of abuse by staff. DON B stated DON B got notified around 2:30 AM that day and staff stated R1 was agitated and was calm now. DON B told staff DON B will look at this on Monday [3/23/26]. DON B stated DON B did not report the allegation to the State Agency (SA), police, or remove staff from working with residents until the investigation was complete. DON B stated on Monday 3/23/26, R1 recanted R1's statement.

Based on observation, interview and record review, the facility did not ensure 3 of 4 residents (R) reviewed were free from chemical restraints. (R1, R4, R14)The facility is not monitoring resident-specific targeted behaviors for R14's, R1's, and R4's psychotropic medication use. There is no evidence the facility is tracking targeted behaviors to assess the therapeutic effects of the psychotropic medications and ensure R14 is receiving the desired benefits and lowest possible dose. Findings include: The facility policy, titled Depression-Clinical Protocol dated 2001, states in part: 1. The physician and staff will review available information and inquired further to identify and document individuals who have a history of depression or another mood disorder, other psychiatric disorders (s), psychiatric treatment or hospitalizations, or suicide attempts. Mentoring and Follow-up The staff and physical will monitor the resident's response to treatment for a mood disorder and will document approaches. Examples of monitoring criteria include improvement or resolution of symptoms, improved quality of life and enjoyment of usual activities and improved sleep. The facility policy, titled Antipsychotic Medication Use, dated 2001, states in part: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological and emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 16. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Example 1 R14 was admitted to the facility 12/18/25, with the diagnoses that included traumatic brain dysfunction, Alzheimer's with late onset, non-Alzheimer's dementia, and anxiety disorder. R14's Minimum Data Set (MDS) assessment, dated 12/22/25, indicated that R14's Brief Interview for Mental Status (BIMS) scored a 00, meaning severely cognitively disable and unable to complete the screening. R14 is independent for movement and mobility, needs partial to substantial assistance for activities of daily living such as bathing and dressing. R14's physician orders include, in part: quetiapine fumarate oral tablet 25 mg Give 0.5 tablet by mouth at bedtime for sleep. sertraline HCl oral tablet 100mg Give 0.5 tablet by mouth in the morning for anxiety. started 1/30/26. sertraline HCL oral tablet 100mg Give 1 tablet by mouth in the morning for anxiety. started 12/18/25; discontinued 1/29/26. donepezil HCL 10mg oral tablet Give 1 tablet by mouth at bedtime for dementia. R14's care plan, dated 12/18/25, printed 1/30/26, states in part: Focus: Behavior Management. Initiated 12/20/25 Undesirable Behavior(s) Will Be Monitored / Managed. Initiated 12/20/25 Establish boundaries and limits with Resident. Initiated 12/20/25 Notify provider of new onset finding. Initiated 12/20/25 R14's Treatment Administration Record for January printed 1/30/26, includes in part: Observe closely for side effects of Antipsychotic medication . every shift. Observe closely for significant side effects of Anti-Depressant medication . every shift. Surveyor reviewed R14's medical record for behavior monitoring and noted no documentation of agitation, depression, or sleep concerns in the Treatment Administration Record (TAR), Medication Administration Record (MAR), or orders. R14's Certified Nursing Assistance (CNA) Care/ Point Click Care Tasks tab reviewed on 1/28/26 did not include targeted behavior monitoring related to R14's depression or anxiety or nonpharmacological interventions when R14 displays target behaviors. On 1/26/28 at 10:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J who stated that R14 has depression and if she is having a bad day or acting different than normal, we would let the nurse know. We do not have to track her behavior, just communicate with the nurse. On 1/28/26 at 10:36 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H who stated we are monitoring R14 for side effects of her medications. Surveyor asked LPN H about behaviors that R14 exhibits that warrant citalopram, olanzapine, and trazadone. LPN H stated that R14 has her days. If she acts out of the norm, I will let others know but we do not monitor and document if behaviors occurred, unless they do. On 1/29/26 at 11:03 AM, Interim Director of Nursing (DON) B stated to Surveyor that she changed the monitoring to Y/N and no longer just a check box. Interim DON B identified she was referring to the observations for side effects. Surveyor clarified with Interim DON B who stated no, behaviors have not been monitored routinely. Example 2 R4 was re-admitted to the facility on [DATE] with pertinent diagnoses of displaced intertrochanteric fracture of left femur, type 2 diabetes mellitus, depression, anxiety, Post Traumatic Stress Disorder (PTSD), and mood disorder. R4's care plan, dated 04/21/25, with a target date of 04/23/26, states: [R4] uses psychotropic medications related to insomnia and depression and a goal to remain free of psychotropic drug related complications, including movement disorder, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions such as discuss with MD, ongoing need for use of medications. Review behaviors/interventions and alternate therapies attempted and their effectiveness per facility policy. Surveyor did not find any specific behaviors to be monitoring R4 for in R4's care plan. R4's care plan, dated 03/07/25, with a target date of 04/23/26, states: [R4] will have improved mood state happier and calmer appearance, no signs and symptoms of depression, anxiety, and or sadness. Review behaviors/interventions for risk of self-harm or others, and monitor/record/report any acute episodes of sadness, loss of pleasure in activities, feelings of guilt/worthlessness, change in appetite, sleep patterns, and diminished concentration. R4's physician orders include: -Quetiapine Fumarate Tab 200 MG, Give 1 tablet orally one time a day for MMD. -Trazadone HCL Tab 150 MG, Give 1 tablet orally one time a day for sleep. -Bupropion HCL Tab ER 24 HR, 300 MG, Give 1 tablet orally one time a day for depression. -Duloxetine HCL Enteric Coated Pellets Cap 60 MG, give 1 capsule orally one time a day related to PTSD. Surveyor reviewed R4's medical record for behavior monitoring and noted no documentation of agitation, depression, or sleep concerns. On 01/29/2026 at 10:58 AM, Surveyor interviewed DON B and Social Services E and asked to clarify R4's diagnosis as Surveyor could not see the reason R4 is on Duloxetine, Quetiapine, and Bupropion altogether with no behavior monitoring indicating depression, anxiety, or behavior monitoring for sleep issues. Social Services E reported to Surveyor that R4's diagnosis in the medical record was depression, anxiety, post traumatic stress disorder, and mood disorder with depressive features. DON B reported to Surveyor that DON B would look for behavior monitoring for sleep and depression behaviors but doubt there is monitoring since other Surveyor brought this to our attention. On 01/29/2026 at 11:56 AM, Surveyor interviewed DON (in training) C and asked if correct diagnosis was in the medical record for R4. DON C reported that the diagnosis of Mood Disorder is a generic term and not the correct diagnosis. DON C reported that behaviors have not been monitored for R4's sleep disturbances since R4 is on Trazadone and no monitoring for depression or anxiety in R4's medical record. Example 3 R1 was admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia moderate, with anxiety and depression unspecified. R1's most recent quarterly Minimum Data Set (MDS) assessment, dated 01/04/26, noted a Brief Interview for Mental Status (BIMS) score could not be completed as resident is rarely/never understood. R1's PHQ9 score is 00, indicating no depression symptoms present. R1 had delusions present, but no physical or verbal behaviors, no rejection of cares, and no wandering. R1 had no physical restraints or alarms used. R1's care plan, dated 02/17/25, with a target date of 04/04/26, states: R1 uses psychotropic medications and a goal to remain free of psychotropic drug related complications or cognitive/behavioral impairment with interventions to review behaviors/interventions and alternate therapies attempted and their effectiveness or not as per facility policy and monitor/record occurrence of target behavior symptoms including. violence/aggression towards staff/others, and document per facility protocol. R1's physician orders include Quetiapine Fumarate Tab 25 MG Give 1 tablet orally one time a day for agitation AND Give 1 tablet orally at bedtime for agitation. Surveyor reviewed R1's monthly medication regimen (MMR) review and noted on 01/15/26, the pharmacist recommended reduction of quetiapine 25 mg if behaviors had resolved. On 01/18/26, the provider responded, .hard to redirect, positive signs of disease progression, see EMR records. Surveyor reviewed R1's medical record for behavior monitoring and noted no documentation of agitation. On 01/29/26 at 8:42 AM, Surveyor interviewed DON C regarding R1's psychotropic medications. Surveyor asked DON C if agitation was an appropriate indication for use of quetiapine. DON C stated no, not typically. Surveyor asked DON C for documentation of R1's behaviors to indicate need for quetiapine. DON C stated she would talk with DON B to find this. On 01/29/26 at 10:57 AM, Surveyor interviewed Interim DON B regarding behavior monitoring. DON B stated no behavior monitoring could be found for R14, R4, and R1.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Certified Nursing Assistant (CNA) D did not use Enhanced Barrier Precautions (EBP) when providing direct care for R7.Licensed Practical Nurse (LPN) F did not perform hand hygiene while changing R4's Libre Sensor (glucose monitoring device).This is evidenced by: Example 1 Facility policy titled, Transmission Based Precautions, with a revised date of 06/04/25, states in part: Procedure: .When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and the type of precaution. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gowns and gloves for high-contact resident care activities is indicated for residents with an infection or colonization of a multidrug resistant organism (MDRO).or for any resident with wounds.Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: .transferring, providing hygiene.changing briefs or assisting with toileting. R7 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus without complications, unspecified urinary incontinence, and weakness. On 01/27/26 at 1:29 PM, Surveyor observed a sign on R7's door indicating EBP precautions were indicated for direct care activities for R7 that included gown and gloves. Surveyor observed PPE cart outside of R7's room that contained hand sanitizer, disposable gloves, gowns, and face masks. Surveyor observed Certified Nursing Assistant (CNA) D enter R7's room and did not don a gown or gloves prior to entering. R7 asked CNA D to assist with using the bathroom. CNA D completed hand hygiene and donned gloves. No gown was used. Surveyor observed CNA D assist R7 to the bathroom using EZ stand lift. Surveyor observed a dressing in place on R7's coccyx. Surveyor observed CNA D assist R7 with peri-care, changing of disposable brief and re-dressing. CNA D assisted R7 into recliner in room and placing of personal items within reach. CNA D discarded gloves, completed hand hygiene, and exited room. On 01/27/26 at 1:52 PM, Surveyor interviewed CNA D regarding observation. Surveyor asked CNA D about the EBP sign on R7's door. CNA D stated that R7 had wounds which meant staff needed to use EBP when doing direct cares. Surveyor asked CNA D if she was wearing the appropriate PPE during R7's cares. CNA D stated no that she should have worn a gown while doing cares. On 01/28/26 at 3:23 PM, Surveyor interviewed Director of Nursing (DON) in-training C regarding EBP. DON C stated that residents with chronic wounds require EBP for direct cares. Surveyor informed DON C about observation of CNA D providing cares for R7 without EBP. DON C stated that a gown should have been used and this is an ongoing concern and re-education would be completed with staff. Example 2 On 01/28/26 at 12:27 PM, Surveyor observed LPN F entering R4's room with short acting insulin and Libre sensor box. LPN F reported to Surveyor that R4 is due to have sensor change in two hours so LPN F is going to go ahead and complete this task. Surveyor observed LPN F enter R4's room without sanitizing hands. LPN F donned gloves, removed R4's contaminated Libre sensor needle, and disposed of the needle. Surveyor observed LPN F then grab new clean Libre sensor and prep R4's skin then applied the new clean Libre Sensor kit with contaminated gloves. Surveyor did not observe LPN F doff gloves, sanitize, and then apply new clean gloves. On 01/28/26 at 12:35 PM, Surveyor interviewed LPN F and asked expectation of hand hygiene during changing the Libre sensor for R4. LPN F reported LPN F should have doffed gloves after removing the contaminated Libre Sensor and then sanitized hands, donned gloves, and then applied the new Libre sensor. On 01/28/26 at 3:20 PM, Surveyor interviewed DON C and asked expectation for LPN F utilizing hand hygiene when applying the Libre sensor to R4. DON C reported to Surveyor that LPN F should sanitize hands entering room, apply gloves, remove contaminated libre sensor, doff gloves, sanitize hands, and don gloves before applying the new sterile Libre sensor.

Based on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts and controlled substances. This occurred for 2 of the 3 medication carts/storage rooms observed. During the three-day survey, 1 of 4 observations were made of medication cart left unlocked when unattended and out of view of staff. One observation was made of a lorazepam liquid bottle that was opened and not stored in a double locked compartment while being stored in the medication storage room. Findings include: Example 1 On 01/29/2026 at 7:34 AM, Surveyor observed medication cart left unlocked in hallway down south wing. Surveyor observed 2 Certified Nursing Assistants (CNA) walking by medication cart down hallway. Surveyor did not observe a nurse around the unlocked medication cart. On 01/29/2026 at 7:38 AM, Surveyor observed Licensed Practical Nurse (LPN) G walk out of a room. Surveyor interviewed LPN G and asked what LPN G's normal process is for leaving medication cart unlocked. LPN G reported to Surveyor that LPN G just quickly walked away from medication cart to administer medications. LPN G reported that LPN G should have locked it when walking away from the medication cart. On 01/29/2026 at 7:55 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B the process for LPN G leaving medication cart unlocked while administering medications. DON B reported that LPN G should always lock medication cart when it is unsupervised. Surveyor requested policy on handling and storage of medications. Example 2 On 01/29/2026 at 7:45 AM, Surveyor toured medication storage room with Registered Nurse (RN) I. Surveyor observed liquid Lorazepam in the medication storage room fridge unlocked. Surveyor interviewed RN I and asked what the expectation for Lorazepam is to be stored. RN I reported that Lorazepam is supposed to be double locked as it's a controlled substance and the medication storage room fridge usually is always locked, but it is not right now. RN I confirmed the fridge was not locked, and RN I immediately locked the fridge with a key located on RN I's key set. On 01/29/2026 at 7:55 AM, Surveyor interviewed DON B and asked what the correct process is for storing Lorazepam or controlled substances in the medication storage room. DON B reported that DON B was just looking into the correct process for controlled substance storage such as Lorazepam but was unsure if the medication storage room being locked and only nurse on the floor had access, was that meeting the requirement. Surveyor informed DON B that Lorazepam is supposed to be double locked to decrease diversion and DON B agreed.

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (R14) reviewed for falls. R14 fell on 1/2/26 and 1/25/26. The facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall, and review and revise care plan fall interventions at time of fall or after IDT meeting.Findings include:Facility policy, titled Assessing Falls and Their Causes, dated 2001, states: [The purposes of these procedures are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of all the fall.]Steps in the ProcedureIdentifying Causes of a Fall or Falls Risk:1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. Refer to resident-specific evidence including medical history, known function impairments, etc.DocumentationWhen a resident falls, the following information should be recorded int eh resident's medical record:6. Appropriate interventions taken to prevent future falls. Per the facility procedural checklist, titled Post Fall Procedure & Checklist (SNF), undated, states:Purpose: to provide nursing staff with a clear, step by step procedure and checklist to follow immediately after a resident fall, aligned with the facility's Falls and Fall Risk policy.Interventions & PreventionUpdate care planTherapy referral if indicated.Signature Nurse:_______________ Date/Time:____________.R14 was admitted to the facility 12/18/25, with diagnoses that included traumatic brain dysfunction, Alzheimer's with late onset, non-Alzheimer's dementia, and anxiety disorder.R14's Minimum Data Set (MDS) assessment, dated 12/22/25, indicated that R14's Brief Interview for Mental Status (BIMS) scored a 00, meaning severely cognitively disabled and unable to complete the screening. R14 is independent for movement and mobility, needs partial to substantial assistance for activities of daily living such as bathing and dressing. R14's care plan, dated 12/18/25, printed 1/30/26, states in part:Focus:R14 is a moderate to high risk for falls r/t Confusion, Gait/balance problems, Incontinence, Poor communication/comprehension, Unaware of safety needs, Vision/hearing problemsFocus: The resident will be free of falls through the review dateInterventions:Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 12/31/25Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 12/31/25Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Initiated 12/31/25Follow fall protocol. Initiated 12/31/25The resident needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach. Initiated 12/31/25Focus: The resident has limited physical mobility r/t Alzheimer's. Initiated 12/19/25Intervention: Ambulation: supervision or touching assistance of 1, front wheeled walker in room and to/from meals and activities.TIPs: please encourage use of front wheeled walker, with assist of 1 and gait belt. Locomotion: n/a Date initiated 12/19/25 Revision 1/28/26Fall incident report from 1/2/26 at 10:30 AM, states: Found resident laying on the floor by her second recliner. There was blood noted on the wall socket, and to the back of her head. She was incontinent with urine at the time. When asked where she was going? She stated I don't know. Immediate action taken included assessment, vital signs and monitoring, resident was not taken to the hospital. No injuries observed at time of incident. The fall incident report did not include root cause or immediate care plan interventions to prevent falls. Surveyor requested the interdisciplinary team (IDT) investigation notes for R14's fall, root cause and interventions to prevent future falls. On 1/29/26 at 10:00 AM, Surveyor reviewed the Interdisciplinary Team (IDT) At-Risk Resident Meeting notes from 1/9/26. Meetings document that R14 had a fall; care plan was updated. No root cause identified, or specific care plan update or intervention implemented. Fall incident report from 1/25/26 at 1:50 PM, states: I was sitting at the nurse's stations charting when another resident approached the nurse's station and said that there was a resident who had fallen in the dining room. When I entered the dining room, I observed resident on the floor sitting on her butt in front of her dining chair. There was spilled milk on the resident's table as well as on the floor in front of the resident's chair. Resident was sitting on her butt but slightly leaning back so her head was underneath the dining room table. Resident was confused per baseline but denied any pain or injury. Resident has active ROM in both upper and lower extremities. A&0 (alert and orientated) is at baseline and resident can answer questions appropriately. DON notified via text message and POA notified. Immediate action taken included resident assisted back to dining room chair via Hoyer lift with a sling. VS and neuros obtained. Patient educated on the importance of waiting for assistance before trying to transfer herself. Resident was not taken to the hospital. The fall incident report did not include root cause or immediate care plan interventions to prevent falls. Reported reminders and educations not added to the care plan as interventions.Surveyor requested the interdisciplinary team (IDT) investigation notes for R14's fall that occurred on Sunday, 1/25/26, and IDT team did not meet until Wednesday, 1/28/26. Fall incident report from 1/27/25 at 4:38 PM, states: Resident has a witnessed fall in the dining room this evening around 1638. Resident was sitting at a table in the dining room and then was walking without her walker and fell near another table. No injuries, did not hit her head. Resident is an [AGE] year-old female with a history of Alzheimer's disease, dementia, GAD, and HTN. Also has a history of falls. When this nurse came into the dining room resident observed sitting on her butt, with activity director holding her hand. Residents denies any pain. Reminded resident to use her walker when walking. Immediate interventions taken included her vitals were taken, (vital signs recorded) . Resident was assisted to her chair using Ez-lift. She was not taken to the hospital. The fall incident report did not include root cause or immediate care plan interventions or update to prevent falls. Surveyor requested the IDT investigation notes for R14's fall, root cause and interventions to prevent future falls. On 1/29/26 at 10:00 AM, Surveyor reviewed IDT At-Risk Resident Meeting notes from 1/28/26 meeting. R14's falls were reviewed. R14 has had five falls in the last month. Rehab will screen her again. Reviewed Care plan. Rehab will update the ambulation section. Discussed options to reduce falls including consideration of moving her room closer and increasing safety checks. Suggestion for gait best to be accessible on front wheeled walker training DON will review with the team. No root cause identified. Of suggested interventions above, only addition or update is the ambulation assessment by therapy.Surveyor's review of R14's care plan did not identify an update for fall interventions in active care plan or history between 12/31/25 and 1/28/26. On 1/2/9/26 at 11:32 AM, Surveyor interviewed Interim Director of Nursing (DON) B who stated the expectation of staff after a resident fall is to update care plan interventions. Interim DON B states something needs to be put in place right away. If more investigation is needed, then within 24 hours interventions should be updated.On 1/29/26 at 11:52 AM, Interim DON B came to Surveyor and handed her a post-it note that stated no care plan revisions from R14's falls 1/2/26. Surveyor asked clarifying question about note. Interim DON B stated no, there were no care plan interventions for January 2nd and January 25th, but you have that there was for January 27th.Note: On 1/29/26 at 8:40 AM, Surveyor asked Nursing Home Administrator (NHA) A for all falls for R14 that occurred during this survey period; 10/23/24 to date. Fall documentation is in a risk management system Surveyor does not have access to. Surveyor received 3 falls to review, all were in the month of January 2026, from NHA A. Surveyor did not realize there were 5 falls in the month of January as documented in the IDT notes until after leaving the survey.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R4 and R31) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R4 and R31 received written information on reserve bed payment policy. R4 was transferred to the Emergency Department (ED) on 10/15/25 and 10/23/25. R4 was not provided with a complete written transfer or bed hold notice. R31 was discharged to home and facility did not have any documentation that Ombudsman was notified.Findings include: Facility's policy titled Transfer or Discharge Notices with reviewed date of March 2025 read in part, .Notice of Transfer or discharge: 3. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge. d. An explanation of the residents' rights to appeal the transfer or discharge to the state, including: 1. The name, address, email, and telephone number of the entity which receives such appeal hearing requests, 2. Information about how to obtain and appeal form, 3. How to get assistance in completing and submitting the appeal hearing request. Example 1 Surveyor reviewed R4's bed hold notice for 10/15/25 and found no daily bed hold rate, appealed rights information for R4, and no specific reason for transfer to the hospital. Surveyor reviewed R4's bed hold notice for 10/23/25 and found no daily bed hold rate, appealed rights information for R4, and no specific reason for transfer to the hospital. On 01/29/2026 at 12:26 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked about bed hold notice, ombudsman notification, and the daily rate on bed hold notices. NHA A reported to Surveyor that NHA A and staff have recently found the bed holds were not being completed correctly. NHA A reported there should be more information on the bed hold policy. NHA A showed Surveyor a new form that NHA A had typed for correction of bed hold notices to show the exact dollar amount for the daily rate of the bed hold. NHA A added the appeals process and resident rights for the bed hold and will make sure staff are educated on the bed hold policy going forward. Example 2 R31 was admitted to the facility on [DATE] for a short-term rehab stay. On 11/26/25, R31 was discharged to home without services. Discharge summary and medication reconciliation completed. No notification of Ombudsman notification was documented. On 01/29/26, Surveyor requested Ombudsman notification from Social Services (SS) E. No documentation was provided.

Based on interview and record review, the facility did not formulate an advance directive for 2 of 16 residents (R)(R32, R33) reviewed.R32 did not have a physician order or code status of DNR documented.R33 did not have R33's code status documented in the medical record or in the binder at the nurse's station, which is for full code status residents.This is evidenced by: Facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation and Basic Life Support, with a revised date of 04/2025, states in part: General Gudielines.2. If the resident's DNR status is unclear, CPR will be initiated and continued until it is determined there is a DNR or a physician's order not to administer CPR.Preparation for Cardiopulmonary Resuscitation.f. Provide information on advance directives to each resident/representative upon admission. g. Document advance directives in the resident medical records and educate staff on how to access this information. Example 1 R32 was admitted to the facility on [DATE] with pertinent diagnoses of metabolic encephalopathy, hepatic encephalopathy, unspecified cirrhosis of liver, ascites, encounter for palliative care, and CKD stage 3a. Surveyor reviewed R32's care plan and noted no care area indicating code status or advance directive. Surveyor reviewed R32's electronic medical record (EMR) and noted no physician orders or advanced directive indicating R32's code status. On [DATE] at 12:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) H regarding R32's code status. LPN H stated that R32 had a Do Not Resuscitate (DNR) code status. Surveyor asked LPN H to show where this was documented. LPN H went into R32's EMR and looked for the physician order or advanced directive to demonstrate this. LPN H stated she was unable to find it. Surveyor asked LPN H how staff knew R32 was a DNR status. LPN H stated that was what they were told on admission. Surveyor asked LPN H where staff should be able to see a resident's code status. LPN H stated there should be an order and a clear indication across the top banner of a resident's EMR. On [DATE] at 12:54 PM, Surveyor interviewed Director of Nursing (DON) in-training C regarding code status. DON C stated a physician order for code status should be on every resident's EMR for easy access. DON C stated this is a recognized area of improvement and the facility is in the process of implementing a new check-off for admissions to review this is in place. DON C stated that there had been some uncertainty of R32's code status and this is why it hadn't been ordered yet. Example 2 On [DATE] at 11:01 AM, Surveyor reviewed R33's code status in Electronic Health Record (EHR). Surveyor could not find a code status. Surveyor reviewed scanned in documents from discharge orders from another facility, which only showed that R33 is a full code status. Surveyor did not find physician orders or acknowledgement showing that the facility addressed R33's code status in the facility's system upon or after admission of [DATE]. On [DATE] at 1:10 PM, Surveyor interviewed LPN F and asked how LPN F knows what code status a resident is in case a resident has an emergency or codes. LPN F reported to Surveyor that LPN F would look in the EHR and at the top left-hand corner on the dashboard underneath resident name is the resident's code status. LPN F reported that LPN F will memorize residents' code statuses to know if they are full code or Do Not Resuscitate (DNR). LPN F reported that if you click the blue link that states Advance Directive in the EHR underneath the code status on dashboard, the EHR will take the nurse to the scanned documents where LPN F would see the code status. Surveyor asked LPN F to check R33's code status in EHR. LPN F pulled R33's EHR up to LPN F's computer. LPN F stated, Oh no, it's not there. LPN F then started searching through scanned documents to try to find R33's code status. LPN F stated, It is not there either. Surveyor asked how LPN F would know R33 is a full code. LPN F reported to Surveyor that on admission all residents who are a full code are placed on a list, which is in a binder at the nurse's station. Surveyor asked LPN F to show Surveyor the code status binder. LPN F grabbed the code status binder and LPN F did not see R33 on the list as full code. Surveyor did not observe R33 to be on the most recent code status sheet in binder. Surveyor asked LPN F how often the code status binder is updated. LPN F reported it should be updated every time there is a new admission who is full code status. On [DATE] at 3:25 PM, Surveyor interviewed DON C and asked what the process is for addressing code status with new admission in the facility. DON C reported staff should be addressing code status with admission and making sure the documentation is in the EHR on dashboard, advance directives in the scanned in documents, and if DNR then a physician order as well. DON C reported that R33 should have had code status addressed but this was missing on admission placing the information into the computer so all staff can see code status.

Based on interview, record review and facility policy review, the facility failed to ensure a complete and accurate medical record for two residents (Residents (R) 1, R2) in a total sample of six. The facility failed to completely describe an accurate description of a fall and document the neurological checks at the time of the fall for R1. This failure placed the residents at risk of unmet care and a diminished quality of life.Findings include: Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed R1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), aortic valve insufficiency, and congestive heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an assessment reference date (ARD) of 10/07/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicated R1 was moderately impaired in cognition. Review of a 12/09/25 at 9:17 PM Incident Note located in the Progress Notes tab of the EMR revealed, [R1] fell out of bed. Blankets fell onto the floor, and [R1] tripped on them. Blankets were picked up, and [R1] was placed back in bed. There are no cuts or bruises at this time. Dr. notified and son notified. The Incident Note did not show a complete and accurate description of the fall including vital signs or neurological checks at the time of the fall. During an interview on 01/07/26 at 12:50 PM, the IDON confirmed R1's medical record was not complete and accurate, and the neurological checks should have been documented at the time of the fall, and not two days later. During an interview on 01/08/25 at 3:19 AM, Registered Nurse (RN) 1 stated, I was on duty the night she fell. She had not had any falls prior to this fall, but she would transfer herself back and forth to the bathroom. [R1] had a lot of anxiety during the night. At the moment of the fall, [Certified Nurse Aide (CNA) 1] alerted me in the hallway. [R1] was lying on [R1's] stomach near the side of the bed, more towards the foot of the bed and [R1] was wrapped up like a cocoon as [R1] would always have at least two comforters on [R1] at night. [R1] did not hit [R1's] head, [RN 1] did the initial neurological checks and the subsequent neurological checks however, they were not documented at the time, it was a busy night and that was a mistake on my [RN 1's] part. Review of the Assessments tab in the EMR revealed R1's neurological check were not documented until 12/11/25 by RN 1.

Based on interviews, record review and review of facility policy, the facility failed to provide a transfer form to the hospital at the time of the transfer for one resident (Resident (R) 2) in a total sample of six. This failure placed residents at risk of lack of information being shared with the hospital.Findings include. Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed R2 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic kidney disease, and a history of urinary tract infections. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the Electronic Medical Record (EMR) revealed R2 had a BIMS score of 10 out of 15, which indicated R2 was moderately impaired in cognition. Review of an 09/16/25 Plan of Care Note located in the Progress Notes tab of the EMR revealed, . Upon inquiry of Res [resident] sitting in her chair with the light on, Res found to be not WNL [within normal limits] for her talking and walking ability. She soiled herself in her chair . Call placed to [Family Member (FM) 2] and she requested that she be taken to the ER for eval [evaluation] . During an interview on 01/08/26 at 3:45 AM, Registered Nurse (RN) 1 stated, I was the Director of Nursing (DON) at that time. The night nurse alerted me that [R2] wasn't doing well, so we sent her to the ER. She was admitted with sepsis [a life-threatening emergency where the body has an overactive response to infection] and she was admitted to the hospital. During an interview on 01/08/26 at 11:30 AM, the IDON stated, I cannot find a transfer notice was done however, a transfer notice should have been done prior to going to the ER. The transfer notice would have included nursing assessment, vital signs, and other pertinent information. Review of the facility policy titled, Charting and Documentation, revised July 2017 revealed, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record . The following information is to be documented in the resident medical record . Objective observations .Medications administered . Treatments or services performed . Changes in the resident's condition .Events, incidents, or accidents involving the resident . Documentation in the medical record will be objective (not opinionated or speculative, complete, and accurate .

Based on interview, record review, and facility policy review, the facility failed to ensure the provider was notified of significant change in condition for one resident (Resident (Resident (R) 1) of three sampled residents reviewed for change in condition in a total sample of six. This failure placed residents at risk of increased medical complications.Findings include. Review of the admission Record provided by the Interim Director of Nursing (IDON) revealed that R1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), aortic valve insufficiency, and congestive heart failure. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an assessment reference date (ARD) of 10/07/25 revealed R1 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicated R1 was moderately impaired in cognition. Review of a 10/11/25 Plan of Care Note, located in the Progress Notes tab of the EMR revealed, . Res [resident] had an episode of weakness and confusion around 0300 [3:00 AM] this am. Writer assessed after CNA [certified nurse aide] walked by and noted that R1 was having difficulty walking. A w/c [wheelchair] was used to finish x-[NAME] [transferring] her to the BR [bathroom] and back to bed . Res breathing was of a labored puffing out exhales. Res admitted to being scared but denied pain. Her L [left] arm was hanging flaccid, her hand grasps were not equal (very weak on the Left noted to be quite swollen), she was able to swallow a drink of water without difficulty, but she did not answer her orientation questions correctly, except for her name. No facial droop and eyes have equal PERRLA [pupils equal, round, reactive to light and accommodation]. A call was placed to [Family Member (FM) 1] and she was ok with having [R1] sleep here, lay down in her own bed, and get rest, as opposed to waiting in the ER [emergency room] with possibly no help for her anyways . The 10/11/25 Plan of Care Note did not contain documentation that the provider was notified of the significant change in condition. During an interview on 01/07/25 at 12:50 PM, the IDON confirmed the provider should have been notified ASAP (as soon as possible). During an interview on 01/08/25 at 3:19 AM, Registered Nurse (RN) 1 stated, I would have called the physician at the time, period. I was the DON at the time, anytime we have a change in condition, you call the physician. I do not remember having received a call from the staff regarding this change in condition and this is the first time I have heard about it. Staff should not have called the family and got directions from them first. Review of the facility policy titled Change in a Resident's Condition or Status, revised December 2025 revealed, . The facility promptly notifies the resident, resident's attending physician or provider, and the resident representative of changes in the resident's condition and/or status .The nurse will notify the resident's attending physician, provider, or physician on call when there has been .Significant change in the resident's physical, emotional, or cognitive condition . Need to alter the resident's medical treatment significantly .

Based on observation, interview and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice for 1 of 3 residents (R) (R1) reviewed.R1 was a brittle diabetic who did not receive medications per physician orders and provider was not notified of abnormal blood glucose levels.This is evidenced by:Facility policy, titled, Change in a Resident's Condition or Status, with a revised date of 02/2021, states in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications two (2) or more consecutive times; i. specific instruction to notify the physician of changes in the resident's condition.Facility policy, titled, Management of Hypoglycemia, with a revised date of 11/2020, states in part: Purpose: To provide guidelines for managing hypoglycemia secondary to insulin therapy.Management of Hypoglycemia: 2. For Level 1 hypoglycemia (<70 mg/dL): a. Give the resident an oral form of rapidly absorbed glucose (15-20 grams); b. Notify the provider immediately;.d. Recheck blood glucose in 15 minutes.Facility policy, titled, Insulin Administration, with a revised date of 09/2014, states in part: Reporting: 1. Notify your supervisor if the resident refuses the insulin injection.Facility's current Continuing Care Center Standing Orders, with no date, states in part: 15. Diabetic Management: b. Notify provider if two BG results are < 70 or > 400 in a 24-hour timeframe and/or change in condition; if no condition change, notify provider on the next business day. 16. Hypoglycemia (BG < 70) d. Communicate occurrence of any hypoglycemic event to provider the next business day.R1 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus, heart failure, and chronic kidney disease.R1's most recent quarterly Minimum Data Set (MDS) assessment, dated 09/01/25, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. R1's medications include antiplatelets and hypoglycemics.R1's care plan, dated 02/05/25, with a target date of 11/23/25, states: Impaired nutrition related to brittle diabetes and unstable blood sugar with interventions to assist R1 in blood sugar control; if R1 refuses insulin, re-educate on insulin's action in bringing down high blood sugars or preventing hyperglycemia.R1's care plan, dated 02/19/25, with a target date of 11/23/25, states: R1 has diabetes mellitus with a goal to have no complications related to diabetes and interventions to give diabetes medication as ordered by doctor, educate that diabetes is a chronic disease and compliance is essential to prevent complications of the disease, if infection is present consult doctor regarding any changes in diabetic medications.R1's physician orders:01/27/25 (discontinued 09/10/25) glucose 4-gram chewable tablet Give 4 tablet orally as needed for HYPOGLYCEMIA related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS.02/03/25 BLOOD GLUCOSE MONITORING AS NEEDED as needed related to Type 2 diabetes mellitus without complications.02/20/25 Ondansetron HCl Oral Tablet 4 MG (Ondansetron HCl) Give 1 tablet by mouth every 6 hours as needed for NAUSEA.02/27/25 (discontinued 09/10/25) Insulin Degludec Soln Pen-Injector 200 Unit/ML Inject 28 unit subcutaneously one time a day related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS.09/10/25 (discontinued 09/23/25) glucose 4-gram chewable tablet Give 4 tablet orally as needed for HYPOGLYCEMIA related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Administer if blood glucose is less than 70.09/23/25 glucose 4-gram chewable tablet Give 4 tablet orally as needed for HYPOGLYCEMIA related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Administer if blood glucose is less than 80.07/24/25 FreeStyle Libre 2 Sensor Miscellaneous (Continuous Glucose System Sensor) Inject 1 applicator subcutaneously one time a day every 14 day(s) related to Type 2 diabetes mellitus without complications.08/22/25 (discontinued 09/30/25) Admelog SoloStar Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 249 = 0U; 250 - 299 = 3U; 300 -349 = 4U; 350 - 399 = 5U; 400 - 999 = 6U >400 Give 6 Units, recheck in 2HRS Notify Provider, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS.09/30/25 Admelog SoloStar Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 249 = 0U; 250 - 299 = 3U; 300 - 349 = 4U; 350 - 399 = 5U; 400 - 999 = 6U >400 Give 6 Units, Recheck in 2HRS Notify Provider, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS Follow up with NP/MD upon next clinic/rounding schedule day if resident refusing or not refusing to take amounts as ordered per her sliding scale order.09/25/25 Basaglar KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Glargine) Inject 28 unit subcutaneously one time a day for DIABETES.Surveyor reviewed R1's Medication Administration Record (MAR) for 07/2025 - 09/2025 and noted the following:In July 2025, R1's MAR noted resident refusal of sliding scale insulin order on 07/01, 07/02, 07/03, 07/05, 07/06, 07/09, 07/10, 07/11, 07/12, 07/14, 07/17, 07/18, 07/19, 07/20, 07/21, 07/22, 07/28, and 07/30.-No documentation of provider notification was noted when R1 refused sliding scale insulin.On 07/03/25 at 8:18 AM, R1's blood sugar was 57. No documentation of glucose tabs given or provider notification noted.On 07/17/25 at 5:16 PM, R1's blood sugar was 357. R1 was noted to refuse sliding scale insulin with a note stating, Only would take 3 units. Order states R1 should have received 5 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 07/22/25 at 4:53 PM, R1's Degludec (long-acting) insulin order for 28 units was noted as administered with a note stating, Only took 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 07/24/25 at 20:20, R1's blood sugar was 562. MAR noted sliding scale insulin was administered with a note stating, Resident requested to only receive 4 unit. 4 units provided. Order states R1 should have received 6 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 07/26/25 at 11:35 AM, R1's blood sugar was 67. No documentation of glucose tabs given or provider notification noted. Next documented blood sugar was noted at 3:47 PM of 270. No follow-up blood sugar within 2 hours was noted.On 07/29/25 at 4:26 AM, glucose 4-gram chewable tablet was noted as administered with a note stating, 3 am blood sugar 65, given choc shake & 2 glucose tabs. No documentation of notifying provider of blood sugar below 70 mg/dL or provider authorization to administer an alternate dose of glucose tabs noted.On 07/30/25 at 1:29 AM, glucose 4-gram chewable tablet was noted as administered with a note stating, Res sat up to eat 3/4 tabs given with 2 juice and 2 Oreo cookies. No blood sugar documented at this time. No documentation of provider authorization to administer an alternate dose of glucose tabs noted.On 07/30/25 at 8:03 PM, R1's blood sugar was 247. MAR noted sliding scale insulin was administered with a note stating, Drug refused and asked for 2 sugar pills. No documentation of provider notification or authorization to administer an alternate dose was noted.On 07/31/25 at 5:20 PM, R1's Degludec (long-acting) insulin order for 28 units was noted as administered with a note stating, Resident stated 'I only want 4 units' Explained of insulin being long acting and continued to demand 'I will only take 4 units. 4 units provided per request. No documentation of provider notification or authorization to administer an alternate dose was noted.In August 2025, R1's MAR noted resident refusal of sliding scale insulin order on 08/01, 08/02, 08/03, 08/04, 08/06, 08/07, 08/09, 08/11-08/22, 08/24, 08/27-08/31.-No documentation of provider notification was noted that R1 refused sliding scale insulin.On 08/05/25 at 8:01 PM, R1's blood sugar was 500. No provider notification noted.On 08/06/25 at 3:00 AM, MAR note stated, Res blood sugar was 'high' at bedtime. No follow-up blood sugar check noted. No documentation of provider notification was noted.On 08/08/25 at 7:42 PM, R1's blood sugar was 500. No documentation of provider notification was noted.On 08/08/25 at 11:02 PM, MAR note stated, Bedtime blood sugar HI. No follow-up blood sugar check noted. No documentation of provider notification was noted.On 08/13/25 at 6:20 PM, R1's blood sugar was 341. R1's Degludec (long-acting) insulin order for 28 units was noted as administered with a note stating, Only allowed 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/17/25 at 11:58 AM, R1's blood sugar was 313. MAR noted sliding scale insulin was administered with a note stating, Resident would only take 2 units. Order states R1 should have received 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/18/25 at 12:26, R1's blood sugar was 455. MAR noted sliding scale insulin was administered with a note stating, Only allowed 3 units. Order states R1 should have received 6 units, and the provider notified. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/18/25 at 6:39 PM, R1's Degludec (long-acting) insulin order for 28 units was noted as administered with a note stating, Only wanted 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/22/25 at 6:36 PM, R1's Degludec (long-acting) insulin order for 28 units was noted as administered with a note stating, Gave only 2 units per resident request. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/24/25 at 4:25 PM, R1's blood sugar was 332. MAR noted sliding scale insulin was administered with a note stating, Resident requested 3 units. R1 should have received 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 08/26/25 at 4:49 AM, R1's blood sugar was 106. MAR noted administration of glucose 4-gram chewable tablet. No documentation of provider authorization to administer an alternate dose was noted.On 08/31/25 at 12:14 PM, R1's blood sugar was 488. MAR noted sliding scale insulin was administered with a note stating, Would only take 2 units. Order states R1 should have received 6 units, and the provider notified. No documentation of provider notification or authorization to administer an alternate dose was noted.In September 2025, R1's MAR noted resident refusal of sliding scale insulin on 09/03-09/06, 09/09-09/18, 09/24-09/29. No documentation was noted for bedtime dose on 09/13 and 09/14.-No documentation of provider notification was noted that R1 refused sliding scale insulin.On 09/03/25 at 5:24 AM, MAR noted administration of glucose 4-gram chewable tablet with a note stating, Res took 2 tabs due to a 59 BG. At 6:28 AM, R1's blood sugar was 59. At 6:54 AM, R1's blood sugar was 59. At 6:57 AM, MAR note states medication was effective. No follow-up blood sugar was noted until 11:47 AM of 176. No documentation of provider notification of low blood sugar or authorization to administer an alternate dose was noted.On 09/10/25 at 6:37 AM, MAR noted administration of glucose 4-gram chewable tablet with a note stating, Res am BG-54. At 7:23 AM, R1's blood sugar was 54. At 7:24 AM, MAR note states medication was effective. No follow-up blood sugar was noted until 12:06 PM of 204. No documentation of provider notification of low blood sugar or authorization to administer an alternate dose was noted.On 09/14/25 at 12:05 PM, R1's blood sugar was 450. MAR noted sliding scale insulin was administered with a note stating, Only allowed 3 units. Order states R1 should have received 6 units and provider notified. No documentation of provider notification of elevated blood sugar or authorization to administer an alternate dose of insulin was noted.On 09/15/25 at 1:29 PM, R1's blood sugar was 400. MAR noted sliding scale insulin was administered with a note stating, Only allowed this nurse to give 3 units. Order states R1 should have received 6 units and provider notified. No documentation of provider notification elevated blood sugar or authorization to administer an alternate dose of insulin was noted.On 09/15/25 at 6:47 PM, R1's Degludec (long-acting) insulin order for 34 units was noted as administered with a note stating, Only allowed to give 4 units. No blood sugar was documented at this time. No documentation of provider notification or authorization to administer an alternate dose was noted.On 09/17/25 at 8:04 PM, R1's blood sugar was 329. MAR noted sliding scale insulin was administered with a note stating, Only gave 3 units per resident. Order states R1 should have received 4 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 09/21/25 at 2:51 AM, MAR noted administration of glucose 4-gram chewable tablet with a note stating, 1:00 AM blood sugar 135 - given 2 glucose tabs. Blood sugar at 3 am 187. No documentation of provider communication to give alternate dose for blood sugar outside of order parameters.On 09/21/25 at 8:03 PM, R1 complained of nausea and PRN ondansetron 4 mg was administered. At 8:05 PM, R1's blood sugar was 357 and PRN med was noted as effective. No communication with provider was noted concerning new onset nausea.On 09/23/25 at 5:20 PM, R1 complained of nausea and PRN ondansetron 4 mg was administered. At 6:14 PM, R1's blood sugar was 168 and PRN med was noted as ineffective. No communication with provider noted.On 09/24/25 at 11:03 AM, R1 complained of nausea and PRN ondansetron 4 mg was administered. At 11:59 AM, R1's blood sugar was 254 and PRN med was noted as effective.On 09/25/25 at 1:03 PM, R1 complained of nausea and PRN ondansetron 4 mg was administered. No blood sugar noted. At 4:17 PM, R1's blood sugar was 312 and PRN med was noted as ineffective. R1 refused sliding scale insulin. At 8:54 PM, MAR noted sliding scale insulin was not administered and R1 was sent to ER.On 09/26/25 at 12:33 AM, MAR noted R1 returned from ER and blood sugar was 198 at 12 AM. At 12:00 PM, R1 complained of nausea and PRN ondansetron was administered. R1's blood sugar was 269. At 12:07 PM, PRN med noted as effective. At 5:54 PM, R1 complained of nausea and PRN ondansetron was administered. R1's blood sugar was 347. At 7:40 PM, PRN med was noted as effective. At 8:07 PM, R1's blood sugar was 499. No documentation of communication with provider was noted regarding R1's elevated blood sugar.On 09/27/25 at 12:20 PM, MAR noted sliding scale insulin was administered with a note stating, Device registered 'HI' resident requested 3 units of insulin. At 5:21 PM, R1's blood sugar was 368. MAR noted sliding scale insulin was administered with a note stating, Resident requested only 3 units. Order states R1 should have received 5 units. No documentation of provider notification or authorization to administer an alternate dose was noted.On 09/29/25 at 8:34 AM, R1's blood sugar was 368. MAR noted sliding scale insulin was administered with a note stating, Resident requested only 3 units. Order states R1 should have received 5 units. At 12:21 PM, MAR noted sliding scale insulin was administered with a note stating, Device reads 'HI,' resident requests 3 units. At 5:36 PM, MAR noted sliding scale insulin was administered with a note stating, Device reads 'hi' resident requests only 3 units. At 8:21 PM, R1's blood sugar was 599. Resident refused sliding scale insulin. No documentation of provider notification of elevated blood sugar, refusal of insulin, or authorization to administer insulin outside of order parameters was noted.On 10/28/25 at 2:56 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding blood sugar monitoring and insulin administration. LPN C stated that if a provider does not have specific orders for communicating blood sugars, the facility uses standing orders to notify provider when blood sugar is lower than 70. LPN C was not certain when to communicate elevated blood sugars but believed it should be above 400. LPN C stated that insulin or hypoglycemic meds should always be administered per the provider orders and any dose changes would be communicated by the provider and then documented in a progress note. Surveyor asked LPN C is it was an acceptable practice to administer an insulin dose different than ordered if the resident requests to do so. LPN C stated, no, that the provider would need to be contacted prior to administering a different dose than ordered.On 10/28/25 at 3:47 PM, Surveyor interviewed Director of Nursing (DON) B regarding R1's diabetic care. DON B stated the provider should be contacted per orders regarding blood sugars and medication refusals. Surveyor asked DON B if it was an acceptable practice for nurses to administer medications outside of order parameters. DON B stated the nurses should not be administering medications differently than the provider ordered. Surveyor asked if she was aware that multiple doses of insulin and glucose tabs were administered to R1 differently than ordered. DON B stated this was something that she had become aware of and was working on re-educating staff on following provider orders.On 10/28/25 at 3:58 PM, Surveyor interviewed LPN E asking about blood sugar monitoring, documentation, insulin administration, and physician notification. LPN E stated a blood sugar over 400, would call the physician. If R1 was given any insulin, R1 would drop. There was nothing in R1's MAR to state when to call the physician. If the blood glucose meter would read 'high', staff would document in the [DATE] and would retake the blood sugar in 10 minutes and give insulin and would be down to 350. If R1 was low, staff would give 2 glucose tabs and would check blood sugar in 10 to 15 minutes later. LPN E stated she did not notify the physician when R1's blood sugar was out of range. R1 would request the amount of insulin R1 wanted and would then administer that amount. LPN E stated the physician was not notified when insulin was not given as ordered. LPN E stated did not receive education at the facility for when blood sugars are out range and when to notify the physician. On 10/29/25 at 10:36 AM, Surveyor interviewed Interim Chief Executive Officer (CEO) D regarding R1's care. CEO D stated there is no question that the expectation is for nurses to follow the provider's orders. Staff would be expected to communicate with the provider if a resident refuses medications or with changes in blood sugars, especially with a brittle diabetic like R1. CEO D stated the facility can definitely do better in this area.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility did not keep a complete surveillance line list which affects all residents (R), did not perform hand hygiene with glove changes during wound cares for 1 of 2 residents (R4), touched medications to be administer with bare hands for 2 of 8 (R6, R7) observations, and did not dispose of PPE properly when caring for residents on enhanced barrier precaution for 2 of 5 residents (R1, R17). This had the potential to affect all residents in the facility. Findings include: Example 1 Facility policy titled: Infection Prevention and Control Program, with a last revised date of 05/14/24, states in part: .Active Surveillance: Conducting surveillance activities that include infection detection, data collection and analysis, monitoring, and evaluation of interventions .monitoring patients, residents, and healthcare workers for acquisition of infections. On 10/22/24, Surveyor reviewed the facility's infection surveillance log for staff and residents and noted the following: The dates included on the log were 01/01/24-10/10/24. No documentation was provided for the dates of 10/11/24-10/21/24 and 10/21/23-12/31/23 for the surveyor to review for a complete year of documentation. All residents listed do not include the date symptoms resolved. All residents listed do not include the date isolation precautions were implemented and discontinued. All residents listed do not include the start and end date of antibiotic, if applicable. On 10/21/24, R12's record review indicated being prescribed an antibiotic for Urinary Tract Infection (UTI). This is not documented on the infection surveillance log. On 10/21/24, R25's record review indicated being prescribed an antibiotic for UTI. This is not documented on the infection surveillance log. On 10/23/24 at 10:03 AM, Surveyor interviewed the Minimum Data Set (MDS) Coordinator G, who was filling in for the Infection Preventionist (IP) being on vacation during the time of survey regarding the infection surveillance log. Surveyor asked MDS Coordinator G who was responsible for completing documentation on the infection surveillance log. MDS Coordinator G stated the IP. Surveyor asked why the infection surveillance log did not include the dates 10/11/24-10/21/24 and 10/21/23-12/31/24. MDS Coordinator G stated that there was no documentation for those dates. Surveyor asked MDS Coordinator why this was not documented. MDS Coordinator G stated the current IP started in January 2024 and began the documentation in 2024, so there was no data available for 2023. MDS Coordinator G stated IP has been on vacation as was to why there is no documentation for 10/11/24-10/21/24. Surveyor asked why laboratory data, isolation precaution dates, and symptom dates were not included on the surveillance log. MDS Coordinator G stated she did not know why. Surveyor asked MDS Coordinator G if she understood the importance of keeping accurate, complete, and ongoing surveillance of infections. MDS Coordinator G stated yes, that she recognizes this prevents potential outbreaks of infection and identifies potential areas of concern in infection control practices. MDS Coordinator G stated that she would speak with IP to improve this practice. 47807 Example 2 Facility policy and procedure titled, Standard Precautions, dated 05/29/24, states in part, Purpose: To provide guidelines of interactions between patients or residents and healthcare providers to prevent the transmission of infectious agents associated with healthcare delivery . Personal protective Equipment (PPE): (PPE) is used to protect staff from contact with infectious agents and to prevent staff from carrying these infectious agents from patient to patient or resident to resident . Gowns: . Gowns are to be removed before leaving the patient or resident's environment On 10/22/24 at 7:17 AM Surveyor observed that R1 was on enhanced barrier precautions due to history of organisms in urine. A sign on R1's door includes enhanced barrier precautions and indicated that providers should wear gown and gloves during high-contact care activities with R1. On 10/22/24 at 8:10 AM, Surveyor observed Certified Nursing Assistant (CNA) I performing morning cares for R1. CNA I used hand hygiene and then donned gown and gloves. CNA I was getting R1 ready for breakfast. CNA I explained R1 was very independent and typically was not wet. They always put on the PPE as they are direct care staff, and it is just easier in the case they need to do direct care. CNA I left the room wearing their PPE and took off all PPE and put in the bottom bin of the PPE container that was located outside of R1's room. The PPE container did not have any labeling indicating which drawer held the clean gowns. Both drawers had gowns that were crumpled up; only one drawer had gowns that were also folded. On 10/22/24 at 9:46 AM, Surveyor interviewed CNA I. CNA I stated she was mistaken and that gowns should have gone into the bin designated for gowns in the room that is labeled gowns. CNA I then said they confirmed where gowns should go with the nurses. They plan to clean out the dirty gowns and make sure there are no more dirty gowns in the PPE storage bin that is located outside of R1's room. On 10/22/24 at 10:31 AM, Surveyor interviewed Director of Nursing (DON) B regarding appropriate usage of personal protective equipment. When asked what the expectations are for donning and doffing PPE, DON B said they would expect that staff don PPE outside of the room and then doff the PPE inside of the room. There should be bins in the room for the dirty PPE; staff should not be taking dirty gown and gloves outside of the room. DON B said we are currently working on infection control processes. Dirty gowns should never go into the enhanced barrier bins, and it is not our expectation to have the bottom drawer of PPE containers to be used for dirty gowns. 48793 Example 3 Surveyor reviewed policy titled, Hand hygiene Policy and Procedure dated May 2022, which stated in part: -Hand hygiene includes the use of either an alcohol-based antiseptic hand rub or washing with soap and water for routinely decontaminating hands in the following clinical situations: -Before having direct contact with patients or residents. -After contact with bodily fluids or excretion's, mucous membranes, non-intact skin, and wound dressings, even if hands are not visibly soiled. -After removing gloves. -After removing personal protective equipment. -When leaving an isolation area . On 10/22/24 at 7:41 AM, Surveyor observed CNA E exit R12's room who is on EBP with CNA E's PPE on. CNA E walked down hallway with dirty linens and dropped them off in trash can in hallway. CNA E walked into R17's room with CNA E's PPE on. CNA E doffed contaminated PPE and placed in R17's linen bin. CNA E then walked to R17's sink and began to wash hands. CNA E exited R17's room. On 10/22/24 at 7:43 AM, Surveyor interviewed CNA E and asked what CNA E's process is for PPE doffing in EBP rooms. CNA E indicated that CNA E will usually doff PPE in the EBP room but R12 was not finished at the sink so CNA E just quickly went into R17's room. CNA E indicated that CNA E should not have exited R12's room without doffing PPE nor should CNA E go into another resident's room with contaminated PPE on. On 10/22/24 at 10:31 AM, Surveyor interviewed DON B regarding appropriate usage of personnel protective equipment (PPE). When asked what the expectations are for donning and doffing PPE, DON B said they would expect that staff don PPE outside of the room and then doff the PPE inside of the room. There should be bins in the room for the dirty PPE; staff should not be taking dirty gown and gloves outside of the room. Example 4 Surveyor reviewed policy titled, Administering oral medications dated on September 04, 2024, which stated in part: -Steps in the procedure: -#1: Wash your hands . On 10/22/24 at 7:21 AM, Surveyor observed Licensed Practical Nurse (LPN) C prepping R6's medications for breakfast. Surveyor observed LPN C drop antacids on the top of medication cart. LPN C grabbed the antacids with bare hands and placed back into medication cup. LPN C administered the contaminated antacids to R6. Surveyor did not observe hand hygiene performed before or after prepping R6's medications. On 10/22/24 at 7:45 AM, Surveyor observed LPN C prepping R7's medications into cup. LPN C popped 3 pills into R7's medication cup but noticed there was a piece of paper from the backing of the pop packs in the medication cup. LPN C took bare index finger and stuck LPN C's finger into R7's medication cup that had all medications inside, to pull out the paper packaging inside medication cup. Surveyor did not observe LPN C perform hand hygiene or wear gloves to grab piece of packaging out of the medication cup. Surveyor observed LPN C administer the medication cup to R7. On 10/22/24 at 12:13 PM, Surveyor observed LPN C prepping R5's medications for lunch. Surveyor observed LPN C drop CO-Q10 medication on the top of medication cart. LPN C grabbed the CO-Q10 medication with gloved hands and placed back into medication cup. LPN C administered the CO-Q10 contaminated medication to R5. Surveyor did not observe hand hygiene performed before gloving or LPN C grab a new medication in place of the contaminated medication. On 10/22/24 at 12:15 PM, Surveyor interviewed LPN C and asked about hand hygiene during medication administration with bare hand touching of medications for R6 and R7's medications. Surveyor also asked about dropping medications on the med cart and placing them back in the medication cup. LPN C indicated that LPN C should not have picked the medications up off the medication cart with bare hands for R6 and should have gotten a new medication in place. LPN C indicated that LPN C should have prepped a new medication for R7's medication. LPN C indicated that when LPN C noticed the bubble wrap of the pill pack inside medication cup, LPN C just stuck finger into the medication cup to retrieve the bubble pack. LPN C indicated that LPN C should have put gloves on to retrieve the bubble pack piece out of medication cup. On 10/22/24 at 2:56 PM, Surveyor interviewed DON B and asked expectation for hand hygiene during medication administration. DON B indicated that expectation is washing hands before and after prepping medications and before and after entering residents' rooms. Surveyor indicated to DON B that Surveyor observed LPN C bare hand touch R7's medications. Surveyor indicated to DON B that Surveyor observed LPN C drop R6 and R5's medications on the medication cart and then LPN C picked the medications up and placed them back in medication cup and administered medications to R6 and R5. DON B indicated that expectation would be that LPN C dispose of dropped medications and prepare new medications to prevent infection. 40181 Example 5 R4 was admitted to the facility on [DATE] and had diagnoses including, in part, acute kidney failure, anemia, type 2 diabetes, and pressure ulcer of right heel. On 10/21/24 at 1:32 PM, Surveyor observed a sign on R4's door that said Enhanced Barrier Precautions (EBP). Surveyor observed a three-drawer bin outside R4's door with Personal Protective Equipment inside. Surveyor interviewed Registered Nurse (RN) D who stated R4 was on EBP for a chronic wound to the heel. On 10/22/24 at 11:23 AM, Surveyor observed LPN C and RN D provide wound care for R4's right heel pressure injury. Both LPN C and RN D used hand sanitizer and put on a gown and gloves prior to entering R4's room. LPN C placed the dressing supplies on a clean towel on a rolling table. LPN C took the boot off R4's foot. LPN C removed the gloves and put on clean gloves without washing hands or using hand sanitizer. RN D held R4's leg up while LPN C provided wound care. LPN C picked up the scissors from table and cut the old bandage and removed the dressing. Part of the bandage was adhered to the wound bed, so LPN C picked up a folded gauze pad, wet it with saline from a bottle and used it to moisten the bandage that was adhering to the wound. LPN C threw old bandage away, removed gloves, and put on clean gloves without washing hands or using hand sanitizer. LPN C picked up a folded gauze, wet it with the bottle of saline, and cleansed the wound bed. After cleansing the wound, LPN C removed gloves, washed hands with soap and water at the sink, and put on clean gloves. LPN C picked up a pre-cut piece of aquacel dressing, a folded gauze pad, and a roll gauze from the rolling table. LPN C placed the aquacel and gauze pad over the wound and wrapped R4's foot and heel with the roll gauze to hold the bandages in place. LPN C removed gloves and did not use hand sanitizer or wash hands. LPN C picked up pre-cut tape from the table and taped the roll gauze in place with bare hands. LPN C then picked up a marker from the table with bare hands and labeled the tape with date and initials. RN D pulled the tubigrip stocking down over the roll gauze dressing and put R4's boot back on. LPN C cleaned up the dressing supplies and put away in a container. LPN C and RN D both removed gowns and gloves, and washed hands prior to leaving room. On 10/22/24 at 12:53 PM, Surveyor interviewed DON B and explained the observation of LPN C changing gloves during wound care for R4 without sanitizing or washing hands between glove changes. DON B stated that was not an appropriate infection control practice. DON B stated LPN C was not following the facility policy and procedure for infection control and hand hygiene.

Based on observation, record review and interview, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and did not ensure medication was labeled to determine the expiration date of opened medications for 7 of 13 residents (R) (R2, R12, R25, R3, R20, R14, and R18). Findings include: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. Surveyor reviewed policy titled, Medication Labeling and Storage dated [DATE], which stated in part: -Medication Storage: #2: The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner. -Medication Labeling: #1: Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. -#2: The medication label includes, at a minimum: d. expiration date, when applicable . Surveyor reviewed policy titled, Administering oral medications dated September 4, 2024, which stated in part: -Steps in the procedure: -#7. Check expiration date on the medication . Surveyor reviewed an open medication need date chart titled, These medications need date when open/expiration stickers dated November 2022, stated in part: -All Insulin pens (expires once opened 28-56 days depending on insulins). -Morphine oral solution (expires 90 days). -Opthalmic drops (expires 28 days) . On 10/22/24 at 8:05 AM, Surveyor observed south hall's medication cart with Registered Nurse (RN) D. Surveyor observed 2 orange glucose tab containers located in the first drawer labeled use for R2 with labels covering the expiration dates on bottles. Surveyor observed 2 Humalog insulin pens for use for R12 and R25 with no open date label. Surveyor observed pharmacy label covering both insulin pens' manufacturing expiration date. Surveyor observed Timolol drops opened with no open date with labeled use for R3. Surveyor interviewed RN D and asked if Timolol drops were used this morning as ordered and how RN D would know when certain medications are expired or had been opened. RN D indicated that all medications that are opened should be labeled with open date. RN D indicated that RN D did give the Timolol drops. RN D viewed the bottle and noted the pharmacy label was covering the manufacturing expiration label but regardless all medications should have an opened date on the bottle so RN D does not administer expired medications on accident. Surveyor observed a bottle of Levetiracetam labeled for use for R20 with no open date label, and pharmacy label covering the manufacturing expiration date. RN D indicated that all medications except orange glucose tabs for R2 have been opened and used for all other residents. RN D indicated all opened medications are supposed to be labeled with the open date to make sure medications aren't expired. On 10/22/24 at 11:58 AM, Surveyor observed north hall's medication cart with Licensed Practical Nurse (LPN) C. Surveyor observed 2 Lantus insulin pens labeled for use for R14 and R18 with no open date label. Surveyor observed pharmacy label covering both pens' manufacturing expiration date. Surveyor observed Tresiba Insulin pen labeled for use for R2 with no open date label. Surveyor observed the pharmacy label covering both pens' manufacturing expiration dates. Surveyor observed 2 Admelog insulin pens labeled for use for R2 with no open date label. Surveyor observed the pharmacy labels covering both pens' manufacturing expiration dates. On 10/22/24 at 11:59 AM, Surveyor interviewed LPN C and asked if all insulin pens observed for R14, R18, and R2 were opened and used recently. LPN C indicated that all pens for R14, R18, and R2 have been used and should have open dates but do not. LPN C indicated that since R14, R18, and R2 use the insulin pens so much that LPN C feels like the insulin pens are used before they even expire, so administering to R14, R18, and R2 should be ok. On 10/22/24 at 12:18 PM, Surveyor toured med storage room with Director of Nursing (DON) B. Surveyor observed Lorazepam 2mg/ml oral concentration bottle labeled for use for R25 with no open date label. Surveyor observed the pharmacy label covering the Lorazepam bottle's manufacturing expiration date. On 10/22/24 at 12:20 PM, Surveyor interviewed DON B and asked what expectation is for labeling open medications for individual resident use. DON B indicated that all medications that are opened should have a label with open date so staff know when medications expire. DON B indicated the Lorazepam bottle has been used for R25, which is located in the med storage refrigeration room, but does not have an open date label located on the Lorazepam bottle. DON B indicated this Lorazepam bottle should be discarded and a new one opened with an open date label before administering.

Based on observation, interview and record review, the facility did not ensure care plans were revised and implemented to reflect changes in care for 2 of 5 residents (R) R12 and R22. R12 had a recent fall and care plan was updated with intervention to include 30 minute - 1 hour safety checks to be completed. This intervention was not completed. Facility did not follow fall care plan interventions for 15-minute checks for R22. Findings include: According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Example 1 R12 was admitted to the facility on [DATE] with pertinent diagnoses of syncope, orthostatic hypertension, atrial fibrillation, and repeated falls. R12's most recent quarterly Minimum Data Set (MDS) dated [DATE] stated a Brief Interview of Mental Status (BIMS) score of 15 indicating R12 is cognitively intact. R12 had no impairment to range of motion in upper and lower extremities and uses a mechanical wheelchair for ambulation. Surveyor reviewed R12's care plan initiated on 06/14/21 and revised on 10/06/24, which states in part: PROBLEM: Fall risk, found sitting on floor next to bed. GOAL: Resident will have no further falls. APPROACHES: -Remind to ask for assist before transfer during the night. -Room check every 1/2 hour. -Encourage to lock wheelchair before transferring. Surveyor reviewed R12's falls documentation: -On 2/19/24 had a fall: Interventions: Educate resident on using call light for assistance to stand/transfer. -On 04/23/24 had a fall: Interventions: Monitor. -On 05/24/24 had a fall: Interventions: Check on resident during the night. Offer assistance to the bathroom once during the night. -On 09/14/24 had a fall: Interventions: Use a sensitive call light on outer side of bed. -On 09/23/24 had a fall: Interventions: Room checks every 30 minutes - 1 hour. Encourage to use call light. Offer assistance before leaving room. -On 09/24/24 had a fall: Interventions: Remind and encourage resident to use call light for standby assist before transferring. Room checks every 30 minutes - 1 hour during the night. Surveyor found no documentation or verification that 30 minute - 1 hours checks were completed. On 10/22/24 at 12:23 PM, Surveyor interviewed DON B and asked if DON B could provide Surveyor with R12's 30 minute - 1 hour documentation from previous falls. DON B indicated that the old DON did not actually have these interventions charted for R12's falls. DON B indicated that staff did not document this information anywhere and DON B is starting the documentation process now. 48793 Example 2 R22 was admitted to the facility on [DATE] with diagnoses including in part, spinal stenosis cervical region, repeated falls, other specified paralytic syndromes, and unspecified osteoarthritis. R22's Minimum Data Set (MDS) assessment, dated 08/14/24, identified R22 had a Brief Interview for Mental Status (BIMS) score of 15. This indicated R22 has intact cognition. The MDS assessment also identified R22 required substanial to maximal assistance of two people for transfers, bed mobility, chair to bed, and toileting. Surveyor reviewed R22's fall care plan initiated on 12/11/23 and revised on 08/27/24 stated, in part: -Maintain a clear pathway. -Keep bed locked and low position. -Keep needed items in reach. -Avoid repositioning furniture. -Room checks hourly. -Call light in reach . Surveyor reviewed R22's nurse progress notes that indicate R22 had a fall dated: -On 01/08/24 had a fall: Interventions: To ring the bell on the supper/meal table to ask for help. -On 01/14/24 had a fall: Interventions: 15-minute checks and encourage to use recliner control appropriately. -On 01/18/24 had a fall: Interventions: 2 assists with ambulation. Staff may have to not give privacy completely to prevent falls on toilet. -On 01/25/24 had a fall: Interventions: Monitor for fatigue when assisting ambulation. Two assists with walking to meals. -On 07/04/24 had a fall: Interventions: Neuro's every shift, Vital signs, 15-minute checks, encourage to stay put until caregiver comes, and monitor for pain. Surveyor found no documentation or verification that 15-minute checks were completed. On 10/22/24 at 12:23 PM, Surveyor interviewed DON B and asked if DON B could provide Surveyor with evidence of R22's 15-minute checks to prevent falls. DON B indicated the old DON did not actually have these interventions charted for R22's falls. DON B indicated that even though staff were checking on R22 every 15-minutes, there is no evidence in the charting that it was completed.

Based on record review and interview, the facility did not develop a comprehensive care plan for 1 of 1 resident (R) R12 reviewed for indwelling catheter. R12 had an indwelling catheter in place. The facility did not develop a care plan to direct care for indwelling catheter. Findings include: R12 was admitted to the facility on [DATE] with pertinent diagnoses of syncope, orthostatic hypertension, atrial fibrillation, and repeated falls. R12's most recent quarterly Minimum Data Set (MDS) dated [DATE] stated a Brief Interview of Mental Status (BIMS) score of 15 indicating R12 is cognitively intact. R12 had no impairment to range of motion in upper and lower extremities and uses a mechanical wheelchair for ambulation. R12 did not have an indwelling catheter and is always continent. Surveyor reviewed R12's care plan. No indication of having an indwelling catheter was noted. Surveyor reviewed R12's nursing progress notes. No documentation of cares provided for catheter noted. Surveyor reviewed R12's urology clinic visit summaries and noted the following: -On 10/07/24 seen in urology clinic - 16french urinary catheter placed for urinary retention. Follow-up appointment scheduled for 11/07/24 for voiding trial. Please continue catheter cares until follow-up appointment. Surveyor reviewed R12's Interdisciplinary Team notes and noted the following: 10/22/24 - has temporary foley cath due to incontinence, has appointment 10/23 for removal On 10/21/24 at 1:35 PM, Surveyor interviewed R12 about his indwelling catheter. R12 stated that it was placed approximately a month ago at the urology clinic. R12 stated having some retention issues and a procedure done, but couldn't remember specifics. R12 stated the catheter was temporary and is scheduled to have it removed on 10/23/24. Surveyor asked R12 who completed cares for the catheter. R12 stated nursing staff does it 3 or 4 times a day. On 10/22/24 at 10:43 AM, Surveyor interviewed Director of Nursing (DON) B regarding R12's care plan. DON B stated the nursing staff were aware of his catheter and were providing cares appropriately. Surveyor asked why this was not added to R12's care plan. DON B stated it must have been missed because it was only expected to be in for a short time. DON B did not provide any further explanation.

Based on interviews and record review, the facility did not investigate, resolve, and record resolution of grievance for 1 of 13 residents (R) R28. R28's Activated Power of Attorney (APOA) K reported a personal item missing and a grievance was not completed. Findings include: Facility policy titled: Grievance Policy with a most recent review date of 03/28/22 stated, in part: The facility grievance process will be overseen by Social Services and the DON, who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, communicate with residents throughout the process to resolution .facility will provide a mechanism for filing a grievance/complaint, will provide residents, resident representatives and others a planned, systematic mechanism for receiving and promptly acting upon issues expressed and provide an ongoing system for monitoring and trending grievances and complaints. R28 was admitted to the facility on [DATE] with a diagnosis of vascular dementia. R28's admission Minimum Data Set (MDS) dated [DATE] stated R28 is rarely/never understood, and no Brief Interview of Mental Status (BIMS) was completed. Surveyor requested to view facility's grievance log. No grievance log was provided. On 10/21/24 at 12:15 PM, Surveyor interviewed APOA K regarding resident rights. APOA K stated that shortly after admission he reported R28's blue luggage bag was missing. Surveyor asked APOA K if he remembered the date this was reported. APOA K stated no. Surveyor asked APOA K if he remembered who this was reported to. APOA K stated reporting it to numerous staff. APOA K stated that after reporting the missing item, he was told a couple times that they were looking for the item, but haven't been able to find it. Surveyor asked APOA K if the facility provided any written documentation for him fill out. APOA K stated no. Surveyor asked APOA K if he was provided any written documentation of investigation findings or offered a resolution to the grievance. APOA K stated no. On 10/22/24 at 2:23 PM, Surveyor interviewed Social Services Manager (SSM) H and Registered Nurse (RN) D regarding R28's missing item. RN D stated remembering APOA K stating that a blue bag was missing. RN D stated that staff attempted to find the item, but staff couldn't recall if the luggage was present on admission and that APOA K appeared to be showing some signs of dementia as well, so they figured the item was likely never brought in to begin with since no staff was able to find it. SSM H stated also remembering hearing about the missing item, but could not recall the outcome. Surveyor asked SSM H why this was not documented on the grievance log. SSM H stated only being in current role for about 3 months and it happened before that, but that this wouldn't be considered a grievance. Surveyor asked SSM H what would be considered a grievance. SSM H stated a grievance would be a complaint or concern voiced by a resident or resident representative. Surveyor asked SSM H if a missing item would be considered a complaint or concern. SSM H stated yes, but the current practice when a resident has a missing item it is reported to the unit nurse and a missing item form is completed. Unit staff keep the form on the unit, notify other staff to look for the item, and then once resolved by either finding it or reimbursing for the item, it is scanned into the resident's chart. Surveyor asked SSM H to see the missing item form for R28's bag. SSM H stated inability to find it. Surveyor asked SSM H if these missing item forms were reviewed by her to include on grievance log. SSM H stated no. Surveyor asked SSM H to see grievance log. SSM H stated no grievances had been filed since December 2023. SSM H stated the facility does not consider lost or missing items to be a grievance and are not included on the grievance log. Surveyor asked SSM H if this practice followed the facility grievance policy of reporting, documenting, investigating, and concluding a grievance or complaint from a resident. SSM H stated no and that she was currently in the process of improving the grievance procedure and policy. SSM H stated recognition of poor practice for grievance reporting and investigating and stated understanding how this practice negatively affects residents' rights.

Based on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R17, R22, and R7) Findings include: Facility document titled Know Your Rights under Federal Nursing Home Regulations states in part, .You have the right to be treated with respect and dignity . Example 1: R17 was admitted to the facility on [DATE] with a diagnosis of unspecified dementia and stroke. R17's Minimum Data Set (MDS) assessment dated [DATE] identified R17 had moderate cognitive impairment and required assistance with eating. On 10/21/24 at 12:30 PM, Surveyor observed Registered Nurse (RN) D assist R17 to eat lunch in the dining room. During the observation, RN D used the clothing protector multiple times to wipe R17's mouth and face rather than a napkin. Example 2: R22 was admitted to the facility on [DATE] with a diagnosis of cerebral palsy. R22's MDS assessment dated [DATE] identified R22 was completely dependent on staff for eating. On 10/22/24 at 8:49 AM, Surveyor observed Licensed Practical Nurse (LPN) C assist R22 eat breakfast in the dining room. Surveyor observed LPN C use the clothing protector multiple times to wipe around R22's mouth and face while eating and drinking instead of a napkin. LPN C held the clothing protector over R22's nose and mouth several times when R22 coughed and then used the clothing protector to wipe R22's nose and mouth instead of a tissue or napkin. At 9:06 AM, Surveyor observed Certified Nursing Assistant (CNA) F sit beside R22 to help R22 finish drinking the beverages. CNA F used the clothing protector to wipe R22's mouth after each drink instead of a napkin. Example 3: R7 was admitted to the facility on [DATE] with a diagnosis of stroke. R7's MDS assessment dated [DATE] identified R7 had moderate cognitive impairment, limited range of motion of one upper extremity, and required assistance from staff for eating. On 10/22/24 at 9:02 AM, Surveyor observed CNA F finish feeding breakfast to R7 in the dining room. CNA F asked R7 if they were done eating and then wiped R7's mouth and around R7's chin with the clothing protector instead of a napkin. On 10/22/24 at 12:55 PM, Surveyor interviewed Director of Nursing (DON) B and explained observations of staff using the clothing protectors to wipe residents' faces when assisting residents to eat. Surveyor asked DON B if this was an acceptable practice. DON B stated that was not respectful of resident's dignity. DON B stated the staff should use a napkin to wipe residents' faces. DON B stated education would be provided.

Based on observation, interview and medical record review, the facility did not provide the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 2 of 2 sampled residents with pressure injuries. 1. Resident #4 developed a stage III pressure injury. The facility did not consult timely with the physician and the Registered Dietician (RD) when the ulcer became larger and when the ulcer developed from a stage II to a stage III pressure injury. The facility did not consistently complete weekly skin assessments. The facility did not update the current interdisciplinary care plan with new interventions when the temporary care plan was discontinued and did not update the care plan with new interventions to prevent pressure to the resident's right ankle when up in a chair. Staff did not use aseptic technique when performing a dressing change. 2. Resident #6 developed a facility-acquired pressure injury on his right heel. The facility did not prevent the pressure injury when he was at high risk for developing one, did not investigate the cause of the wound, did not notify the RD until two weeks after the pressure injury was discovered, did not do weekly measurements, did not document weekly descriptions, did not follow aseptic technique for wound care, did not put an air mattress on Resident #6's bed until the surveyor mentioned one, and did not provide a pressure relieving boot on Resident #6's other foot. This is evidenced by: The facility protocol entitled, Pressure Ulcers/Skin Breakdown-Clinical Protocol dated March 2014 states in part, Assessment and Recognition-1. The nursing staff and Attending Physician will assess and document as individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active [DIAGNOSES REDACTED]. 2. The physician will help staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions .4. Because a resident at risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers . Documentation: The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment conducted (for example,Admission Assessment, Weekly Skin Integrity tool). 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e. the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure .12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated .Stage II Protocol- Stage II Pressure Ulcer Interventions/Care Strategies: Evaluate and determine pain level with pain assessment . Treatment- Steps in the Procedure- 1. Clean bedside stand. Establish a clean field. 2. Place the clean equipment on the clean field .6. Wash and dry your hands thoroughly. 7. Put on clean gloves,. Loosen tape and remove soiled dressing. 8. Pull glove over dressing and discard into plastic or biohazard bag. 9. Wash and dry your hands thoroughly. 10. Open dry, clean dressing (s) by pulling corners of the exterior wrapping outward, touching only the exterior surface .12. Using clean technique, open other products (i.e., prescribed dressing, dry, clean gauze). 13. Wash and dry your hands thoroughly. 14. Put on clean gloves. 15. Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stage. 16. Cleanse the wound with ordered cleanser .17. Use dry gauze to pat the wound dry. 18. Apply the ordered dressing and secure with tape or bordered dressing per order .19. Discard disposable items into the designated container. 20. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly .23. Clean the bedside stand. 24. Wash and dry your hands thoroughly .General Guidelines- 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. Interventions and Preventive Measures: General 2. For a person in bed- a. Change position at least every two hours or more frequently if needed; b. Determine if resident needs a special mattress .3. For a person in a chair- a. Change position at least every hour .9. Routinely assess and document the condition of the resident's skin per Weekly Skin Integrity form or any signs and symptoms of irritation or breakdown. 10. Report any signs of a developing pressure ulcer to the physician. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. Interventions and Preventive Measures: Residents with Risk Factors 2. Risk Factor- Friction and Shear i. Shoes need to be monitored for proper fit to avoid development of blisters, corns and calloused areas .5. Risk Factor- Immobility b. Use pillows, wedges or other off-loading devices to keep bony prominences such as knees or ankles from touching each other .7. Risk Factor - Poor Nutrition a. Dietician will assess nutrition and hydration and make recommendations based on the individual resident's assessment. 1. On 05/02/16 at 3:00 p.m., Surveyor reviewed Resident #4's medical record. Resident #4 has the following Diagnoses: [REDACTED]. The quarterly Minimum Data Set (MDS) with a assessment reference date of 06/24/15 documented the resident was at risk for developing pressure injuries. Resident #4 had no current pressure injuries and no ulcers present on the previous assessment. The analysis of findings stated, Resident is at risk for skin breakdown due to inability to independently change position, fragile skin due to age. The Braden Scale, dated 12/18/15, was scored at a 16 for mild risk of developing a pressure injury. The Braden Scale, dated 03/18/16, was scored at 14 for moderate risk of developing a pressure injury. The annual MDS with assessment reference date of 03/23/16 documented Resident #4 was at risk for developing a pressure injury. Resident #4 currently had one stage III pressure injury measuring 0.7 centimeters (cm) by 0.5 cm by 0.3 cm with slough. The pressure injury was present on the prior assessment as a stage II. Skin and ulcer treatments identified included pressure reducing device in chair and bed, nutrition or hydration intervention, pressure ulcer care and application of dressing to the feet. The Wound Healing Progress Report, dated 01/11/16, documented Resident #4 had a stage II pressure ulcer on the right lateral ankle measuring 1 centimeters (cm) by 1 cm by 0.2 cm. that was not present on admission. The Wound Assessment Report, dated 01/13/16, stated, Dorsalis Pedis- Palpable/weak. Posterior Tibial Palpable/weak. Treatment Do not wear shoes for 3 weeks (can wear slippers) has pressure sores near ankles stop 2/4/16. (Surveyor could find no RD assessment and dietary notes in Resident #4's medical record related to the new pressure ulcer.) On 01/13/16, the physician progress notes [REDACTED].#4's name) has recently acquired a new pair of shoes and now has developed a pressure sore to his right posterior malleolus and indeed I think mechanistically this is probably what has happened. His care workers I thinks are very aware of this, they are working to maybe convert back to his old pair of shoes for awhile and maybe provide added padding to his sock etc. but right now he has a small sore, it is superficial, but it is macerated, it is open for 1 cm in diameter. I think if he keeps his foot in normal position he is probably fine but if he happens to sit in chair and evert his foot I think this has promoted the problem. I have therefore recommended that he kind of work more to his slippers or old pair of shoes or maybe pad up this area, even band aid would work and I think that if we just manage this appropriately for 2-3 weeks it will likely improve. Impressions: Long-term parkinsonism, a new pressure sore 1 cm diameter right posterior inferior malleolus likely will heal with symptomatic measures. Per Treatment Administration Record (TAR) on 01/13/16, the physician gave orders for Resident #4 to not wear shoes for three weeks and to stop this order on 02/04/16. The Wound Healing Progress Report, dated 01/19/16, documented Resident #4 had a stage II pressure ulcer on the right lateral ankle measuring 1.75 cm by 1.25 cm by 0.0 cm. The report stated the wound status was unchanged. The Wounds Assessment Report, dated 01/19/16, stated, Area is scabbed, [MEDICAL CONDITION] surrounding scabbed area. Summary & Nursing Actions The surface area of this pressure ulcer is larger than last assessment. The wound condition is unchanged since last assessment, consider treatment change. The weight has changed since last assessment. (Surveyor could find no documentation that the physician had been consulted related to the pressure ulcer increasing in size until 02/01/16. No RD assessment was found in the medical record until 02/03/16.) Per temporary care plan, dated 01/21/16, an air mattress was added to Resident #4's bed. On 02/01/16, the facility sent a fax to the physician notifying the physician of Resident #4's open area on the right ankle. The fax stated, Resident has open Rt (Right) ankle from laying on it. We have heel protectors on and are off loading area at HS (Hour of Sleep) and when in bed. Heel protectors to areas at all times. May we have order for: Cleanse with H20 and soap. Cover with Meplix AG and secure with gauze and tape, every 3 days and PRN. And for him to be seen by podiatry (MD J's name). The physician gave the above orders. Resident #4 was scheduled for a podiatry consult on 02/26/16. This treatment was discontinued on 02/17/16. On 02/03/16 at 2:14 p.m., dietary note written by Registred Nurse (RN) L stated, Currently skin on R ankle breakdown treated and followed by wound team . Recommend initiation of Boost supplement. Continue with adequate protein and nutrition to meet Resident needs. Monitor for high risk due to presence of wound, and history of skin breakdown. Surveyor could find no weekly skin assessments from 01/19/16 to 02/17/16. The Wound Healing Progress Report, dated 02/17/16, documented Resident #4 had a stage III pressure ulcer on the right lateral ankle measuring 1.20 cm by 1.00 cm by 0.4 cm. with no infection. The report stated the wound status had deteriorated. The Wound Assessment Report, dated 02/17/16, documented by Wound Certified RN B documented Resident #4 had a stage III pressure ulcer. The Wound Assessment Report stated, The wound is a small round hole at this point. Scant amount of serous drainage. Center has slough in bottom unable to see wound bed. Wound cleansed and Duoderm applied to self debride wound. Nursing to follow. Weight unchanged. Physician will be updated on nursing home rounds. Nursing Order: Cleanse wound to right outer ankle with soap, and water. Pat dry. Apply Duoderm to open area. Change q 72 hours, and prn until healed. The wound is now a higher stage than last assessment. The drainage/exudate from this pressure ulcer is a new symptom. The wound condition is deteriorated, physician notification is warranted. The weight has changed since last assessment. (Surveyor could find no documentation that the physician had been consulted related to the pressure ulcer now assessed as a stage III until 02/26/16. No RD assessment was found in the medical record until 03/26/16.) Per the TAR on 02/17/16, a nursing order was implemented of the following: Cleanse wound to right outer ankle with soap and water. Pat dry. Apply Duoderm to open area. Change every 72 hours, and prn until healed. This order was discontinued on 02/26/16. On 02/26/16, the physician ordered a dry dressing to the right ankle every day, a x-ray of the right ankle and ABI and a follow up appointment with podiatry in two weeks on 03/11/16. Surveyor could find no weekly skin assessments from 02/17/16 to 02/29/16 in the medical record. On 02/29/16, the podiatry consult note stated, Patient appears in no apparent distress. Ulceration lateral right ankle at level of distal fibula measuring 1.0 X 1.0 X 0.4 cm with a mixed granular and fibrotic base. It appears to probe to deeper tissues. Does not appear to probe to bone or periosteum. Slight undermining noted at 11 o'clock. There is [MEDICAL CONDITION] about the right ankle with no [DIAGNOSES REDACTED], no ascending [MEDICAL CONDITION] right, no active drainage noted right. Non palpable DP and PT noted right lower extremity .Plan I did discuss with (Resident #4's name) that the ulceration on the right ankle appears to be stable although it does probe to deeper tissues. I would like to evaluate for possible underlying osteo[DIAGNOSES REDACTED]. I have referred him for CRP, ABIs and x-ray of right ankle. I excisionally debrided the ulceration right ankle today with 15 blade into subcutaneous tissue removing nonviable tissue, [MEDICATION NAME] one sq cm .Orders written to reapply light gauze dressing daily. On 03/02/16, the bilateral ABI showed the right ankle could not be compressed with pressures up to 220 mm of Mercury. Findings suggest calcific [MEDICAL CONDITION] change. Study is non-diagnostic. The Wound Healing Progress Report, dated 03/05/16, completed by Wound Certified RN B documented Resident #4 had a stage III pressure ulcer on the right lateral ankle measuring 1 cm by 1 cm by 0.3 cm. with no infection. The report stated the wound status had improved. The Wound Assessment Report, dated 03/05/16, stated, The wound is a small round hole at this point. Scant amount of serousanguinous drainage. Inside outer edges has slough and bottom wound bed is pink. Wound is cleansed and dry dressing applied to self debride wound. Nursing to follow. Weight unchanged. Recently saw (Podiatrist MD J) and also had a ABI ultrasound done. On 03/09/16, the physician progress notes [REDACTED]. We have some concern that it might be osteo[DIAGNOSES REDACTED]. C reactive protein did come back significantly elevated at 6.6. The x-rays were non-diagnostic, but CT of the ankle is to be considered. I am going to let (MD J's name) make that decision in 48 hours, but wound seems to be healing slowly. Unfortunately, it's my suspicion that there is still potential for osteo[DIAGNOSES REDACTED]. Assessment Parkinsonism with non-healing right ankle wound, etiology unclear. Questionable osteo[DIAGNOSES REDACTED] with elevated C reactive protein. Unfortunately, non-diagnostic x-ray. CT of ankle may be necessary. Consultation pending with (MD J's name). Otherwise status reasonable stable and no changes in therapies recommended. On 03/11/16, the podiatrist note stated, Lateral right ankle at the distal fibula with a full-thickness ulceration, mixed fiber granular base upon debridement is predominantly granular, it does probe deep however no periosteal exposure. Wound measures 0.6 x 0.5 with depth of 0.4 which is somewhat improved from previous examination. There is [MEDICAL CONDITION] which is mildy pitting in nature. There is no warmth, [DIAGNOSES REDACTED], crepitation, purulence or signs to suggest abscess. Pedal pulses are non-palpable. Capillary refill is approximately 4 seconds to all digits. Assessment: 1. Ulceration right ankle. 2. [MEDICAL CONDITION] .The outline of the ulceration is noted which appears deep however does not extend to the level of osseous tissue at this time . The wound was excisionally debrided into subcutaneous tissue to remove non-viable devitalized tissue . We will consider MRI or bone scan to further evaluate for potential for osseous infection which was again discussed today. On 03/21/16 at 1:06 p.m., RD L note did not include assessment of Resident #4's right ankle pressure injury. Surveyor could find no weekly skin assessments in the medical record from 03/05/16 to 03/22/16. The Wound Healing Progress Report, dated 03/22/16, documented Resident #4 had a stage III pressure ulcer on the right lateral ankle measuring 0.70 cm by 0.50 cm by 0.3 cm. The report stated the wound status had improved. The Wound Assessment Report, dated 03/22/16, stated, Stage 3. Drainage- Serous, Scant. No infection. The wound is a small round hole at this point. Scant amount of serous drainage. Wound bed is pink. Wound cleansed and dry dressing applied. On 03/24/16, the physician ordered an MRI of the right ankle. On 03/26/16, the Nutritional Re-Assessment report completed by RD L does not mention that Resident #4 has a pressure ulcer on his ankle. On 03/29/16, the podiatry note stated, Wound is unchanged, approximately 0.6 c 0.5 cm in size. There is no purulence, there is no associated crepitation or clinical findings to suggest abscess. There are no acute signs of infection seen at this time. Assessment : 1. Ulceration right ankle, chronic. Suspect osteo[DIAGNOSES REDACTED] .Plan MRI is pending authorization to further evaluate extent of osseous involvement. Patient will likely need IV antibiotic therapy as well as potential for debridement. Currently no systemic complaints or acute signs of infection that would warrant urgent surgical matter. Will discuss with primary regarding initiation of IV antibiotic therapy pending MRI findings. On 04/04/16 at 1:03 p.m., nurse's note stated, Resident went down for an MRI of his ankle. CR lab test completed. Test unsuccessful as resident was unable to lie still, or flat. (MD J's name) was notified. On 04/08/16, the podiatry note stated, An MRI was ordered however patient was unable to stay still during the exam itself. A bone scan was subsequently ordered. Objective: Ulceration lateral right ankle measuring 0.6 x 0.6 x 0.2 cm with granular and fibrotic base. Appears to probe deep tissues, does not appear to probe to bone. No [DIAGNOSES REDACTED] noted right ankle .Assessment: 1. Ulceration right ankle concerning for osteo[DIAGNOSES REDACTED] .Orders written to re-apply a light dry gauze dressing q. day. On 04/08/16, the physician ordered the following: Apply gauze dressing to right ankle every day. No shoe on right foot. Follow up with podiatry 2 weeks. 04/22/16. On 04/09/16, the bone scan findings stated suspicious for osteo[DIAGNOSES REDACTED]. The Wound Healing Progress Report, dated 04/17/16, documented Resident #4 had a stage III pressure ulcer on the right lateral ankle measuring 0.50 cm by 0.50 cm by 0.1 cm. The report stated the wound status was improved. The Wound Assessment, dated 04/17/16, stated, Stage 3. No infection. Drainage-Serous,scant. The wound is a small round hole at this point. Scant amount of serous drainage. Wound bed is pink. Wound cleansed and dry dressing applied. On 04/22/16, the podiatry note stated, Ulceration lateral right ankle distal fibula measuring 0.3 x 0.3 x 0.2 cm with granular base. This does not probe or track deep tissues. No [DIAGNOSES REDACTED] or active drainage noted right ankle Assessment 1. Ulceration right ankle. 2. [DIAGNOSES REDACTED] right ankle. Plan: I reviewed the bone scan result with the patient and his daughter today which indicated high suspicion for osteo[DIAGNOSES REDACTED] about the distal tibia right ankle. Of note, the report does mention left ankle but I clarified with radiology that the right ankle is in fact the correct laterality for the osteo[DIAGNOSES REDACTED]. I have referred the patient for consultation with Infectious Disease at this time at Heath East and they will schedule appropriately. Procedure: I excisionally debrided the ulceration right ankle today and subcutaneous tissue with 15 blade. Excisional debridement was performed. I applied a light gauze dressing. Order is written to continue with light gauze dressing application daily. On 04/22/16, the physician ordered a dry gauze dressing to be applied to the right ankle every day, schedule an appointment with infectious disease and follow up with podiatry in two weeks (05/13/16). The Weekly Assessment Report, dated 05/03/16, completed by RN B stated, Stage 3. Drainage Serous,scant. Measurements 1.0 cm by 1.0 cm. No infection. Wounds status unchanged. The wound is a small round hole at the center of the lateral malleolus which is 1 cm X 1 cm. Surrounding tissue is reddened with some [MEDICAL CONDITION]. Reddened area is 6.5 x 5.2. There is no drainage from wound. Resident does not complain of pain in his ankle with dressing change. Patient is currently working with (MD J's name) and (MD K's name) for his foot issues. Surveyor was present during the wound assessment. On 05/04/16, the physician note from Infectious Disease stated, Chronic wound lateral R (Right) ankle. Positive bone scan at R tibia. Non healing wound R ankle with likely osteo[DIAGNOSES REDACTED]. Culture obtained in clinic today. May just yield skin flora but may help guide antibiotics. I will discuss with (MD K's name) to see if any debridement with deep cultures is possible. Consented today for PICC if this is needed .Once you have seen (MD K's name) and I have cultures back, we can likely start treatment, probably with an IV antibiotic. Interviews On 05/03/16 at 1:30 p.m., Surveyor interviewed the Director of Nursing (DON). The DON stated Resident #4's pressure ulcer on the right ankle was unavoidable due to the resident dislikes lying on opposite side. Resident #4 has a history of needing a pacemaker and declined. The facility has offloaded Resident #4's feet when in bed but the resident often moves. MD M believes the ulcer may have been caused from Resident #4's shoe. Interventions in place prior to the development of the ulcer were as follows: Resident #4 was more mobile, on a walking program, had a pressure relieving mattress, was on a repositioning plan, and a good nutrition program. The wound developed at the facility. Resident #4 had no history of heel ulcers. Resident #4 has decreased circulation and has a desire to be more comfortable in certain positions. The DON stated, It was our own failure to always maintain off loading at all times as he moves his legs a lot especially with increase in [MEDICAL CONDITION] symptoms. The DON further stated interventions that were put into place were more intense repositioning, increased nutritional support, boot, more rest periods, assessing and regular podiatrist assessments were done. On 05/04/16 at 9:55 a.m., Surveyor interviewed the DON. The DON stated the floor nurses do weekly skin measurements. RN B assesses Resident #4 when called. Surveyor requested treatment orders, notification to MD when changes occurred in the pressure ulcer, all weekly skin measurements, all RD and dietary assessments related to the pressure ulcer, new interventions and when implemented, and updates to the care plan On 05/04/16 at 10:45 a.m., Surveyor interviewed Resident #4's primary physician, MD M, who stated the resident got his foot pinched by a shoe. Resident #4 has [MEDICAL CONDITION] and his foot turns out. Resident #4 is flat footed and the new bigger shoe was more rigid and bumped his malleolus. MD D stated there is 1/8 inch skin covering the malleolus. The shoe rode high on the ankle and caused the open area. Resident #4 has a non-healing ulcer. The facility has repositioned Resident #4 and has the resident wear slippers. The ulcer didn't change in three weeks and Resident #4 was sent to podiatry. The podiatrist debrided the ulcer, recommended x-rays and a bone scan. On 03/09/16, MD M stated he saw Resident #4 and stated the wound was not purulent but wouldn't heal by the bony malleolus. The nurses updated him and faxes are delivered to MD M's box at the clinic. MD M checks them at the end of the day. If urgent the nurses walk over to the clinic. MD M stated he checks Resident #4's ankle ulcer on routine visits. MD M stated the bone scan was indicative of osteo[DIAGNOSES REDACTED]. On 05/04/16 at 2:10 p.m., the DON provided Surveyor with additional information related to interventions put into place after Resident #4's ulcer developed into a stage III. The DON provided the surveyor with a written note describing the interventions put in place as follows: 1. Notified Wound Care Nurse/Dietician. 2. Notified podiatrist from order of personal dr. 3. Continue turning/reposition- off load 4. Continue recording intakes for adequacy -good. 5. RA exercise program. 6. Continue protect foot with pillow in chair. 7. Adjust (per provider) his [MEDICAL CONDITION] med for therapeutic leg movement. 8. Continued boot protection (but he often didn't like and kicked off). The DON told Surveyor that the facility continued interventions as they knew they were doing the right thing and were following podiatry orders. On 05/05/16 at 10:50 a.m., Surveyor questioned the DON if she had any further information. The DON stated she would check. No further information was provided. Care Plan On 05/02/16 at 12:00 p.m., Surveyor observed Resident #4 in the dining room seated in a wheelchair with a sock on his right foot. On 05/03/16 at 7:00 a.m., Surveyor observed Resident #4 in his room seated in a wheelchair with a sock on his right foot. On 05/04/16 at 4:15 p.m., Surveyor observed Resident #4 in the hallway seated in a wheelchair with a sock on his right foot. On 05/05/16 at 8:00 a.m., Surveyor observed Resident #4 in the dining room seated in a wheelchair with a sock on his right foot. On 05/02/16 at 3:00 p.m., Surveyor reviewed the resident's current interdisciplinary care plan last updated on 03/28/16. The current care plan states, Turning schedule. Reposition while in chair every ____ hour(s). Heel relief boots. Regular mattress. The temporary care plan, dated 02/26/16, stated, Reposition when in bed q (every) 2 hours and off load heels/ankles. Air mattress. This information has not been transferred to the current interdisciplinary care plan. The current care plan does not state when boots are to be applied and does not include an intervention to protect Resident #4's heel when up in a chair. On 05/03/16 at 9:30 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) E who was assigned to care for Resident #4. CNA E stated Resident #4 wears a heel protector on his left foot and a foam boot on his right foot when in bed. CNA E stated during the day Resident #4 wears a grippy sock on his right foot and doesn't wear a shoe on the right foot as it rubs against his sore. On 05/03/16 at 9:45 a.m., Licensed Practical Nurse (LPN) D told Surveyor Resident #4 wears a sheepskin protector on the left foot and a foam boot on the right foot when in bed. On 05/03/16 at 9:55 a.m., Surveyor interviewed the DON related to how the facility is protecting Resident #4's right ankle ulcer when the resident is out of bed. Surveyor informed the DON of the observations of Resident #4 wearing only a sock on the right foot. The DON stated she would review it. Dressing Change On 05/03/16 at 1:40 p.m., Surveyor observed RN A and RN B change Resident #4's dressing on the right ankle. RN A did not cleanse the bedside table prior to placing clean 4 x 4 gauze directly on the bedside table without a clean barrier underneath. RN A removed the soiled dressing, cleansed the pressure ulcer with gauze from the bedside table, placed a clean gauze from the bedside table on Resident #4's pressure ulcer. RN B wrapped Resident #4's ankle with roller gauze and taped the dressing in place. RN A removed the clean dressing supplies and did not cleanse the bedside table. Resident #4 had his drink cups and newspaper stored on the bedside table. On 05/04/16 at 9:55 a.m., Surveyor informed the DON of the dressing change observation. The DON stated its nursing policy is to put clean dressing supplies on a clean place. 2. Resident #6's medical record states that he has [DIAGNOSES REDACTED]. When Resident #6 was admitted to the facility in January 2016, he was independently ambulatory. Resident #6's [MEDICAL CONDITION] disorder progressed rapidly, and he was having difficulty walking; Resident #6 fell on ,[DATE] and 02/20/16, and then needed to be transferred mechanically. Resident #6's legs were described as swollen, red, tender, warm to touch from his feet to his thighs. On 02/24/16, notes state that Resident #6 kept hanging his legs over the side of the bed, and would scream when his legs were touched. This can be an indication of claudication, which is pain caused by arterial obstruction. This can predispose a resident for developing pressure injuries. The facility did not develop a care plan to address the potential for pressure injuries for Resident #6. Resident #6's weight increased from 179 pounds to 210 pounds by 02/18/16 due to [MEDICAL CONDITION] and appetite. Ted hose had been ordered, but at times nurses had to use ace wraps because Resident #6 could not tolerate the ted hose. On 03/05/16, a nurse's note states that Resident #6 yelled out in pain, mostly when working with his right leg. Resident #6 had a change of condition where he spent more time in bed and on 03/06/16 was described as lethargic. Multiple nurses' notes documented Resident #6's yelling out Ow ow ow during cares and repositioning. On 03/15/16, a Physical Therapist evaluated Resident #6 and stated that Resident #6 was in pain when his legs were moved. There is no indication that the facility floated Resident #6's heels before 03/21/16. Resident #6's care plan addressing his toileting plan instructs staff to Check skin for signs of redness, breakdown and tell charge nurse. On 03/21/16, the facility discovered a 4 by 8 centimeter pressure injury described as a blood blister with bloody drainage on his right heel. The assessment performed on this date stated that Resident #6 was grimacing and moaning with wound care, and the pain management was ineffective. The second page of this assessment states, in part, The resident's pain may not be managed effectively. The cause of the wound is stated as, Accident/other trauma but the facility did not investigate the cause of the wound. Resident #6's pedal pulses are described as Palpable/weak and his skin was described as pale and cool. A Duoderm dressing was placed on Resident #6's heel and was to be changed every three days. Subsequent nurses' notes stated that the Duoderm was intact, but there were no comprehensive descriptions of the wound when the Duoderm was changed. The RD was not notified of Resident #6's pressure injury until 04/07/16. Nurses did not measure Resident #6's pressure injury or write a description of the wound on a weekly basis. The facility's Certified Wound Care nurse, RN B, saw Resident #6's pressure injury for the first time on 04/06/16. This wound now measured 2 by 3.5 cm with moderate serosanguineious drainage. LPN D documented, Wound was looked at by myself and wound nurse today after his bath. She wants to continue with current tx (treatment) plan until the rest of the eschar comes off. The presence of eschar i

Based on medical record review, policy review, interview and observation, the facility did not ensure that care and services were provided to attain or maintain the highest practicable well-being for 1 of 7 residents reviewed who have pain. Resident #6 has experienced pain during wound care performed on the pressure injury on his heel. Comprehensive pain assessments have not been performed during cares or wound care, and no care plan addressing pain during wound care has been developed. The facility did not consistantly anticipate Resident #6's pain, and did not consistantly pre-medicate Resident #6 before wound care. This is evidenced by: The facility's policy, revised March of 2015, and entitled Pain Assessment and Management states that the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. This policy states that pain management includes the following. a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. This policy states that the facility will 5. Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Resident #6's medical record states that he has [DIAGNOSES REDACTED]. When Resident #6 was admitted to the facility in January 2016, he was independently ambulatory. Resident #6's [MEDICAL CONDITION] disorder progressed rapidly, and he was having difficulty walking; Resident #6 fell on ,[DATE] and 02/20/16, and then needed to be transferred mechanically. Resident #6's legs were described as swollen, red, tender, warm to touch from his feet to his thighs. On 02/24/16, notes state that Resident #6 kept hanging his legs over the side of the bed, and would scream when his legs were touched. Multiple nurses' notes state that Resident #6 cried out ow ow ow during cares, and that his crying out normally ended when cares were finished. Resident #6's physician ordered [MEDICATION NAME] (an NSAID - nonsteroidal anti-[MEDICAL CONDITION] drug) to treat his arthritic pain. Resident #6's care plan states that he has DJD ([MEDICAL CONDITION] joint disease), with the goal of increased pain will be treated, and intervention listed is monitor behavior, pain. This does not list specific, individualized interventions to lessen Resident #6's pain, and does not specifically mention the pain in his legs, or his back pain which he complained of on 02/21/16. Resident #6 was administered Tylenol when he complained of pain. On 03/05/16, a nurse's note states that Resident #6 yelled out in pain, mostly when working with his right leg. Resident #6 had a change of condition where he spent more time in bed and at times was described as lethargic. On 03/21/16, the facility discovered a 4 by 8 centimeter pressure injury described as a blood blister with bloody drainage on his right heel. The assessment performed on this date stated that Resident #6 was grimacing and moaning with wound care, and the pain management was ineffective. The care plan does not state that Resident #6 has pain with wound care. Surveyor observed Registered Nurse (RN) B, who is the facility's Certified Wound Care Nurse, perform wound care for Resident #6 at 9:50 a.m. on 05/03/16, with Licensed Practical Nurse (LPN) D present, who stood behind Resident #6's recliner, on his left side. RN B removed the Duoderm which had been on Resident #6's right heel. While RN B cleansed the wound, Resident #6 grimaced and flinched while the foot was cleaned, and shook his head, and LPN D asked him, Is it a little bit sore? and Resident #6 said, Yes. RN B cleansed the wound a second time and Resident #6 grimaced. RN B's documentation of her assessment on 05/03/16 states that Resident #6 had pain with wound care, and the pain management was ineffective. Surveyor reviewed Resident #6's Medication Administration Record [REDACTED]. In the three wound assessment reports, dated 03/21/16, 04/07/16, and 05/03/16, it is indicated that Resident #6 did have pain with wound/treatment, and that pain management was Ineffective. On 03/21/16 and 04/06/16, these assessment state that Resident #6 was Moaning, Grimacing. Surveyor reviewed Resident #6's treatment records, and noted that he had wound care performed on the following dates: 03/25/16, 03/28/16, 03/31/16, 04/03/16, 04/06/16, 04/09/16, 04/12/16, 04/15/16, 04/18/16, 04/21/16, 04/24/16, 04/27/16, 04/30/16, and 05/03/16. According to the MAR, the only days Resident #6 was pre-medicated with Tylenol before wound care were on 04/03/16 and 04/07/16. The survey team asked for pain assessments for the residents on 05/03/16. On 05/04/16, the facility provided a print-out of Resident #6's Minimum Data Set (MDS) Section J, which states that he denied pain. There were no further assessments provided. Surveyor interviewed RN I, who is the facility's MDS coordinator, on 05/04/16 at 12:23 p.m. Surveyor asked if RN I assesses for pain by observing cares and wound care. RN I stated, No. I wouldn't interrupt their cares. I ask them about pain when they're up in their chairs. I'll ask them if they can remember when they last had pain, ask about pain in their hips and shoulders and back. But sometimes, they say they don't have pain. RN I described Resident #6 as very verbal, so he can tell you. RN I stated if the nurses on the floor see a resident is having pain during wound care, they are responsible for developing a temporary care plan. Surveyor asked how long the facility normally maintains a temporary care plan before it becomes permanent. RN I stated, Two to three weeks, four at the most. Surveyor asked about the pain with Resident #6's wound care, since 03/21/16, not mentioned on the care plan, and RN I stated, That should have been developed, then moved to the long term care plan, but I like the temporary care plans, because then they document on it every week. On 05/04/16 at 8:55 a.m., Surveyor interviewed the Director of Nursing and it was noted that Resident #6 has not received any Tylenol since 04/11/16, although he has had wound care every three days The pain during wound care is not addressed on his care plan, pain assessments are done quarterly and state that Resident #6 does not have pain.