Every finding on record at Capitol Hill Skilled Nursing and Therapy

Based on observation, interview, and facility policy review, the facility failed to ensure the 2 (Dumpster #1 and Dumpster #2) of 3 dumpsters in the facility were kept covered at all times. This deficient practice had the potential to affect all residents who currently reside in the facility.Findings included: An undated facility policy titled, Safe Facilities and Pest Management, specified, Make sure the containers have tight-fitting lids and are kept covered at all times. During an observation of the facility garbage receptable area on 06/15/2026 at 9:02 AM, the surveyor noted there were three dumpsters and Dumpster #1 had no side door to close the dumpster and there was opened access to the trash located in the dumpster. The surveyor noted Dumpster #2 did not have a functioning lid, it was left opened and there were flying insects in and around both Dumpster #1 and Dumpster #2. During an observation of the facility garbage receptable area on 06/16/2026 at 12:49 PM with the Dietary Supervisor (DS) and the Regional Dietary Consultant (RDC), the surveyor noted Dumpster #2 had no side door, no functioning lid, and there were flying insects in and around the dumpster. During an interview on 06/16/2026 at 12:51 PM, the DS stated the dumpsters had been without a side door or functioning lid for about a year and a half. According to the DS, she informed the Administrator of the missing side doors and nonfunctional lid, but nothing had been done. The DS stated the Administrator she told was no longer employed with the facility. During an interview on 06/16/2026 at 12:53 PM, the RDC stated his expectation would be to have a garbage receptacle/dumpster with side doors and lid in place so that the dumpster could be securely closed. During an interview on 06/16/2026 at 1:51 PM, the Administrator stated her expectation was for the dumpsters to have an operating side door and top lid that could be closed. The Administrator acknowledged no one had been called to replace the dumpsters. During an interview on 06/19/2026 at 8:25 AM, Director of Nursing #1 stated she would expect the dumpsters to have functioning doors and lids to keep pests and weather away from the trash.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey agency for 1 (Resident #72) of 1 sampled resident reviewed for abuse.Findings included: A facility policy titled, Reports to State and Federal Agencies, revised 02/02/2018, revealed, Timeline for Reporting. All reports to the Department shall be made by telephone or facsimile. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries on 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. An admission Record revealed the facility admitted Resident #72 on 11/06/2025. According to the admission Record, the resident had a medical history that included a diagnosis of malignant neoplasm of bone. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/2025, revealed Resident #72 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #72's incident report prepared by Director of Nursing (DON) #1 and dated 12/18/2025 at 4:00 PM, indicated the resident reported to hospice staff that during the evening hours on 12/17/2025, a certified nursing assistant (CNA) was rough with them during the provision of incontinence care. Per the incident report, the hospice nurse reported the incident to staff, who then reported the incident to DON #1 and the Administrator. The incident report specified, Immediate Action Taken Description: Notified Administrator of allegation. The incident report indicated the physician and resident's family member were notified on 12/18/2025 at 4:23 PM. The Incident Report Form indicated the physician, resident's family, local law enforcement, and the nurse aide registry were notified on 12/18/2025 at 4:00 PM of an allegation of abuse/mistreatment. Per the Incident Report Form, Resident #72 alleged a CNA was rough with them during incontinence care. The Fax Transmission Report revealed the facility reported the allegation of abuse to the state survey agency on 12/18/2025 at 7:31 PM. During an interview on 06/18/2026 at 11:20 AM, DON #1 stated an allegation of abuse was supposed to be reported to the state survey agency within two hours. During an interview on 06/18/2026 at 10:32 AM, the former Administrator stated Resident #72 reported an allegation of abuse to a hospice nurse on 12/18/2025 and the hospice nurse informed her of the allegation on 12/18/2025 around lunchtime. During an interview on 06/18/2026 at 11:44 AM, the Administrator stated allegations of abuse should be reported to the state survey agency within two hours of staff becoming aware of the allegation. The Administrator stated the Incident Report Form indicated the resident's family, physician, local law enforcement, and nurse aide registry were notified of the allegation of abuse on 12/18/2025 at 4:00 PM and according to the Fax Transmission Report, the facility reported the allegation of abuse to the state survey agency on 12/18/2025 at 7:31 PM. The Administrator stated the initial report was not submitted to the state survey agency within two hours. Per the Administrator, she expected allegations of abuse to be reported within two hours.

Based on observation, interview, and document review, the facility failed to educate the staff on the proper usage of a pull-cord alarm for 1 (Resident #30) of 1 sampled resident who required a specialized call light. Findings included: On 06/16/2026 at 10:30 AM, the Administrator stated the facility did not have a policy regarding accommodation of residents' needs. A document titled, AliMed Worry-Free Pull-Cord Alarm, #72140 Instructions for Use and Care, indicated, A tug on the cord in any direction will cause magnetic sensor to release and alarm will be triggered. An admission Record revealed the facility admitted Resident #30 on 10/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an impairment on both sides in their upper extremities. Resident #30's Care Plan Report included a focus area revised 12/12/2025, that indicated admission / discharge plan miscellaneous. Interventions specified the resident's call light alternative was a clip alarm (initiated 05/11/2026). During a concurrent observation and interview on 06/15/2026 at 10:40 AM, Nurse Aide (NA) #13 stated Resident #30 was not able to use a regular call light, but the resident had a hand-held alarm. NA #13 located the pull-cord alarm and pinned it to Resident #30's clothing on the left chest area. Resident #30 attempted to reach for the pull-cord alarm and was unsuccessful. NA #13 then placed the pull-cord alarm without the string in Resident #30's right hand and left the resident's room. During a concurrent observation and interview on 06/16/2026 at 2:05 PM, NA #13 stated she thought Resident #30 was able to use the pull-cord alarm by using their thumb to trigger the alarm. NA #13 placed the pull-cord alarm without the string in the resident's hand, and requested for the resident attempt to trigger (initiate) the alarm, but the resident was unsuccessful. NA #13 stated the alarm had to be positioned a certain way before Resident #30 was able to get their thumb to trigger the alarm. NA #13 stated she had not received any training on the call light that Resident #30 used and was only told by other staff how to use the call light. During an interview on 06/16/2026 at 12:15 PM, NA #14 stated he thought Resident #30 held the pull-cord alarm in their hand and used their thumb to trigger (initiate) the alarm. NA #14 stated he had not received any training for the specialized call light used by Resident #30. During a telephone interview on 06/16/2026 at 9:55 PM, Licensed Practical Nurse #15 stated she had not received any training on how to use the pull-cord alarm utilized by Resident #30. During a telephone interview on 06/16/2026 at 10:17 PM, NA #16 stated he had not received any training on how to use the pull-cord alarm utilized by Resident #30. During an interview on 06/19/2026 at 9:49 AM, Director of Nursing #1 stated the facility staff had not been trained on the pull-cord alarm, used by Resident #30, During an interview on 06/19/2026 at 10:09 AM, the Administrator stated the staff had not received any training on the pull-cord alarm used by Resident #30.

Based on interview, record review, and facility policy review, the facility failed to ensure as-needed antipsychotic medication was limited to 14 days for 1 (Resident #59) of 5 sampled residents reviewed for unnecessary medications.Findings included: A facility policy titled, Appendix 19: Medications Requiring Behavior & Side Effect Monitoring, updated 10/25/2021, specified, PRN [pro re nata, as needed] anxiolytics can have only an initial 14 day stop date. They can be continued for longer periods of time such as 30 [days], 60 [days], or 90 [days] days as long as the prescribing physician indicates that new stop date - they cannot be continued indefinitely. Per the Appendix 19: Medications Requiring Behavior & Side Effect Monitoring, Xanax was listed as an anxiolytic medication. An admission Record indicated the facility admitted Resident #59 on 01/04/2023. According to the admission Record, the resident had a medical history that included a diagnosis of anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/10/2026, revealed Resident #59 had a Brief Interview of Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident received antianxiety medication during the last seven days of the assessment period. Resident #59's Order Summary Report with active orders as of 06/16/2026, revealed an order dated 01/28/2026, for Xanax oral tablet 0.25 milligrams, give one tablet by mouth every 12 hours as needed for anxiety. Per the Order Summary Report, there was no end date specified for the Xanax medication. During an interview on 06/17/2026 at 12:38 PM, Nurse Practitioner (NP) #10 stated PRN medications required a 14-day stop (end) date. NP #10 reviewed Resident #59's medical record and confirmed the order for PRN Xanax was listed with no end date. NP #10 stated he expected PRN Xanax to have a stop date. During an interview on 06/17/2026 at 1:39 PM, the Medical Director (MD) stated PRN Xanax should have a stop (end) date of 14 days. The MD reviewed the order for PRN Xanax for Resident #59 and stated medication should have a stop end date as PRN Xanax should always have a stop date. During an interview on 06/17/2026 at 2:02 PM, Director of Nursing (DON) #1 stated psychotropic medication was supposed to have a stop (end) date. Per DON #1, PRN Xanax should have a stop date. DON #1 reviewed the order for Resident #59 and stated the PRN Xanax should have a stop date. DON #1 stated she expected PRN Xanax to have a stop date. During an interview on 06/17/2026 at 2:21 PM, the Administrator stated she was not involved in the process of PRN medications and stop (end) dates.

Based on observation, interview, and document review, the facility failed to accommodate the needs for 1 (Resident #30) of 1 sampled resident who required a specialized call light. Findings included: On 06/16/2026 at 10:30 AM, the Administrator stated the facility did not have a policy regarding accommodation of residents' needs. A document titled, AliMed Worry-Free Pull-Cord Alarm, #72140 Instructions for Use and Care, indicated, A tug on the cord in any direction will cause magnetic sensor to release and alarm will be triggered. An admission Record revealed the facility admitted Resident #30 on 10/19/2025. According to the admission Record, the resident had a medical history that included diagnoses of dementia and hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2026, revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had an impairment on both sides in their upper extremities. Resident #30's Care Plan Report included a focus area revised 12/12/2025, that indicated admission / discharge plan miscellaneous. Interventions specified the resident's call light alternative was a clip alarm (initiated 05/11/2026). During a concurrent observation and interview on 06/15/2026 at 10:18 AM, Resident #30 stated they were supposed to have a call light in their hand. The surveyor did not observe a call light in Resident #30's hand. During a concurrent observation and interview on 06/15/2026 at 10:40 AM, Nurse Aide (NA) #13 stated Resident #30 was not able to use a regular call light, but the resident had a hand-held alarm. NA #13 located the pull-cord alarm and pinned it to Resident #30's clothing on the left chest area. Resident #30 attempted to reach for the pull-cord alarm and was unsuccessful. NA #13 then placed the pull-cord alarm without the string in Resident #30's right hand and left the resident's room. During an observation on 06/16/2026 at 11:35 AM and 11:43 AM, Resident #30's pull-cord alarm was pinned to the resident's left chest area and there was no string observed in the resident's hand. Resident #30 was unable to reach and initiate the pull-cord alarm. During a concurrent observation and interview on 06/16/2026 at 2:05 PM, NA #13 stated she thought Resident #30 was able to use the pull-cord alarm by using their thumb to trigger the alarm. NA #13 placed the pull-cord alarm without the string in the resident's hand, and requested for the resident attempt to trigger (initiate) the alarm, but the resident was unsuccessful. NA #13 stated the alarm had to be positioned a certain way before Resident #30 was able to get their thumb to trigger the alarm. During a telephone interview on 06/16/2026 at 9:55 PM, Licensed Practical Nurse #15 stated Resident #30 was not able to use a typical call light so staff placed an alarm in the resident's right hand, and she thought the resident was able to use the alarm. During a telephone interview on 06/16/2026 at 10:17 PM, NA #16 stated Resident #30 had a hand-held alarm, but he had not seen the resident trigger (initiate) the alarm. During an interview on 06/18/2026 at 2:22 PM, NA #17 stated if staff placed the blue part (the part without the string) of the alarm into Resident #30's hand that was wrong because the resident was not able to initiate the alarm. NA #17 stated she noticed that other staff placed the call light in Resident #30's hand wrong as they placed the alarm in the resident's hand instead of the string, but had not reported it to anyone. During an interview on 06/19/2026 at 9:49 AM, Director of Nursing #1 stated she expected the residents to have a call light that they could use to request assistance. During an interview on 06/19/2026 at 10:09 AM, the Administrator stated she expected the staff to properly place a resident's call light that was appropriate for the resident.

Based on observation, interview, and facility policy review, the facility failed to ensure 1 (200 Hall medication cart) of 5 medication carts in the facility was kept locked when out of sight of the staff authorized to have access. Findings included: A facility policy titled, Medication Storage in the Facility, effective 01/2022, indicated, Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is assessable only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy specified, Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. During a concurrent interview and medication administration observation on 06/16/2026 at 7:52 AM, Certified Medication Aide (CMA) #12, being trained by Licensed Practical Nurse (LPN) #8, was observed to leave the medication cart on the 200 Hall unlocked while she administered a resident's medications in the resident's room approximately 55 feet away from the medication cart. The top drawer of the medication cart consisted of over-the-counter medications such as aspirin, vitamins, stool softeners, glucometer strips, and lancets, and the second drawer consisted of bubble packs of residents' medications to include Eliquis, a blood thinner; metoprolol, an antihypertensive medication; methocarbamol, a muscle relaxant; and furosemide, a diuretic medication. At 7:58 AM, both CMA #12 and LPN #8 walked back to the medication cart and upon reaching the cart, LPN #8 locked the medication cart. At that time, they were both asked if they left the medication cart unlocked and they both replied, the medication cart was unlocked. The Pharmacy Consultant (PC) was observed standing approximately 2 feet away from the unlocked cart. CMA #12 stated she thought she locked the medication cart, and LPN #8 stated she did not notice the medication cart was unlocked until she returned to the medication cart. Both, CMA #12 and LPN #8, stated they had been trained to keep the medication cart locked when unattended. During an interview on 06/16/2026 at 8:04 AM, the PC stated there was not a problem with medication labeling but there was a problem with storage as she witnessed the unlocked medication cart. During an interview on 06/19/2026 at 1:30 PM, Director of Nursing #1 stated she expected the nurses and medication aides to keep the medication carts locked when the medication carts were out of their sight. During an interview on 06/19/2026 at 1:48 PM, the Administrator stated she expected the nurses and medication aides to keep the medication carts locked when the medication carts were out of their sight.

Based on record review and interview, the facility failed to: a. report an abnormal urinalysis result to the provider in a timely manner for one (#35) of six sampled residents reviewed for laboratory services; and b. develop a lab policy. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and UTI. A Physician's Telephone Order, dated 10/15/24, documented CBC, CMP, PCR UA, TSH, and Depakote level for generalized weakness. A Lab Report, documented a urine specimen was collected on 10/26/24 and reported on 10/29/24. It documented Resident #35 was positive for a UTI. A Physician Order, dated 11/05/24, documented Cipro (an antibiotic) 500 mg give one tablet by mouth two times a day for UTI for seven days. There was no documentation the provider was notified of the abnormal urinalysis result on 10/29/24. On 11/08/24 at 9:32 a.m., LPN #4 reviewed Resident #35's urinalysis result. They stated the results were reported to the facility on [DATE]. On 11/08/24 at 9:35 a.m., LPN #4 stated the provider must have been notified because there was a new order for an antibiotic on 11/05/24. They stated there was no documentation the provider was notified on 10/29/24 about the abnormal urinalysis result. On 11/08/24 at 9:38 a.m., LPN #4 stated the provider was not notified in a timely manner. On 11/08/24 at 10:05 a.m., the DON stated staff were to notify the physician and family as soon as they pulled the results. They stated all nurses had access to the online lab reporting system. On 11/08/24 at 10:19 a.m., Corp Nurse Consult #1 stated the provider was notified about the abnormal urinalysis result on 11/05/24. On 11/08/24 at 10:20 a.m., Corp Nurse Consult #1 stated they did not have a lab policy. They stated the urinalysis result was reported in a timely manner. On 11/08/24 at 11:02 a.m., Corp Nurse Consult #1 stated they did not have a lab policy on provider notification of abnormal lab results.

Based on observation, record review, and interview, the facility failed to ensure a resident had a privacy curtain for one (#55) of 24 sampled resident rooms reviewed for privacy. The administrator identified 65 residents resided in the facility. Findings: Resident #55 had diagnoses which included diabetes mellitus type two. A Quarterly Assessment, dated 10/18/24, documented Resident #55's cognition was intact. On 11/06/24 at 8:52 a.m., Resident #55 was observed sitting on their bed in their room. There was not a privacy curtain available to pull across the room to provide complete privacy. Resident #55 stated they would have liked to have one for privacy. On 11/12/24 at 8:26 a.m., LPN #1 stated the curtains were to be closed to provide privacy to the residents. LPN #1 was asked to look at Resident #55's room. They were asked if the resident had curtains to provide privacy. They stated, If [they] want one. Resident #55 stated, Yes, I want one for privacy.

Based on observation, record review, and interview, the facility failed to adhere to enhanced barrier precautions for one (#26) of one sampled resident reviewed for enhanced barrier precautions. The administrator identified 65 residents resided in the facility and 19 residents were on enhanced barrier precautions. Findings: The Enhanced Barrier Precautions policy, revised 03/28/24, read in part, Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier precautions include: Device care or use .feeding tube. Resident #26 had diagnoses which included cachexia and severe protein-calorie malnutrition. Resident #26's care plan for EBP, revised 09/24/24, documented the resident was at risk for infection related to peg tube and secondary to in-house MDRO. It documented to maintain enhanced barrier precautions. On 11/06/24 at 2:29 p.m., LPN #2 was observed entering Resident #26's room. There was an EBP sign on the door for bed A. There were gowns hung on a yellow storage container on the bathroom door. On 11/06/24 at 2:30 p.m., LPN #2 with gloves on, removed a split gauze from the resident's peg tube and discarded it. They donned new gloves, cleansed the peg tube site, and applied a new split gauze. Then they applied tape. LPN #2 removed and discarded their gloves and used ABHR. LPN #2 did not wear a gown during the care of the peg tube. On 11/06/24 at 2:33 p.m., LPN #2 stated the EBP sign on Resident #26's door was for handwashing. They stated if the sign were to wear a gown, the PPE would be provided in a plastic bin, and placed outside of the resident's door. On 11/06/24 at 2:35 p.m., LPN #2 stated they did not notice the gowns in the resident's room. On 11/06/24 at 2:36 p.m., LPN #2 stated they did not have to wear a gown during peg tube care. On 11/06/24 at 2:46 p.m., the DON stated enhanced barrier precautions required staff to wear a gown and gloves during peg tube care.

Based on record review and interview, the facility failed to follow up on a physician ordered dental referral for one (#60) of three sampled residents reviewed for dental care. The administrator identified 65 residents resided in the facility. Findings: A Dentures and Related Services policy, dated 06/27/17, documented when the provision of denture services were medically appropriate, the facility must make timely arrangements. Resident #60 had diagnoses which included chronic obstructive pulmonary disease. An Admission Note, dated 06/13/24 at 3:22 p.m., documented Resident #60 wore upper dentures and had their own teeth on the bottom. A physician's order, dated 09/24/24, documented to refer Resident #60 to a dentist for a new upper denture plate. A Quarterly Assessment, dated 09/26/24, documented Resident #60's cognition was intact. It documented the resident had broken or loosely fitting full or partial denture. On 11/06/24 at 9:26 a.m., Resident #60 stated they had lost their dentures about a month ago. They stated they had told their physician and they had wrote an order, but they had not seen a dentist. On 11/12/24 at 9:35 a.m., LPN #1 was asked what the procedure was for when a resident needed to see a dentist. They stated they would obtain an order then give it to the social services worker. LPN #1 stated Resident #60 had an order to see a dentist, but had not seen one. On 11/12/24 at 9:42 a.m., the activities director stated they had helped out with social service duties. They stated if a resident needed to see a physician, and they did not see the vendor who came to the facility, they would have to set up an appointment. They stated Resident #60 had not seen a dentist because they did not know the resident needed to. On 11/12/24 at 9:58 a.m., the activities director stated the previous social service worker had the order, but Never did anything with it.

Based on record review and interview, the facility failed to ensure a urinalysis specimen was obtained in a timely manner for one (#35) of six sampled residents reviewed for laboratory services. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and UTI. A Physician's Telephone Order, dated 10/15/24, documented CBC, CMP, PCR UA, TSH, and Depakote level for generalized weakness. A Lab Report, dated 10/16/24, documented a urine specimen was collected. On 11/08/24 at 9:27 a.m., LPN #4 stated nurses were responsible for obtaining urine specimens. On 11/08/24 at 9:28 a.m., LPN #4 stated they spoke with the resident's family member on 10/25/24. The resident's family member had inquired about the status of the urinalysis. They stated the urine specimen that was collected was not sent to the lab. LPN #4 stated the urine specimen was still in the ice box. They stated they called the provider to verify it was ok to obtain another urine specimen. LPN #4 stated a new urine specimen was collected on 10/25/24 and lab was called for pick up. On 11/08/24 at 9:38 a.m., LPN #4 reviewed Resident #35's urine lab order. They stated the urine specimen was not obtained in a timely manner. On 11/08/24 at 10:02 a.m., the DON stated staff were to notify lab to pick up urine specimens after collection. On 11/08/24 at 10:04 a.m., the DON stated urine specimens should be obtained as soon as possible.

Based on observation, record review, and interview, the facility failed to ensure expired medication was removed from circulation in one of one medication storage rooms. The administrator identified 65 residents resided in the facility. Findings: A Medication Storage in the Facility policy, dated ,d+[DATE], read in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal Resident #12 had diagnoses which included other recurrent depressive disorders. A Physician Order, dated [DATE], documented sertraline (Zoloft an antidepressant medication) 100 mg give one tablet by mouth one time a day related to other recurrent depressive disorders. On [DATE] at 7:07 a.m., the medication storage room was observed with the DON present. The DON stated staff printed off an order, faxed it to the pharmacy, and called the pharmacy to reorder medications. The DON stated the facility ordered different things daily. They stated staff were to follow the first in first out process for rotating stock in the medication room. On [DATE] at 7:09 a.m., a card of pill packed Zoloft 100 mg count of 30 was observed in the medication container labeled for Resident #12. The fill date was [DATE] with an expiration date of [DATE]. On [DATE] at 7:17 a.m., the ADON stated the medication aides were supposed to rotate the medication stock and use what was first received. The ADON stated when a medication was expired, or getting ready to expire, the medication would be pulled and placed with the discontinued medications. The DON and ADON reviewed Resident #12's medication card for Zoloft and stated it was expired.

Based on record review and interview, the facility failed to hold a care plan meeting for one (#35) of one sampled resident reviewed for a care plan meeting. The administrator identified 65 residents resided in the facility. Findings: Resident #35 had diagnoses which included unspecified dementia and need for assistance with personal care. On 11/07/24 at 1:19 p.m., Resident Rep #1 stated a care plan meeting was scheduled for 10/24/24. They stated the facility did not inform them the reason the care plan meeting was not held and if it would be rescheduled. On 11/08/24 at 8:01 a.m., the administrator stated the social worker was responsible for care plan meetings. They stated the current social worker had been in their position for a week. The administrator stated care plan meetings were held quarterly. On 11/08/24 at 8:06 a.m., the administrator stated the last care plan meeting held for Resident #35 was on 07/25/24. They stated another meeting was scheduled for 10/24/24. On 11/08/24 at 8:08 a.m., the administrator stated the care plan meeting was not held because the social worker had quit their job. They stated the family was not notified about the missed meeting or given any information on rescheduling.

Based on record review and interview, the facility failed to ensure a MDS was coded accurately for one (#42) of 17 sampled residents reviewed for MDS assessments. The administrator identified 65 residents resided in the facility. They identified one resident received dialysis. Findings: Resident #42 had diagnoses which included end stage renal disease. A Care Plan, dated 07/11/24, documented the resident received dialysis at a local facility three times a week. A Quarterly Assessment, dated 10/01/24, did not code Resident #42 received dialysis. On 11/07/24 at 11:01 a.m., MDS Coordinator #1 stated if someone was receiving dialysis then it would be coded on the MDS. They reviewed Resident #42's MDS and stated it was not coded. They stated it was not accurate.

Based on observation, record review, and interview, the facility failed to ensure a resident's ceiling vent was cleaned for one (#55) of three sampled residents reviewed for a clean, comfortable, and homelike environment. The administrator identified 65 residents resided in the facility. Findings: The Housekeeping Policies and Procedures policy, revised 06/29/12, read in part, Weekly Procedures: Begin cleaning resident rooms from the ceiling and work toward the floor. The only part of the room which is allowed to be dry dusted is the ceiling, high vents, and other high dust areas. Resident #55's quarterly resident assessment, dated 10/18/24, documented Resident #55 was cognitively intact. On 11/06/24 at 8:56 a.m., Resident #55's ceiling vent was observed to have moderate dust build up. On 11/08/24 at 12:04 p.m., Resident #55's ceiling vent was observed to have moderate dust build up. Resident #55 stated they had not cleaned the vent. On 11/08/24 at 12:59 p.m., Housekeeper #1 stated they had not paid attention to the ceiling vents in the resident rooms during their cleaning procedures. On 11/08/24 at 1:00 p.m., Housekeeper #1 observed the vent in Resident #55's room. They stated it needed to be cleaned.

Based on observation, record review, and interview, the facility failed to ensure a call light was within reach of a resident for one (#20) of 24 sampled residents observed for call lights in reach. The administrator identified 65 residents resided in the facility. Findings: Resident #20 had diagnoses which included chronic respiratory failure with hypercapnia. Resident #20's quarterly resident assessment, dated 09/27/24, documented the resident had moderate cognitive impairment. Resident #20's care plan for falls, revised 10/17/24, documented call light in reach and encourage to use. On 11/06/24 at 10:41 a.m., Resident #20 called out to the surveyor and asked the surveyor to hand them their call light. The call light was on the recliner and out of the reach of the resident. Resident #20 was sitting in a wheelchair. The resident was asked how they would call for help with the call light out of their reach. Resident #20 stated, They cant. The resident stated they needed ice water. On 11/06/24 at 10:54 a.m., CNA #4 stated the policy was to ensure the call light was always in reach. They stated Resident #20 could use their call light. On 11/06/24 at 10:55 a.m., CNA #4 made an observation of Resident #20's call light. They stated it was not in reach. CNA #4 pinned the resident's call light to their blanket and proceeded to offer the resident ice water.

Based on record review and interview, the facility failed to obtain physician ordered labs for one (#14) of five sampled residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: Resident #14 had diagnoses which included type two diabetes mellitus, hypertension, chronic respiratory failure, and artherosclerotic heart disease of native coronary artery without angina pectoris. A Physician Progress Note, dated 06/04/23, read in part, .LAB .Order: A1c q6 Months .recheck BMP and Magnesium in 10 days . The progress note was electronically signed by Physician #1 on 06/06/23. There were no results for the above lab orders located in Resident #14's record. On 08/29/23 at 8:26 a.m., the Administrator was asked to provide the lab results for Resident #14's A1c, BMP, and magnesium lab order documented in Physician #1's 06/04/23 note. On 08/29/23 at 10:15 a.m., the DON stated the facility did not get a verbal or telephone order at the time Physician #1 wrote the order in the progress note dated 06/04/23 for Resident #14. The DON stated the labs were not drawn.

Based on observation, record review, and interview, the facility failed to ensure an expired medication was not prepared for administration for one (#35) of three residents observed during medication administration. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: A Medication Storage in the Facility policy, dated January 2022, read in part, .Outdated .medications .are immediately removed from inventory, disposed of .Medication storage conditions are monitored on a monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified .The nurse will check the expiration date of each medication before administering it. No expired medication will be administered to a resident. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining . Resident #35 admitted with diagnoses which included hypotension and history of traumatic brain injury. A physician order, dated 08/11/23, documented Midodrine HCL tablet 10 mg one tablet by mouth three times a day for hypotension. On 08/28/23 at 8:05 a.m., CMA #1 was observed preparing the Resident #35's medication. They popped one Midodrine HCL 10 mg tablet out of the blister pack and placed it into the cup with the other prepared medications and then handed the medication card to the surveyor. The expiration date on the card was observed to be dated 08/17/23 with a filled date of 08/17/22. On 08/28/23 at 8:13 a.m., CMA #1 was asked when the medication expired. They stated 08/17/23. They removed the Midodrine tablet from the cup of medication and put it in the sharps container. CMA #1 went to the medication room and retrieved a new card with an expiration date of 05/11/24 with the fill date of 05/11/23. On 08/28/23 at 8:15 a.m., CMA #1 was asked what was checked when preparing medications. They stated, name, medication, and dose. The CMA was asked if they checked the expiration date. They stated, When I order, that's my bad, today is ordering day. On 08/28/23 at 10:46 a.m., the DON was asked what the policy and procedure was to ensure medications were not expired. They stated The Pharmacist and staff checked. The DON was asked how often. They stated the Pharmacist checked monthly. The Pharmacist entered the office and stated they went through the cart this month and just missed it. The DON stated the CMA should be checking monthly.

Based on observation, record review, and interview, the facility failed to ensure the sink located in the resident's room was operational for one (room [ROOM NUMBER]) of 23 sampled resident rooms observed. The Resident Census and Conditions of Residents report, dated 08/24/23, documented 56 residents resided in the facility. Findings: The facility's Maintenance policy, dated 06/27/06, read in part, .The maintenance department will be given checklists to assure orientation to their responsibilities of preventative maintenance items, and assure the good repair of the entire facility .In the event that an item is in need of repair, the defect should be reported to the maintenance department on form MAINT-054, and the maintenance department will repair them promptly . On 08/24/23 at 9:42 a.m., Resident #14 stated the sink in resident room [ROOM NUMBER] had not worked in a month. Resident #14 stated the maintenance man turned off the water a month ago due to a leak. The sink was turned on and no water was observed to flow from the hot or cold side. On 08/28/23 at 9:49 a.m., LPN #3 and CNA #2 were observed in room [ROOM NUMBER] assisting Resident #3. CNA #2 stated, This sink don't work. CNA #2 and LPN #3 sanitized their hands and donned a pair of gloves. They checked Resident #3 for incontinence, stated the resident was dry, removed their gloves and sanitized their hands. CNA #2 and LPN #3 placed clothes and shoes on Resident #3. On 08/28/23 at 10:03 a.m., LPN #3 came back to room [ROOM NUMBER] with a wet washcloth in a clear plastic bag and handed it to CNA #2. CNA #2 cleaned Resident #3's face with the wet washcloth. On 08/28/23 at 10:53 a.m., LPN #3 was asked the reason they left the resident's room [ROOM NUMBER] to get a wet washcloth. They stated the sink did not work. On 08/28/23 at 10:55 a.m., CNA #2 was asked how long the sink in resident room [ROOM NUMBER] had not worked. CNA #2 stated a few days, or sometime last week. CNA #2 stated they reported the issue to maintenance a few times. CNA #2 was asked how they washed their hands after resident care in room [ROOM NUMBER]. CNA #2 stated they washed their hands outside in the employee bathroom. On 08/28/23 at 11:11 a.m., Maintenance #1 was asked to observed resident room [ROOM NUMBER]'s sink. Maintenance #1 bent down, opened the sink cabinet, made a twist motion, got up, turned on the sink handle, and stated it was working. On 08/28/23 at 11:13 a.m., Maintenance #1 was asked if the sink could be turned on and off under the cabinet. Maintenance #1 stated Yes. They were asked if they had just turned the sink on and they stated Yes. On 08/28/23 at 11:15 a.m., there was a leak with moderate flow observed under the sink. Maintenance #1 was asked if the leak could flow onto the resident's floor and they stated Yes. On On 08/28/23 at 11:16 a.m., Maintenance #1 stated they did not know the sink was leaking.

Based on record review, observations, and interviews, the facility failed to ensure call lights were within reach for three (#5, 6 and #9) of 43 sampled residents who were observed without their call lights in reach. The Resident Census and Conditions of Residents, documented 43 residents resided in the facility. Findings: 1. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/01/22 at 6:04 a.m., call light was observed on the floor between the wall and the foot of the bed. Resident #5 stated, No, I can't ever reach it. 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/01/22 at 4:44 a.m., resident #6's call light was observed not to be in reach. 3. At 4:50a.m., resident #9's call light was not in reach of the resident. On 11/01/22 at 9:34 a.m., the DON was ask if Resident's call lights were within reach. They stated the call lights (Resident #5, #6, and #9) were not in reach. The DON stated their policy for call lights was that they should be in reach of each resident.

Based on record review and interview, it was determined the facility failed to assess and monitor an area of compromised skin to a resident's toe for one (#1) of one resident reviewed for compromised skin issues with a [DIAGNOSES REDACTED]. This had the potential to affect five other residents with compromised skin issues to their foot/feet with the [DIAGNOSES REDACTED]. Resident #1 had [DIAGNOSES REDACTED]. A readmission assessment, dated 07/14/15, documented the resident had an open area to his right great toe. A nurse's note, dated 07/15/15, documented the resident had a scab that was dark, red and intact. The documented measurements of the area were 1.2 centimeters (cm) by 0.6 cm by 0.1 cm. A physician's orders [REDACTED]. The quarterly assessment, dated 08/22/15, documented his cognition was moderately impaired. He required extensive assistance with transfers, dressing, eating, personal hygiene and bathing. He was incontinent of bowel and bladder. The clinical record had not documented any other assessments of the resident's right great toe. A nurse's note, dated 09/10/15, documented the resident was experiencing vomiting. The physician was notified and an order was received to send the resident to a local hospital emergency room . The resident was later admitted to a local hospital with the [DIAGNOSES REDACTED]. A hospital admission history and physical, dated 09/11/15, documented the resident had dry gangrene to his right great toe. The area to the right great toe was not documented as a scab. On 12/15/15 at 3:45 p.m., the regional registered nurse (RN) was in agreement the resident's foot had not been assessed and monitored. She stated the facility had recognized issues in regard to residents' skin not having been assessed and monitored per the facility policy in early October 2015. She stated the facility had implemented measures to ensure residents' skin would be assessed and monitored. The regional RN stated the facility's wound nurse was replaced in October 2015. A skin sweep was performed by facility staff in October 2015. The facility put the following interventions in place to correct the failure to assess and monitor residents' skin on a continuous basis. The interventions had been documented and verified as having been completed by the regional RN. ~10/15/15- the entire nursing staff was inserviced on the facility's wound program. ~11/09/15- the new wound nurse was inserviced on the facility's policy and procedure, risk sheets, care plan revision, skin reports, Braden scales, weekly calls and documentation. ~11/25/15- the entire nursing staff was inserviced on documentation, physician orders [REDACTED]. ~12/03/15- the wound care nurse was reoriented on policy and procedure of wounds and technique. ~12/07/15- the entire nursing staff was inserviced related to infection control, hydration, call lights, skin infection prevention. ~Residents with a Braden score of 18 or less or residents with a wound would have a skin assessment completed weekly. She further stated the wound care nurse was no longer on the facility call rotation as they had been before, to ensure they had adequate time to complete their assigned wound program. The call rotation was explained by the regional RN as the wound care nurse had to cover shifts for other nurses if they had called in to work and had not shown up. The wound care nurse would have been the charge nurse for the shift, and not had time to do her wound care duties. A quality manager (QM) was hired by the facility the first part of December 2015. The QM would be responsible to go on rounds with the wound care nurse weekly to look at wounds and ensure proper treatments were in place. The QM would check weekly wound reports, care plans and physician orders [REDACTED]. The wound nurse would go over the wound reports during the facility's morning meetings to inform the administration staff of current wounds and their status. The facility wound consultant would be utilized as needed. On 12/15/15 at 4:30 p.m., the administrator stated any resident with a wound who was not showing signs of improvement in thirty days would be referred to the facility wound consultant.

Based on record review, observation and interview, it was determined the facility failed to ensure the physician was notified of a change of condition for 2 (#2 and #3) of 6 sampled residents whose clinical records were reviewed. For resident #2, the physician was not notified of the resident's red, swollen, pus-draining, painful penis for a period of 9 days. For resident #3, the physician was not notified of a significant weight loss for 15 days. Seventy-five residents resided in the facility. Findings: 1. Resident #2 had [DIAGNOSES REDACTED]. The admission assessment, dated 02/05/13, documented the resident required limited assistance with transfer and required extensive assistance with dressing, hygiene and bathing. The care plan, dated 02/06/13, documented the resident had a Foley catheter. The goal was the resident would have no signs or symptoms of a urinary tract infection through the next review date. Interventions included: "Monitor indwelling catheter and change catheter bag as ordered and (as needed). Monitor urine for sediment, cloudiness, odor, blood, amount and report to (physician)...Provide good (catheter) care and perineal care..." Physician's telephone orders, dated 01/30/13, documented the resident was to have a Foley catheter for the [DIAGNOSES REDACTED]. A letter, dated 03/15/13, had been written by a nursing instructor who had supervised students in the facility. The letter, given to the facility's administrator on 03/15/13, documented: "During our clinical rotation on March 8, 2013 two students and clinical instructor with facility LPN (licensed practical nurse) present changed out the catheter for (name deleted, resident #2) in (resident's room number). Observation of the catheter bag when walking into the room was that the bag was very full of sediment and had red in color in bag. The tubing also had clot like buildup. When removing the catheter (to replace with new catheter) excessive yellow, pudding like discharge came out of the urethra. Patient was in extreme pain the whole time during the procedure as evidenced by patient bearing down, screaming, clinched fists, eyes bulged, irregular breathing, and turning red in color. When providing sterile cleaning and pulling back the foreskin, due to being uncircumcised, there was a large amount of pus underneath the foreskin. Sterile care was provided and placement of the catheter was successful. Once catheter was placed, pus was noted running down the tube of the catheter. When the LPN noticed pus coming out of the resident's penis, he stated (statement deleted).... Also the patient stated that "he has never had this done before" when asked if this hurt this bad the last time this was performed. The LPN informed us that documentation would be charted in the patient's chart regarding the apparent infection and the LPN told the patient that he would "talk to the doctor about getting on some antibiotics." The LPN told the students and clinical instructor that he would talk to his staff regarding daily catheter care and look to see when the last time the catheter was changed." The letter continued to document: "When arriving on March 15, 2013 to the facility, student went to check (name withheld, resident #2's) chart to see if documentation was provided regarding March 8, 2013 and to see if any antibiotics had been prescribed. As of (8:35 a.m.) on March 15, 2013, patient's chart provided no documentation regarding the possible infection of (name withheld, resident #2) and needing antibiotics. In the TAR (treatment administration record) for (name withheld, resident #2), there is an order for [REDACTED]. The chart also reflected that (catheter) care has been provided for March 15, 2013 yet, it was only (8:35 a.m.) at the time of these findings. The chart has stated (catheter) care was provided daily, twice a day since March 1, 2013..." The letter continued: "...At (11:30 a.m.) on March 15, 2013, catheter care was performed by two students and clinical instructor. Patient still complains of extreme pain in catheter area. Area was cleaned with sea cleanse and skin protectant was applied after care to external areas that were raw and red. Catheter still shows signs of infection as evidence by pus still secreting from urethra. Foreskin was cleaned and retracted after care...LPN was not able to be present during cleaning." Nurses' notes were reviewed. There were no nurses' notes between 02/27/13 at 7:30 a.m. and 03/17/13 at 12:15 a.m. There was no documentation to indicate the resident's penis and/or pain and/or urine had not been assessed/monitored during that time frame. There was no documentation to indicate the resident's physician had been notified of the above documented observations by the nursing instructor and her students. At 10:35 a.m., the surveyor asked LPN #3, who had documented on the TAR that she had provided catheter care for the resident during the 7 a.m. to 7 p.m. shift on 03/10/13, if she had noted any redness or swelling of the penis. She stated there was redness at the tip of the penis, but no swelling had been noted. She stated the resident had complained of pain and she had the certified medication aide administer some [MEDICATION NAME]. The surveyor asked if pain was something she normally observed during catheter care. She stated, "No." The surveyor asked if she reported the pain to anyone. She stated, "No." The surveyor asked if she had notified the physician. The LPN stated, "No." At 10:48 a.m., the surveyor asked the DON when she was informed of the nursing instructor's and nursing students' observations on 03/08/13. She stated she was informed on 03/18/13. The surveyor asked if she had confirmed the nursing instructor's observations with LPN #1. She stated LPN #1 had confirmed there was "milky discharge" from the resident's penis. She stated LPN #1 had acknowledged he had told the nursing students he would document the observations and call the physician but had not done so. The DON reported the LPN did not report the redness or swelling of the resident's penis. The surveyor asked the DON if the resident had been assessed/monitored for infection/pain on 03/08/13. She stated, "No." The surveyor asked if the facility had intervened for the resident's condition on 03/08/13. She stated, "No." The surveyor asked if the physician had been notified of the resident's change of condition on 03/08/13. She stated, "No." The surveyor asked if the resident was assessed when the facility was notified of the nursing students' observations on 03/15/13. The DON stated, "No." The surveyor asked if the physician was notified at that time. She stated, "No." The surveyor asked if any interventions were initiated for the care/treatment of [REDACTED]. She stated, "No." At 3:30 p.m., the surveyor showed LPN #2 the TAR, dated 03/2013, and asked if she had provided catheter care for resident #2 at any time from 03/08/13 to 03/16/13. She stated she had performed the catheter care during the 7 a.m. to 7 p.m. shift on 03/12/13. The surveyor asked what she observed during the catheter care. She stated the resident's penis was reddened and he had grimaced during the catheter care. The surveyor asked the LPN if she had documented her observations anywhere and showed her there was no nurse's note dated 03/12/13. She stated she had not documented her observations. The surveyor asked if she had assessed the resident as to why his penis was painful. She stated, "No." The surveyor asked if she had called the physician. The LPN stated, "No." 2. Resident # 3 had [DIAGNOSES REDACTED]. The significant change assessment, dated 01/18/13, documented the resident was severely impaired in cognitive skills for daily decision making and had behaviors, both verbal and physical, directed towards others daily. The assessment documented the resident required extensive assistance with eating and hygiene. The care plan, dated 06/07/12, documented the resident had a problem with alteration in nutritional status. The interventions were to observe for signs and symptoms of dehydration, monitor laboratory values, provide the diet as ordered, and encourage fluids. On 12/21/13, the care plan was updated to reflect a significant weight loss. The interventions were to administer an appetite stimulant, administer a vitamin supplement, provide a nutritional supplement, and notify the physician of weight loss. The care plan also indicated the resident was moved to the feeding assist dining room. The resident weight report provided by the facility documented the following weights: 11/06/12 242 pounds (lbs.), 12/05/12 225.8 lbs, for a 6.6% weight loss in 30 days, and 01/05/12 215.2 lbs. The clinical record contained documentation the physician was notified on 12/21/12, 15 days after the December weight was obtained, of the significant weight loss from 11/06/12 to 12/05/12. On 03/26/13 at 11:00 a.m., the director of nurses was asked when the physician had been notified of the significant weight loss. She stated that a time lag had occurred in entering the weights into the computer, and she did know when he had been notified. At 11:05 a.m., the assistant director of nurses was asked if the physician had been notified of the weight loss prior to 12/21/12. She stated she had talked to the physician when the resident was moved to the feeding assist dining room on 12/21/12. She stated she did not think he had been notified of the weight loss prior to that date.

Based on record review, observation and interview, it was determined the facility failed to: a. assess, monitor and intervene in regard to a resident's red, swollen, pus-draining, painful penis for a period of 9 days b. administer topical medication to the resident's infected penis per the physician's orders [REDACTED]. This affected 1 (#2) of 6 sampled residents whose clinical records were reviewed for assessment, monitoring and intervention for quality of care issues. Seventy-five residents resided in the facility. Findings: Resident #2 had [DIAGNOSES REDACTED]. The admission assessment, dated 02/05/13, documented the resident required limited assistance with transfer and required extensive assistance with dressing, hygiene and bathing. The care plan, dated 02/06/13, documented the resident had a Foley catheter. The goal was the resident would have no signs or symptoms of a urinary tract infection through the next review date. Interventions included: "Monitor indwelling catheter and change catheter bag as ordered and (as needed). Monitor urine for sediment, cloudiness, odor, blood, amount and report to (physician)...Provide good (catheter) care and perineal care..." Physician's telephone orders, dated 01/30/13, documented the resident was to have a Foley catheter for the [DIAGNOSES REDACTED]. A letter, dated 03/15/13, had been written by a nursing instructor who had supervised students in the facility. The letter, given to the facility's administrator on 03/15/13, documented: "During our clinical rotation on March 8, 2013 two students and clinical instructor with facility LPN (licensed practical nurse) present changed out the catheter for (name deleted, resident #2) in (resident's room number). Observation of the catheter bag when walking into the room was that the bag was very full of sediment and had red in color in bag. The tubing also had clot like buildup. When removing the catheter (to replace with new catheter) excessive yellow, pudding like discharge came out of the urethra. Patient was in extreme pain the whole time during the procedure as evidenced by patient bearing down, screaming, clinched fists, eyes bulged, irregular breathing, and turning red in color. When providing sterile cleaning and pulling back the foreskin, due to being uncircumcised, there was a large amount of pus underneath the foreskin. Sterile care was provided and placement of the catheter was successful. Once catheter was placed, pus was noted running down the tube of the catheter." The letter continued: "When the LPN noticed pus coming out of the penis, he stated to the patient (statement deleted) ...Also the patient stated that "he has never had this done before" when asked if this hurt this bad the last time this was performed. The LPN informed us that documentation would be charted in the patient's chart regarding the apparent infection and the LPN told the patient that he would "talk to the doctor about getting on some antibiotics." The LPN told the students and clinical instructor that he would talk to his staff regarding daily catheter care and look to see when the last time the catheter was changed." The letter continued to document: "When arriving on March 15, 2013 to the facility, student went to check (name withheld, resident #2's) chart to see if documentation was provided regarding March 8, 2013 and to see if any antibiotics had been prescribed. As of (8:35 a.m.) on March 15, 2013, patient's chart provided no documentation regarding the possible infection of (name withheld, resident #2) and needing antibiotics. In the TAR (treatment administration record) for (name withheld, resident #2), there is an order for [REDACTED]. The chart also reflected that (catheter) care has been provided for March 15, 2013 yet, it was only (8:35 a.m.) at the time of these findings. The chart has stated (catheter) care was provided daily, twice a day since March 1, 2013..." The letter continued: "...At (11:30 a.m.) on March 15, 2013, catheter care was performed by two students and clinical instructor. Patient still complains of extreme pain in catheter area. Area was cleaned with sea cleanse and skin protectant was applied after care to external areas that were raw and red. Catheter still shows signs of infection as evidence by pus still secreting from urethra. Foreskin was cleaned and retracted after care...LPN was not able to be present during cleaning." Nurses' notes were reviewed. There were no nurses' notes between 02/27/13 at 7:30 a.m. and 03/17/13 at 12:15 a.m. There was no documentation to indicate the resident's penis and/or pain and/or urine had not been assessed/monitored during that time frame. There was no documentation to indicate the resident's physician had been notified of the above documented observations by the nursing instructor and her students. The nurse's note, dated 03/17/13 at 12:15 a.m., documented: "...Noted (resident's) scrotum/testicles swollen and red, painful to touch. Penis painful to touch tip of penis swollen. (Resident) verbalized to be very (miserable). Area (not) warm to touch. (Physician) called and updated..." The note did not document a description of the resident's urine. A physician's telephone order, dated 03/17/13 at 12:10 a.m., documented Keflex 500 mg was to be administered by mouth 3 times daily for 10 days for the [DIAGNOSES REDACTED]." A nurse's note dated 03/17/13 at 10:00 a.m., documented the resident's scrotal area remained "inflamed." A nurse's note, dated 03/18/13 at 3:20 a.m., documented the initial dose of Keflex was administered. The note documented the resident's penis/testicles remained "swollen, red and sensitive to touch." A nurse's note, dated 03/18/13 at 3:35 a.m., documented the Foley catheter was draining clear yellow urine with no odor. A nurse's note, dated 03/18/13 at 10:55 a.m., documented: "Focus assessment related to pain in penis/catheter insertion site. Elder noted (with) hand holding penis & testicles on outside of (pajamas). States it hurts. Assessment noted (with) catheter (with) cloudy yellow urine, (with) sediment noted in tubing. Insertion site (with) mucousy yellow substance around catheter & tip of penis (after) foreskin retracted. (Complains of) pain (with) touching catheter penis or testicles..." The nurse's note documented the resident would be added to the physician's clinical nurse specialist's list of residents to be seen that day. The note documented the nurse practitioner would be requested to evaluate the resident's "catheter/penis/testicle pain, catheter placement/cloudy color and request for routine pain (medications) for 7 days to assist (with) pain control..." A progress note, dated 03/18/13, written by a clinical nurse specialist, documented the resident had associated signs/symptoms of balanoposthitis, an inflammation of the glans penis and the foreskin, and was to be started on [MEDICATION NAME] topical cream to the head of penis every 8 hours for 7 days and then reevaluated. In the review of the resident's genito-urinary system, the clinical nurse specialist documented: "no urine retention, no dysuria, no discharge." A physician's telephone order, dated 03/18/13, documented [MEDICATION NAME] cream was to be applied to the head of the resident's penis every 8 hours after cleaning with normal saline and patting dry with a clean 4X4 for 7 days. The [DIAGNOSES REDACTED]. The order had been noted by a facility LPN on 03/21/13. A nurse's note, dated 03/19/13 at 6:55 p.m., documented the resident verbalized a reduction in pain to his penis and a decrease in redness and less swelling had been noted. The resident's urine was clear yellow. A nurse's note, dated 03/20/13 at 1:58 a.m., documented catheter care had been done. No assessment of the penis and/or description of the urine was documented. A nurse's note, dated 03/20/13 at 6:25 p.m., documented a decrease in redness and less swelling to the penis. No description of the urine was documented. A nurse's note, dated 03/21/13 at 1:00 p.m., documented the resident's physician had made rounds and had discontinued the Keflex. A physician's telephone order, dated 03/21/13, documented the Keflex was to be discontinued. No assessment of the resident's penis and/or pain and no description of the urine was documented. A packing list, dated 03/21/13, documented [MEDICATION NAME] was delivered to the facility. There were no nurse's notes between 03/21/13 at 1:00 p.m. and 03/25/13 at 8:00 p.m. There was no documentation the resident's penis and/or pain and/or urine had been assessed/monitored during that time frame. The TAR, dated 03/2013, documented Foley catheter care had been provided by licensed staff twice daily throughout the month. The TAR documented the catheter and the Foley drain bag had been changed on 03/03/13. The TAR documented the [MEDICATION NAME] had been administered to the resident's penis on 03/23/13 at 8 a.m. No additional applications of the medication were documented. On 03/25/13 at 4:40 p.m., the surveyor asked LPN #1, if he was present during a catheter change and catheter care for resident #2 by student nurses. He stated he was present. The surveyor asked for the date of that catheter change. He stated he thought it was 03/14/13. The surveyor asked if the resident had exhibited any pain during the procedures. He stated the only discomfort the resident had exhibited was during the insertion of the catheter. He was asked if there was any documentation of the procedures. He stated he had not documented his observations. The surveyor showed the LPN the physician's orders [REDACTED]. He stated he had not seen the order when it was written on 03/18/13, but had found it on 03/21/13 and noted it. He acknowledged the medication had been administered once per documentation on the TAR. On 03/25/13 at 5:05 p.m., the surveyor asked the director of nurses (DON) if the observations of resident #2's catheter change and catheter care on 03/08/13 had been documented. She stated she had asked LPN #1 about the incident and he had admitted he had not documented his observations. She stated LPN #1 had told her he would write a late entry. The DON had reviewed the nurse's notes and acknowledged no nurse's note had been written. The surveyor showed the DON the physician's orders [REDACTED]. On 03/25/13 at 5:20 p.m., LPN #1 was standing at the Hall 200 treatment cart. The surveyor asked him to see resident #2's tube of [MEDICATION NAME]. The LPN looked through the drawer and could not find any [MEDICATION NAME] for the resident. On 03/26/13 at 9:04 a.m., the surveyor asked the administrator what information had been reported to him regarding a catheter change and catheter care for resident #2 on 03/08/13. He stated a nursing instructor had told him LPN #1 had changed the catheter and there was pus in the tubing. He stated he was told the resident had grimaced during the procedure. The administrator stated he was told the LPN had made inappropriate comments to the resident. He stated he had spoken to the resident who had stated he was not offended by the LPN's comments. At 9:25 a.m., the assistant director of nurses (ADON) was asked what observations she had made during the provision of catheter care for resident #2 on 03/23/13, as documented on the TAR. She stated there was pus around the penis and sediment in the Foley bag. The clinical record did not contain documentation of the observation by the ADON on 03/23/13. At 10:35 a.m., the surveyor asked LPN #3, who had documented on the TAR that she had provided catheter care for the resident during the 7 a.m. to 7 p.m. shift on 03/10/13, if she had noted any redness or swelling of the penis. She stated there was redness at the tip of the penis, but no swelling had been noted. She stated the resident had complained of pain and she had the certified medication aide administer some [MEDICATION NAME]. The surveyor asked if pain was something she normally observed during catheter care. She stated, "No." The surveyor asked if she reported the pain to anyone. She stated, "No." The surveyor asked if she had notified the physician. The LPN stated, "No." At 10:48 a.m., the surveyor asked the DON when she was informed of the nursing instructor's and nursing students' observations on 03/08/13. She stated she was informed on 03/18/13. The surveyor asked if she had confirmed the nursing instructor's observations with LPN #1. She stated LPN #1 had confirmed there was "milky discharge" from the resident's penis. She stated LPN #1 had acknowledged he had told the nursing students he would document the observations and call the physician but had not done so. The DON reported the LPN did not report the redness or swelling of the resident's penis. The surveyor asked the DON if the resident had been assessed/monitored for infection/pain on 03/08/13. She stated, "No." The surveyor asked if the facility had intervened for the resident's condition on 03/08/13. She stated, "No." The surveyor asked if the physician had been notified of the resident's change of condition on 03/08/13. She stated, "No." The surveyor asked if the resident was assessed when the facility was notified of the nursing students' observations on 03/15/13. The DON stated, "No." The surveyor asked if the physician was notified at that time. She stated, "No." The surveyor asked if any interventions were initiated for the care/treatment of [REDACTED]. She stated, "No." At 1:03 p.m., the surveyor asked the administrator if the nursing instructor had provided a written account of her and her students' observations of the catheter change and catheter care on 03/08/13. He stated she had. The surveyor asked for a copy of the letter and the administrator stated he had destroyed it per corporate policy. At 1:30 p.m., the surveyor observed the provision of catheter care by LPN #4. The resident's penis and scrotum were slightly reddened and the resident moaned and grimaced throughout the procedure. The LPN stated she had offered the resident pain medication prior to the procedure and he had refused it. The resident's urine was clear yellow with a large amount of white sediment. At 3:30 p.m., the surveyor showed LPN #2 the TAR, dated 03/2013, and asked if she had provided catheter care for resident #2 at any time from 03/08/13 to 03/16/13. She stated she had performed the catheter care during the 7 a.m. to 7 p.m. shift on 03/12/13. The surveyor asked what she observed during the catheter care. She stated the resident's penis was reddened and he had grimaced during the catheter care. The surveyor asked the LPN if she had documented her observations anywhere and showed her there was no nurse's note dated 03/12/13. She stated she had not documented her observations. The surveyor asked if she had assessed the resident as to why his penis was painful. She stated, "No." The surveyor asked if she had called the physician. The LPN stated, "No."

On [DATE] at 2:00 p.m., an Immediate Jeopardy (IJ) situation was identified related to the failure of the facility to provide immediate cardio [MEDICAL CONDITION] resuscitation (CPR) to an unresponsive resident, who had requested to be on full code status. The staff waited, after the resident was found unresponsive on the floor, before initiating CPR due to the staffs lack of information regarding the resident's code status. On [DATE] at 2:05 p.m., the existence of an IJ was verified with the Oklahoma State Department of Health (OSDH). On [DATE] at 2:20 p.m., the facility administrator and the director of nursing (DON) were notified of the existence of an IJ pertaining to the failure of the staff to provide immediate CPR to an unresponsive resident who had a full code status. On [DATE] at 3:30 p.m., the plan of removal was received and accepted. The facility's Plan of Removal documented: "1. Director of Nursing will print out a current census and will go through the facility to ensure that there are name plates on the door with the current coding as to the code status of the residents. Green = full code, Red = DNR (do not resuscitate). Each name will be marked off the census as the residents code status is identified and /or corrected. Charts for residents with an advanced directive will have red folders in the charts that identify the area to contain information on the residents code status. 2. The Assistant Director of Nursing will be responsible for making the color coded name tags during the week and the on call nurse manager will be responsible for making the color coded name tags on the weekends. 3. The Assistant Director of Nursing, Director of Nursing and/or Administrator will ensure that all new admissions and room transfers, will have a color coded name tag on the door at the time of admission. Weekend admissions and transfers will be responsible of the on call nurse manager. 4. All employees will be in-serviced regarding the code status of residents and what the color coding means. Green = Full code, Red = DNR. Charts will be flagged with red folders that identify the area that advanced directives are kept. Employees that are currently in the building will be in-serviced first, then employees not currently here will be called and in-serviced over the phone. Any employee not in-serviced will not be allowed to return to work until they have been in-serviced. The Director of Nursing is responsible for in-servicing all staff. Staff in-services will be completed by midnight on [DATE]. 5. Any resident found to be without a name on the door, that identifies the code status, will have CPR started immediately in the absence of respirations or heart beat." On [DATE] at 9:30 a.m., the DON was asked if the nursing staff had been inseviced on interventions for an unresponsive resident and if each resident had a colored code name plate at the entrance to their room. She stated eighteen of the eighty-five employees had not been inserviced. She stated no one would be allowed to return to work with out having been inserviced. Documentation of the inservices was provided to the state surveyors. On [DATE] at 9:35 a.m., the surveyor informed the facility's administrator the IJ was removed as of [DATE] at 12 midnight. The staff was interviewed to verify the inservices had taken place and each resident had a color coded name plate on the entrance to their room. The deficient practice remained at a level of actual harm at a pattern. Based on observation, interview and record review, it was determined the facility failed to ensure staff initiated CPR (cardio [MEDICAL CONDITION] resuscitation) immediately to an unresponsive resident (#12) whose code status was not known when the resident's room was entered by staff and the resident was found unresponsive. The facility identified two additional residents without name plates on the entrance to their rooms. One of the residents was a full code status and one was a DNR. The facility identified 58 residents were full codes and 27 residents were DNRs. Findings: The facility policy documented: "1. ...When medically indicated, cardiopulmonary resuscitation (CPR) should be administered to a Resident in the event of cardiac or respiratory arrest, unless one or more of the following conditions, of which the Resident's attending physician and/or facility staff have actual knowledge, apply: ...(a) The Resident has notified his/her attending physician that he/she does not consent to the administration of CPR and the attending physician has entered a DNR Order in the resident's record:... ...(b) A DNR Consent form...has been executed for the resident... ...(c) An executed Directive, ...directing that life-sustaining treatment not be performed in the event of a cardiac or respiratory arrest, is in effect for the Resident...." The care plan for resident #12, updated on [DATE], did not address the resident's code status. On [DATE] at 9:10 a.m., an initial tour of the facility was conducted with licensed practical nurse #1 (LPN). He was asked about the significance of the colored name plates. He stated red name plates were a DNR and green name plates were a CPR. He was standing outside of room [ROOM NUMBER], resident # 12's room, when he was asked this question. He stated this resident did not have a name plate. He stated he didn't know where it went. Itt was there last Friday. At 1:40 p.m., a staff member was heard yelling for a nurse stat (immediately). About thirty seconds later the staff member was heard repeating the call for a nurse to assist her immediately. Several staff members were observed running down the hall to room [ROOM NUMBER] to assist the staff member calling for help. The resident was observed flat on his back on the floor of his restroom. No respiratory effort was observed from his chest. His lips were blue as well as the top of his head. His skin was white with a waxy appearance on his face. LPN #1 was heard to say he does not have a carotid pulse, he is unresponsive. He asked, "Is he a DNR?" Three staff members in the room stated they did not know. Certified nurse aide #1 (CNA) stated she would get his chart. She left the room. It was observed the resident still did not have a name plate at the entrance to his room. Prior to initiating CPR, staff members had been coming in and out of his room asking if he was a code. No one knew. Some one said they couldn't find his chart. At 1:44 p.m., CNA #1 returned to the room, she stated he was a full code and 911 had been phoned. At that time CPR was initiated. At 1:50 p.m., the firemen emergency crew arrived and took over the efforts to resuscitate the resident. At 2:20 p.m., the emergency personnel spoke to the emergency department physician at a local hospital. The electrocardiogram was reviewed and the resident's unresponsive condition was described to the physician. The physician told the emergency crew to stop efforts to resuscitate the resident. At 2:20 p.m., the assistant director of nursing was asked what the staff should have done if they did not know the code status of a resident. She stated, "If the status is unknown, the staff should started CPR. LPN #1 was asked if he should have started CPR immediately. He stated he believed some one would find the chart quickly and determine the code status of the resident. On [DATE] at 9:00 a.m., CNA #1 stated she found the resident. She noticed he did not have a color coded name plate. She called out for a nurse, then went to get his chart. The chart was not where it was supposed to be. She stated she had to look for it, she stated she finally found it on a desk. She added 911 had been called and she returned to the room to inform the nurse the resident was a full code. The resident's Admissions Summary, dated [DATE], documented the resident was not a DNR. The facility's Medication Administration Record, [REDACTED]. The physician's computerized order sheet, dated [DATE], documented the resident was a full code. On [DATE] at 10:10 a.m., the administrator was asked how staff was informed about the significance of the red and green name plates. He stated staff should have been oriented upon hire by the staffing coordinator. He was asked if he was aware some of the residents didn't have name plates. He stated he was told the resident did have a name tag during the weekend. The resident's clinical record documented the resident wished to receive CPR in the event of a cardiac and/or respiratory arrest.

Based on observation, record review and interview, it was determined the facility failed to ensure: ~ a CNA (certified nurse aide) notified the charge nurse of a resident's inability to eat during meal services for one (#11) of one sampled resident. The Resident Census and Condition, dated 05/22/11, documented 22 residents required assistance with meals. ~ it was determined the facility failed to ensure a Registered Nurse performed a pain assessment upon admission to determine the appropriate dose of a pain medication to be administered to a resident who was also receiving an anti-anxiety medication and ensure this decision was not being made by a certified medication aide for one (#11) of two new admissions on the sample. The facility Census report documented 24 new admissions in the last 3 months. ~ residents received medications to relieve nausea for one (#2) of one sampled residents who experienced nausea. Findings: Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She had previously resided in her home with her husband. The clinical records documented the resident weighed 93 pounds at the time of admission. A nurse's note, dated 05/18/11, documented, "3:30 p.m...(no) s/s (signs or symptoms) of pain or discomfort @ present." There was no documentation in the clinical record to show a comprehensive pain assessment was conducted upon admission. An admitting physician's orders [REDACTED]. NTE (not to exceed) 4000 mg ( milligrams) APAP dose in 24 hours from all sources. Dx (diagnosis): [MEDICATION NAME] ([MEDICATION NAME]) 1 mg i/i (one) SL (sublingual) q (every) 6 (hours) prn (as needed) DX: anxiety." The initial plan of care, dated 05/18/11, documented under the pain and/or discomfort problem: 1. Assess resident for pain or discomfort. 2. Offer comfort measures: warm blanket, pillows, reposition, range of motion exercises, etc. 3. Administer pain medication if ordered. If not consult physician regarding discomfort and need for some type of pain medication. 4. The resident is on routine [MEDICATION NAME]. The individual narcotic record, dated 05/19/11, documented the resident received [MEDICATION NAME] at 4:00 p.m. There was no documentation the resident was exhibiting signs of anxiety. The individual narcotic record, dated 05/20/11, documented the resident received [MEDICATION NAME] at 8:00 a.m., and 4:30 p.m. A nurse's note, dated 05/20/11, documented, "3:30 p.m...(no) s/s of pain or discomfort @ present." The back of the MARs (medication administration records), dated 05/21/11, documented the resident received [MEDICATION NAME] at 9:00 a.m., and 9:00 p.m. The MAR indicated [REDACTED]. The individual narcotic record documented the resident received the [MEDICATION NAME] at 8:00 a.m. and 8:00 p.m. A nurse's note, dated 05/21/11, documented, "(no time of entry)...(no) s/s or discomfort voiced / noted @ this time." On 05/22/11, at 3:00 p.m., during the initial tour, the resident was observed to be asleep in her bed and at 6:10 p.m., as well. The back of the MARs, dated 05/22/11, documented the resident received [MEDICATION NAME] at 9:00 a.m., 3:00 p.m., and 9:00 p.m. for complaints of anxiety. The MAR indicated [REDACTED]. The individual narcotic record documented the resident received the medication at 8:00 a.m. and 3:00 p.m. The MAR, dated 05/23/11, documented the resident received [MEDICATION NAME] at 2:00 p.m., for anxiety. There was no documentation the resident was exhibiting signs of anxiety. The individual narcotic record documented the resident received [MEDICATION NAME] at 9:00 a.m. The MAR, dated 05/24/11, did not document the resident received [MEDICATION NAME]. There was no documentation the resident was exhibiting signs of anxiety. On 05/24/11 at 1:00 p.m., the resident was observed lying in bed with her eyes closed. She was on her back with the head of the bed at a 45 degree angle. A lunch tray, wrapped in plastic wrap and covered with a lid, was observed beside the sink. At 1:12 p.m., CMA (certified medication aide) #7 entered the room. The resident's roommate informed the CMA the resident had not eaten. The CMA picked up the food tray and placed it on the bed side table. The head of the bed remained at a 45 degree angle. The CMA attempted to awaken the resident. When she shook the resident's shoulder she awakened with a startled reaction then returned to sleep. The CMA placed a bite of meat in the resident's mouth and instructed her to wake up and eat. The resident awakened with a startled reaction. She asked the resident to chew, the resident fell asleep. The process was repeated again. The piece of meat was removed from the resident's mouth. The same process was repeated several times with a bite of mashed potatoes with gravy. The food was removed from the resident's mouth. The CMA attempted to awaken the resident to drink milk from a glass and another unidentified liquid in a glass. The fluids ran down the resident's chin. The CMA stated she was going to get a can of Ensure. She was asked if the resident was too sleepy to eat, would she be able to drink the Ensure. She said, "Well, I have to try if she will not eat." The CMA was observed as she walked to the kitchen to get a can of Ensure. She did not inform the charge nurse of the resident's level of consciousness. At 1:30 p.m., the CMA returned with a can of Ensure and began coaxing the resident to drink. A small amount of Ensure was poured into the resident's mouth and she was encouraged to swallow. The resident returned to sleep after each swallow. The process was repeated until the resident consumed the can of Ensure. At 1:50 p.m., the CMA was asked if the resident was awake enough to be fed. She said, "She needed to eat. I did tell someone she was sleepy." At 1:55 p.m., the ADON (assistant director of nurses) was asked if she was the charge nurse for CMA #7. She stated she was a charge nurse. She was asked if the CMA had told her the resident was too sleepy to eat She said, "No, but the family has instructed us to keep the resident sedated." At 2:30 p.m., the resident was observed lying in her bed with her eyes closed. At 3:20 p.m., the resident was observed lying in her bed with her eyes closed. The resident's roommate stated she is still asleep, she tried to wake her up, to give her some ice cream. She loves ice cream, but she wouldn't wake up. An observation was made at 3:57 p.m., with LPN #5 and CMA #8, of the resident having [MEDICAL CONDITION] activity. The resident's body was stiff and rigid, shaking so vigorously the bed was vibrating. The CMA told the LPN she had just administered [MEDICATION NAME] to the resident. The LPN stated, "I have never seen her do this before. I'm going to take her blood pressure." The event lasted about a minute. The resident did not respond to verbal stimuli. The resident's upper arms and facial muscles were twitching. After the event had finished the resident called out with jumbled words. A nurse's note, dated 05/24/11, documented, "4:05 p.m. This nurse was standing outside pt's (patients) room when it was noticed that pt was shaking. This nurse & CNA entered room. Pt laying in bed on back. Shaking stopped after about 30-45 seconds. BP 116/73 P - 101, R - 22. Pt eyes opened & some speech but not clear. Pt squeezing this nurses hands. Pt. (without) s/s of distress." At 4:05 p.m., the LPN stated, "I'll call hospice now, they know her." At 4:15 p.m., CMA #8 was asked if she documented the resident's level of consciousness when she administered the [MEDICATION NAME]. She stated not if it is a routine medication. We only do that for a prn (as necessary) medication. A nurse's note, dated 05/24/11, documented, "4:15 p.m. notified (name-deleted hospice nurse) she stated that she hadn't known of her to ever have a [MEDICAL CONDITION] before or exhibit shaking behavior...a hospice nurse would come to eval (evaluate) her tomorrow & that if anything should change to call them back." At 4:20 p.m., LPN #5 was asked what notification had been done regarding the resident's episode. She stated hospice told her the resident does it all the time, then she wakes up fine. She was asked if the physician had been notified. She stated, "No. Hospice said to call if there was a problem. I'm never going to get out of here." She was asked if notifying the hospice relieved her of the responsibility of assessing and notifying the physician. She stated, "I'm going to phone the physician. I just haven't had time." On 05/25/11 at 7:40 a.m., the resident was observed seated at the assisted table in the dining room. She was overheard telling a staff member, "I'm tired. I can't eat." At 10:15 a.m., the resident's husband was interviewed. He was asked what medication she took while she was at home. He stated she took a nerve pill when she needed it. He was asked if she received pain medication while she was at home. He stated, "No." He was asked if she was able to ask for nerve pills at home. He stated, "Not really." He was asked if the resident was adjusting to living in the facility. He stated she mostly slept. He was asked if she was more alert and awake when she was at home than she is now. He stated, "Well, yes. She was more awake a few weeks ago." He was asked if she had ever had any [MEDICAL CONDITION] or shaking episodes in the past. He stated no. He added sometimes her hands would shake when she drank coffee. At 4:20 p.m., the DON (director of nurses), ADON #1 and LPN #6 were interviewed regarding resident #11. The DON was asked if a pain assessment had been conducted upon admission. She said, "No, I have two weeks to complete that." The nursing check list, dated 05/18/11, documented the pain assessment was to be completed before the end of the admitting shift. N/A (non-applicable) was hand written at the end of the line where the nurse's initials should appear when the assessment was completed. She was asked how and who decided the resident was to be administered the maximum dose of 10 mls of [MEDICATION NAME]. She stated she had never seen the order. They were asked if the CMAs should make the decision about what dose of a pain medication a resident should be administered. The ADON stated the CMAs were giving the maximum dose to control the pain. She added an assessment should have been conducted then the lowest dose should have been administered first. The CMAs should not have determined what dose the resident should receive, they should have checked with a nurse first. The admission nurse's note documented, "...(No) pain upon arrival...Hospice nurse for resident was also here to see elder..." The DON was asked if there was documentation the resident had verbalized or demonstrated pain. She stated no because her pain was under control. She was asked if there was documentation the resident demonstrated anxiety symptoms. She stated there was not. She reviewed the records and stated they contained no documentation the resident complained of pain. She reviewed the MARs and stated they contained no documentation the resident complained of pain. The DON was asked if the resident was ever awake. She stated the resident is awake in the morning at breakfast, but after breakfast she sleeps most of the day. The DON was asked what an LPN should do if they observed a resident suddenly become rigid and start shaking. She stated the physician should have been notified first. The DON and ADON were asked if a CNA should have attempted to feed a resident that was too sleepy to stay awake. They stated the CNA should have notified a nurse concerning the resident's level of consciousness. 2. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive resident assessment, dated 03/24/11, documented the resident was able to make herself understood to others and was able to understand others. It documented she required extensive assistance with transfers, dressing, and hygiene. The physician's orders [REDACTED]. 1 tab (tablet) by mouth every 6 hours PRN (as needed) nausea/vomiting (03/27/11)." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 05/22/11 at 6:10 p.m., resident #2 was seated in her wheelchair in her room. She was asked why she was not down eating supper. She stated she couldn't eat, she was nauseated. She was asked if she was able to eat her lunch today. She stated, "No." She was asked if she received anything for the nausea and she stated she wasn't given anything. On 05/23/11 at 7:40 a.m., the resident was in bed. She was asked if she was having nausea this morning. She stated, "Not yet." At 6:00 p.m., the resident was asked if she was able to eat lunch. She said, "A little, but my stomach is still a little upset." She was asked if she was given anything for her nausea. She stated "Yes. They gave me a laxative." At 6:25 p.m., CMA #4 was asked if resident #2 had informed her that she was nauseated. She stated, "Yes. She told me she was nauseated so I gave her a laxative about 45 minutes ago. I also have her some prune juice." On 05/24/11 at 9:15 a.m., the resident was observed wheeling herself down the hall towards her room. A trail of watery fecal stool was coming from the wheelchair. The resident was asked if she was feeling okay. She stated, "If I could just get rid of this diarrhea I would be okay." At 2:50 p.m., ADON #2 was informed of the resident complaining of nausea and the CMA administering a laxative. She was also informed of the loose, watery stools. She stated, "She should have consulted with the nurse." On 05/25/11 at 8:00 a.m., the resident was asked how she was feeling. She stated, "I am feeling much better. I am going to breakfast. I got my medicine last night and I slept really good. I am not nauseated this morning."