Every finding on record at Care Haven Center

Based on record review and staff interview, the facility failed to ensure a complete and accurate medical record related to resident meal percentages. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #14. Facility census: 65.Findings include: a) Resident #14 A review of meal documentation (how much a resident ate during each meal) on 01/20/26 at 10:59 AM, for Resident #14 from 12/22/25 to 01/14/26, revealed that out of 23 days, only six (6) days had all three (3) meals documented. During an interview on 01/20/26 at 10:59 AM, the Director of Nursing (DON) confirmed they should be documenting for each meal that a resident receives.

Based on resident interview, staff interview, and food tray temperatures, the facility failed to serve food that was palatable and at an appetizing temperature. The facility failed to ensure hot foods were served hot and cold foods were served cold. This practice was true for three (3) of the four (4) hallways tested for milk on the beverage carts and food tray temperatures for two (2) of two (2) meal trays tested throughout the survey process. Facility census 65 Findings included a) Policy Review Review of the facility's policy read in part, all foods will be held at appropriate temperatures, greater than 135 degrees (or as state regulation requires) for hot foods and less than 41 degrees for cold food b) Palatable and Food Temperatures Interviews with 18 of 23 sampled residents revealed consistent complaints of the meals not being palatable because hot foods were being served cold. A test tray, on 01/19/26 at 2:00 PM, was served to surveyors to test the palatability of the food. The meal palatability tray revealed the Salisbury steak tasted bland and the scallop potatoes had minimal flavor and were barely warm. Review of resident council minutes and food committee minutes revealed the following details:. -Resident Council requested the State Agency (SA) attend a food committee meeting on 01/20/26 at 2:15 PM. Resident Council members as a whole agreed that the food was cold. The Dietary Manager (DM) in attendance acknowledged that she had heard those complaints and was working on getting some plate warmers. Further in the meeting, the Resident Council as a whole asked if the food was homemade. The DM told them that some of it was and some of it wasn't. The SA asked the DM if the Salisbury steak served yesterday was homemade? The DM replied, No, it was a hamburger with brown gravy. An observation for meal service, on 01/19/26 at 12:36 PM, revealed [NAME] #82 placing approximately 12 plates on the counter then placing meal tickets (which include the resident name, dietary order, and room number) beside each plate. Then the cook began to add each individual meal item one-by-one to all 12 plates. It took up to 10 minutes to ensure all 12 plates were ready to be served. For residents eating in the dining room, the Certified Nursing Assistants (CNAs) would take each plate to the dining room. For residents in their rooms, the tray aide would place each plate on a tray then add the tray to the meal delivery cart. Once the meal delivery cart was full, the tray aide would transport it to the assigned hallway. On 01/20/26 at 1:54 PM, food temperatures were taken from a test tray for each meal item being served. The Dining Manager was responsible for taking the temperatures of each item and verified the following cold foods as being too hot.Peaches - 52.2 degrees Fahrenheit (F)Milk - 48.0 degrees F The noon meal pass was observed on 01/21/26 at 1:27 PM. The meal being served included:-Hotdog with relish and mustard-Baked beans-Chicken noodle soup-Ice cream. Resident #66 reported the hotdog and soup are very cold. The resident also noted the ice cream very soft. Resident #9 reported the hotdog could be warmer but it would do. Resident #38 reported the hotdog was cold, the plate is cold, the soup is semi warm. The SA requested a test tray and the Dining Manager was responsible for taking the food temperatures. The Dining Manager also verified the hotdog and chicken noodle soup were too cold. She also confirmed the ice cream and the milk were too warm. -Hotdog - 105.6 degrees Fahrenheit (F)-Chicken noodle soup - 147.7 degrees F-Ice cream very soft -Carton of milk - 51.1 degrees F

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. This practice had the potential to affect more than a limited number of residents receiving nourishment from the kitchen. Facility census: 65.Findings include: a) Policy Review of the facility's policy for food storage reads in part, Food is to be stored, prepared, distributed and served in accordance with professional standards. Ensuring food service safety, sanitary condition and the prevention of foodborne illnesses. b) Kitchen Tour On 01/19/2026 at 8:00 AM during an initial walk through, [NAME] #82 was observed without a hairnet and had a cap on with dread unrestrained.Additionally, the following items were verified by [NAME] #82:-There was a dried sticky substance on top of the ice maker.-Food debris was found in a container holding lids.-A dried, red sticky residue was in the two (2) bowl sink.-A case of bananas with received date 12/23/25 were dark brown in color and very soft in the walk in refrigerator.-In the dry stock room, there was food debris in the bottom of the container holding packets of ketchup.-In the floor of the dry stock room there were several packets of sugar substitute.-In the reach-in refrigerator, there was a dried white substance along the edges inside of the door and along the gasket. On 01/20/25 at 11:41AM, the state agency surveyor observed insulated plate bases on the food delivery carts with wet nesting (practice of stacking wet dishes in a manner that does not allow proper air flow for drying.) Ten (10) of ten (10) bases were observed wet nesting. This was verified by the Dining Manager.

Based on record review and staff interview, the facility failed to develop and/or implement care plans related to Hospice services and meal intake percentages. This failed practice was found true for (3) three of 23 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #65, #5, #12. Facility Census 65.Findings included: a) Resident #5 On 01/20/26 at 8:16 AM, a review of physician orders and Resident #5's care plan was completed as it related to nutrition. The care plan in part stated,monitor intake all meals. A review of meal percentage documentation (which outlines how much a resident consumed at each meal) revealed 15 out of 30 days reviewed where not all meals were entered: -12/20/25, only one (1) meal was recorded. -12/22/25, only two (2) meals were recorded. -12/23/25, only two (2) meals were recorded. -12/26/25, only one (1) meal was recorded. -12/28/25 only one (1) meal was recorded. -12/30/25, only two (2) meals were recorded. -12/31/25, only one (1) meal was recorded. -01/01/26, only two (2) meals were recorded. -01/03/26, only two (2) meals were recorded. -01/04/26, only one (1) meal was recorded. -01/08/26, only two (2) meals were recorded. -01/09/26, only one (1) meal was recorded. -01/12/26, only two (2) meals were recorded. -01/14/26, only one (1) meal was recorded. -01/16/26, only two (2) meals were recorded. On 01/20/26 at approximately 1:00 PM, the DON confirmed that the facility had failed to document all three (3) meal percentages for Resident #5. b) Resident #12 Review of Resident #12's comprehensive care plan showed the following focus was initiated on 02/01/21 and most recently revised on 07/24/23: [Resident #12] is at nutritional risk r/t [related to] hx [history] of: Parkinson's, cellulitis, DM2 [diabetes type II], Diarrhea, vomiting, Hyperkalemia, CKD [chronic kidney disease] stage 4, Atherosclerotic heart disease, UTI [urinary tract infection], Anemia, Edema, TIA [transient ischemic attack], Obesity, Depression, PNA [pneumonia], Fluid overload, COPD [chronic obstructive pulmonary disease], GERD [gastroesophageal reflux disease], Constipation, HTN [hypertension], hx of insignificant expected weight loss (fluid overload: was given diuretic: resolved), repeated falls, significant weight loss (weight stabilized). An intervention initiated on 02/01/21 was to Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. Resident #12's meal intake percentage documentation was reviewed for the previous 30 days. Meal intake percentages were not documented for all three (3) meals on the following dates: -On 12/22/25, only two (2) meals were documented. -On 12/23/25, only two (2) meals were documented. -On 12/24/25, no meals were documented. -On 12/25/25, no meals were documented. -On 12/26/25, only one (1) meal was documented. -On 12/27/25, no meals were documented. -On 12/29/25, no meals were documented. -On 12/30/25, no meals were documented. -On 12/31/25, only one (1) meal was documented. -On 01/01/26, only two (2) meals were documented. -On 01/03/26, only one (1) meal was documented. -On 01/04/26, no meals were documented. -On 01/05/26, only two (2) meals were documented. -On 01/06/26, only one (1) meals was documented. -On 01/07/26, only two (2) meals were documented. -On 01/08/26, only two (2) meals were documented. -On 01/09/26, only two (2) meals were documented. -On 01/10/26, only one (1) meal was documented. -On 01/11/26, only one (1) meal was documented. -On 01/12/26, no meals were documented. -On 01/13/26, only two (2) meals were documented. -On 01/14/26, no meals were documented. -On 01/15/26, only two (2) meals were documented. -On 01/17/26, no meals were documented. -On 01/18/26, no meals were documented. On 01/20/2026 at 9:52 AM, the Director of Nursing confirmed Resident #12's meal intake percentages were not recorded every meal as specified in her care plan. c) Resident #65 A record review on 01/20/26 at 12:09 PM, revealed an order for Resident #65 stating the resident admitted to Hospice Services on 12/17/25. Further record review of Resident #65's care plan, revealed that a Hospice care plan had not been put in place. During an interview on 01/20/26 at 1:30 PM, the Director of Nursing (DON) confirmed that the Hospice care plan was not in there and, further stated, We do not have it. I do not know why. We put everything else in. I guess we just missed it.

Based on observation, record review, resident interview, and staff interview the facility failed to follow resident's therapeutic diet for fortified foods. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #14, and #1. Facility census: 65.Findings included: a) Resident #1 Resident #1 had the following diet order written on 12/08/25, Regular/Liberalized diet, Regular texture, Standard Thin Liquids consistency, fortified food with all meals: oatmeal with breakfast, mashed potatoes with lunch and pudding with dinner. Resident #1, who was eating in her room, was served her lunch tray on 01/21/26 at 1:14 PM. Her lunch tray was served by the Kitchen Account Manager. The surveyor noted the resident didn't have mashed potatoes on her tray and fortified food was not noted on the resident's meal tray ticket. The Kitchen Account Manager stated, She's not on fortified food. On 01/21/2026 at 1:30 PM, the Administrator confirmed Resident #1 had an order for fortified food at each meal, but this was not noted on the resident's meal tray ticket. No further information was provided through the completion of the survey process. b) Resident #14 An observation on 01/21/26 at 1:15 PM, showed Resident #14 in her bed eating her lunch. A review of Resident #14's meal ticket on her tray read that she was to receive 1/2 cup of fortified mashed potatoes. The mashed potatoes were not on the tray. Resident #14 stated, There is a lot of times that I do not get the mashed potatoes. During an interview in Resident #14's room with the Director of Nursing (DON), on 01/21/26 at 1:20 PM, the DON confirmed that Resident #14 did not get fortified potatoes as ordered.

Based on observation, record review, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. The resident's Peripherally Inserted Central Catheter (PICC line) dressing was not changed in accordance with professional standards of practice. This was true for one (1) of one (1) residents with PICC lines reviewed. Resident Identifier: #30. Facility Census: 65. Findings included: a) Resident #30 The facility's policy titled Dressing Change for Vascular Access Devices dated 2011 stated Peripherally Inserted Central Catheter (PICC line) dressings were to be changed every seven (7) days. On 01/19/26 at 9:10 AM, Resident #30 was noted to have a right arm peripheral catheter. The resident stated he was receiving intravenous antibiotics through the catheter. The catheter had a date of 01/07/26 written on the dressing to indicate when the dressing had last been changed. Review of Resident #30's medical records showed his right arm peripheral catheter was a PICC line that had been inserted in the hospital before the resident was admitted to the facility on [DATE]. Review of Resident #30's physician's orders showed no orders for PICC line dressing changes. On 01/19/2026 at 9:17 AM, the Director of Nursing (DON) confirmed the date on Resident #30's PICC line dressing was 01/07/26 and the dressing should have been changed. No further information was provided through the completion of the survey process.

Based on observation and staff interview the facility failed to serve food in accordance with professional standards for food serve safety. This had the ability to effect more than a limited number of residents. Facility census: 64. Findings included: a) Initial Kitchen Tour During the initial kitchen tour on 09/03/24 at 1:20 PM an observation of tray service found the Dietary Manager (DM) dipping food with gloved hands, touching and opening hamburger buns, touching serving scoops, the plate warming cart, the counter, bowls, bowl rack, and the environment around the service area. Continued observation found The DM using the plate lifter to get the plates from the warmer and when not in use, suction the plate lifter to the countertop. During an interview at 09/03/24 1:35 PM the DM stated that she only cleans the top counter after breakfast, lunch and dinner. The DM confirmed that suctioning the plate lifter to the countertop could cause germs to be spread. She also verified that she was touching the surrounding environment and the resident's hamburger buns without changing her gloves.

Based on observations, record review, resident interview, and staff interview, the facility failed to maintain regularly scheduled mealtimes. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census: 64. Findings Included: a) Dining Observation An observation on 09/03/24 at 12:30 PM revealed the lunch meal had not been served. 16 residents were in the dining room waiting for their meal. A review of the posted mealtimes found that the lunch meal was scheduled to start at 12:15 PM daily. An interview with Nurse Aide #29 on 09/03/24 at 12:44 PM revealed the lunch meal was late most days. During an interview, on 09/03/24 at 12:56 PM, Certified Dietary Manager (CDM) verified the noon meal was not served on time. She stated breakfast was late so they could not start on time for the lunch meal. Continued observation on 09/03/24 found drinks were not served until 1:05 PM, upon inquiry by the surveyor. Observation continued to find the first tray was served in the dining room at 1:20 PM.

43340 Based on record review and staff interview, the facility failed to maintain accurate records on two (2) out of 22 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #64 and #119. Facility census: 64. Findings included: a) Resident #64 A record review, completed on 09/05/24 at 7:30 PM, revealed resident had been hospitalized on [DATE] and had not returned to the facility. There was also a nurse practitioner (NP) note, dated on 6/25/2024 at 10:52 PM, that listed the date of service (date of NP visit at the facility) as 06/25/24. Details of the note were, She is seen resting to bed with no grimaces or s/s (signs and symptoms of) pain. She was recommended hospice by oncology however declined. Labs and meds reviewed. She continues rehab for weakness. This shift increased weakness reported with general declines. The note indicated the NP had spent 46 minutes total meeting with resident and reviewing resident's chart. During an interview, on 09/06/24 at 10:05 AM, the Director of Nursing (DON) reported there was an error with the date of service listed in the chart. The DON further explained it was a telehealth vist that was made on 06/19/24 prior to Resident #64 going to the hospital.

Based on medical record review and staff interview the facility failed to ensure one (1) of one (1) residents reviewed for nutrition received the correct therapeutic diet. Resident #119. Facility census: 64. Findings included: a) Resident #119 A record review on 09/04/24 at 11:45 AM found, two (2) conflicting orders for a diet: --2 gm Sodium (2g Na) diet, Dysphagia Advanced texture, Standard Thin Liquids consistency diet. Order date 09/02/24. --2 gm Sodium (2g Na) diet, Regular Texture, Standard Thin Liquids consistency diet. Order date 8/26/2024. An interview 09/04/24 at 1:28 PM the Director of Nursing (DON) verified Resident #119 had two (2) different diet orders on her active chart. The DON stated that they should have discontinued the regular texture diet out of the active orders.

Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64. Findings included: a) Resident #119 An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered. An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray. During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.

Based on medical record review, observation, and staff interview, the facility failed to ensure one (1) residents received treatment and care in accordance with professional standards of practice. Resident identifier: #30. Facility census: 64. Findings included: a) Resident #30 A record review on 09/05/24 at approximately 8:00 AM, revealed nurses documenting Blood pressure (BP) being taken in the right arm. Further record review revealed the resident had a Physician order which stated, Do not take B/P in the right arm, with an order date of 08/14/24. Continued record review on 09/05/24 shows resident having orders - Dialysis port location: right upper chest. - Monitor hemodialysis catheter site 2 lumens, right upper chest for signs and symptoms infection, edema, bleeding, and upon return from dialysis. Notify primary care physician and dialysis unit if there are signs and symptoms of infection. If catheter site is bleeding apply pressure for 15 minutes and notify MD/physician if bleeding does not stop, every shift and as needed. Do Not Change End Caps. On 09/05/24 at 9:52 AM a call was placed to Resident #30's dialysis center revealed the order for no BP in right arm did not come from the dialysis center or Neurologist. There is no reason to not take B/P in right arm from them. It was stated that mapping, or shunt / fistula placement has not taken place yet. On 09/05/24 at 10:32 AM, The Director of Nursing stated that the order was put in place just for precautions and would not hurt him if the B/P was taken in the right arm. The (DON) also stated, The orders and care plan should have been followed to not take a B/P in the left arm.

Based on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64. Findings included: a) Resident #119 An observation on 09/03/24 at 2:26 PM the lunch tray was sitting in front of resident, she was not eating, no assistance was offered. An bservation of the meal service on 09/04/24 at 1:24 PM revealed a tray set up in front of Resident #119 with food spillage all over her. She was trying to drink her sherbet. She had her phone receiver laying in the middle of her tray. During an interview with the Director of Nursing (DON) on 09/04/24 at 1:28 PM she verified Resident #119 was an assist with meals. At this time the DON went to get Resident #119 assistance.

Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for Resident #15 that was trauma-informed and would allow Resident #15 to attain or maintain his highest practicable physical, mental, and psychosocial well-being. This was true for one (1) of three (3) residents reviewed for the diagnosis of Post Traumatic Stress Disorder (PTSD). Resident identifier: #15. Facility census: 64. Findings included: a) Resident #15 A record review, completed on 09/04/24 at 2:52 PM, revealed Resident #15 was admitted to the facility on [DATE] with a PTSD diagnosis. Review of Resident #15's Care Plan revealed the following: Focus: [Resident #15] has the potential to exhibit signs or symptoms of anxiety or depression r/t (related to) a dx (diagnosis) of Post Traumatic Stress Disorder. Goal: [Resident #15] will be free of signs or symptoms of depression or anxiety throughout next review. Interventions: -Provide a calm, quiet, well-lit environment -Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating. -Social Service visits to provide support, as needed and/or requested by resident/patient During an interview on 09/05/24 at 2:00 PM, Social Worker #62 reported she did not know the reason for Resident's PTSD diagnosis. Social Worker #62 reported she recognized she did not have possible PTSD triggers care planned or appropriate staff interventions.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #25. Facility census: 64. Findings included: a) Resident #25 On 09/06/24 at 8:36 AM, a review was completed regarding the beneficiary protection notification liability notices given for Resident #25 who remained at the facility following her last covered day of Medicare Part A services: Resident #25 began Medicare Part A skilled services on 08/15/24. The last covered day of Part A service was 08/28/24. Notice of Medicare Non-Coverage (NOMNC) was signed and dated on 06/26/24. No SNF ABN form was provided. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires Skilled Nursing Facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial. On 09/06/24 at 9:45 AM, Clinical Reimbursement Coordinator #58 acknowledged the facility failed to provide SNF ABN form to Resident #25 to her last covered day of Medicare Part A skilled services.

Based on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: #119. Facility census: 64. Findings included: b) Resident #119 An observation on 09/03/24 at 2:26 PM of Resident #119 lying in bed with her noon meal tray sitting on bed side table not opened. During a second observation of the meal service on 09/03/24 at 2:43 PM revealed Nurse Aide (NA) #12 was standing over Resident #119 feeding her in bed. During an interview on 09/03/24 at 2:45 PM the Director of Nursing confirmed NA #12 was standing over Resident #119 feeding her at this time. The DON corrected NA #12 at this time.

Based on record review and staff interview, the facility failed to protect the personal privacy and confidentiality of residents ' medical records. This was true for two (2) residents as a random opportunity for discovery. Resident identifiers: #47 and #59. Facility census: 64. Findings included: a) At 2:30 PM on 9/4/24, the surveyor discovered that pharmacist medication regimen review paperwork dated 8/28/24 (entitled PharMerica Recommendation maintain current dose Citalopram .pdf) containing Resident #59's name and medication information was scanned into Resident #47's medical record. Further record review revealed that the same document had been scanned into resident #59's record. The two residents' respective medication reviews were included on a single printed sheet, and medical records did not redact the name before the document was scanned in. On 09/04/24 at 2:50 PM, the surveyor informed the Director of Nursing (DON) who reviewed the record and confirmed that the record, as present, contained the combined personal health information of Resident #47 and #59.

Based on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time-frames. This was a random opportunity for discovery. Resident identifier: #8. Facility census: 64. Findings include: a) Resident #8 An investigation of a Facility Reported Incident of abuse that accrued on 03/23/24 revealed that the Incident was not reported to appropriate agencies until 04/05/24. Continued record review found multiple statements from Registered Nurses #47 and #39 and Nurse aide #13 stating they witnessed Nurse Aide # 74 clap her hands and yell at Resident #8 on 03/23/24. During an interview with the Administrator and Director of Nursing on 09/05/24 at 2:32 PM they verified the incident on 03/23/24 for Resident #8 was not reported within prescribe time-frames. It was also verified that all employees at the facility were mandatory reporters.

Based on observation, interview and record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice regarding parameters for pain medications. This was true for four (4) of four (4) residents reviewed for pain. Resident identifiers: #28, #164, #56, #42. Facility census: 66. Findings included: a) Resident #28 Medical record review for Resident # 28 found a physician's order: --Acetaminophen Extra Strength Tablet 500 MG (Acetaminophen) Give two (2) tablets by mouth every six (6) hours as needed for mild pain, with a start date 04/07/22. A continued review of Medication Administration Record (MAR) revealed: --02/20/23 at 7:41 PM pain level 7 -Acetaminophen tablet given. --02/24/23 at 5:00 PM pain level 4 -Acetaminophen tablet given. --02/26/23 at 5:40 PM pain level 4 -Acetaminophen tablet given. During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #28 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain. b) Resident #56 An observation on 02/21/23 at 3:30 PM on initial tour Resident #56 was screaming, crying, and displaying restless movement. Medical record review for Resident #56 found a physician's orders: --Acetaminophen Extra Strength Tablet 500 MG (Acetaminophen) Give two (2) tablets by mouth every six (6) hours as needed for mild pain, with a start date 04/07/22. --Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate pain. Start date 02/22/23. --Oxycodone HCl tablet 5 MG Controlled Drug, give two (2) tablets by mouth every four (4) hours as needed for moderate pain. Start date 02/22/23. --Roxicodone (Oxycodone HCl) tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate pain. Start date 12/20/22. --Roxicodone (Oxycodone HCl) tablet 5 MG Controlled Drug, give two (2) tablets by mouth every four (4) hours as needed for Severe pain. Start date 12/20/22. A continued review of Medication Administration Record (MAR) revealed: --02/01/23 at 1:10 AM pain level 5 -Roxicodone one (1) tablet given. --02/01/23 at 8:04 PM pain level 8-Roxicodone one (1) tablet given. --02/03/23 at 6:11 PM pain level 10-Roxicodone two (2) tablet given. --02/04/23 at 10:08 AM pain level 7-Roxicodone one (1) tablet given. --02/06/23 at 3:27 AM pain level 9-Roxicodone two (2) tablet given. --02/06/23 at 1:38 PM pain level 8-Roxicodone one (1) tablet given. --02/06/23 at 7:02 PM pain level 6-Roxicodone one (1) tablet given. --02/07/23 at 8:27 AM pain level 7-Roxicodone two (2) tablet given. --02/07/23 at 8:10 PM pain level 8-Roxicodone two (2) tablet given. --02/08/23 at 2:00 AM pain level 8-Roxicodone two (2) tablet given. --02/08/23 at 8:36 PM pain level 8-Roxicodone two (2) tablet given. --02/09/23 at 9:00 PM pain level 8-Roxicodone two (2) tablet given. --02/10/23 at 2:10 AM pain level 8-Roxicodone two (2) tablet given. --02/11/23 at 1:15 AM pain level 8-Roxicodone one (1) tablet given. --02/12/23 at 3:02 PM pain level 5-Roxicodone two (2) tablet given. --02/13/23 at 10:00 AM pain level 10-Roxicodone two (2) tablet given. --02/13/23 at 11:56 PM pain level 8-Roxicodone two (2) tablet given. --02/14/23 at 8:53 PM pain level 7-Roxicodone two (2) tablet given. --02/14/23 at 7:57 PM pain level 8-Roxicodone one (1) tablet given. --02/15/23 at 12:24 AM pain level 7-Roxicodone two (2) tablet given. --02/15/23 at 9:33 AM pain level 7-Roxicodone one (1) tablet given. --02/16/23 at 9:45 AM pain level 3-Roxicodone one (1) tablet given. --02/16/23 at 6:00 PM pain level 8-Roxicodone two (2) tablet given. --02/17/23 at 2:11 AM pain level 8-Roxicodone two (2) tablet given. --02/18/23 at 10:30 PM pain level 8-Roxicodone two (2) tablet given. --02/19/23 at 7:00 PM pain level 8-Roxicodone two (2) tablet given. --02/20/23 at 12:40 PM pain level 8-Roxicodone two (2) tablet given. --02/20/23 at 7:41 PM pain level 7 -Acetaminophen tablet given. --02/21/23 at 12:27 AM pain level 5-Roxicodone one (1) tablet given. --02/21/23 at 10:03 AM pain level 8-Roxicodone one (1) tablet given. --02/24/23 at 5:00 PM pain level 4 -Acetaminophen tablet given. --02/26/23 at 5:40 PM pain level 4 -Acetaminophen tablet given. During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #56 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain. c) Resident #164 On 02/21/23 at 3:19 PM during an interview with Resident #164, She stated that she had a broken hip and arm. She stated that she feels that they make her wait for her pain medication. A record review revealed a physician order for Resident #164: --Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate to severe pain. --Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give one (1) tablet by mouth every six (6) hours as needed for mild pain. During an interview on 2/28/23 9:34 AM the Director of Nursing, verified Resident #56 had no physician prescribed parameters for pain medications. She stated that pain medications should be given for pain levels 1-3 mild pain 4-7 moderate pain and 8-10 severe pain. 31518 d) Resident (R) #42 Review of the medical record revealed R#42 receives Gabapentin 100 milligrams (mg) at bedtime and Xtampza 9 mg twice a day for chronic pain. In addition she has physician orders for as needed pain medications without defined parameters for administration. The orders include Acetaminophen 500 milligrams (mg) two tablets (1000 mg) every six hours for mild to moderate pain and Oxycodone hydrochloride five mg every eight hours for moderate to severe pain. The medication administration record (MAR) for the month of February 2023 notes the resident was given Acetaminophen 1000 mg on 02/03/23 for a pain level of 10 of 10, 02/08/23 for a pain level of 6 of 10, 02/24/23 for a pain level of 9 of 10, 02/26/23 for a pain level of 10 of 10 and 02/27/23 for a pain level of 4 of 10. R#42 received Oxycodone 5 mg for reported pain levels of 5 to 10 out of 10 on the following dates in February 2023: 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22 23, 24, 25, 26, 27 and 28. During an interview on 02/28/23 at 12:30 PM, Registered Nurse (RN) #38 confirmed the physician orders lacked specific parameters for the nurses to follow when administering the as needed pain medications to R#42.

Based on record review and staff interview, the facility failed to address resident preference and potential for future discharge within resident care plans. This was true for Residents #55, #46, and #12. The facility also failed to develop a care plan for non-pharmacological interventions for pain. This was true for Residents #164 and #42. The facility's failure to ensure accurate comprehensive care plans was true for five (5) of 21 sampled residents in the long-term care survey process. Resident identifiers: #55, #46, #12, #164, and #42. Facility census: 67. a) Resident #12 A record review, completed on 02/27/23 at 9:04 PM, revealed the care plan did not address Resident #12's preference and potential for future discharge. During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included. b) Resident #46 A record review, completed on 02/27/23 at 9:13 PM, revealed the care plan did not address Resident #46's preference and potential for future discharge. During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included. c) Resident #55 A record review, completed on 02/27/23 at 8:53 PM, revealed the care plan did not address Resident #55's preference and potential for future discharge. During an interview on 02/28/23 at 8:34 AM, the Acting Interim Director / Director of Nursing (DON) acknowledged the care plan was lacking resident's potential for discharge. The the Acting Interim Director / DON stated she would need to follow-up with the facility's Social Worker to determine why it had not been included. 42120 d) Resident #164 On 02/21/23 at 3:19 PM during an interview with Resident #164, She stated that she had a broken hip and arm. She stated that she feels that they make her wait for her pain medication. A record review revealed a physician order for Resident #164: --Oxycodone HCl tablet 5 MG Controlled Drug, give one (1) tablet by mouth every four (4) hours as needed for moderate to severe pain. --Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give one (1) tablet by mouth every six (6) hours as needed for mild pain. A review of Resident #56's Care Plan found no non-pharmacological treatments for pain: Focus: --Resident #146 exhibits or is at risk for alterations in comfort related to surgical-post-operation pain, and right femur Goal: --Resident #164 will achieve acceptable level of pain control through next review. Interventions: --Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors. --Utilize pain scale 0-10. --Advise her to request pain medication before pain becomes severe. --Medicate her as ordered for pain and monitor for effectiveness and monitor for side effects such as nausea and vomiting, constipation, headache, dizziness, lightheadedness, drowsiness, weakness or lack of energy, severe itching, report to physician as indicated. --Monitor frequency of episodes of breakthrough pain to determine the need for pain med adjustment. --Medicate 30-45 mins prior to treatment or therapy. --Complete pain assessment per protocol --Assist her to a position of comfort, utilizing pillows and appropriate positioning devices. --Manage Pain by providing ice packs or cold compresses to applicable area During an interview on 2/28/23 9:34 AM the Director of Nursing, verified the care plan did not have no non-pharmacological treatments for pain. 31518 e) Resident (R) #42 Review of the medical record revealed R#42 has ongoing pain issues and receives Gabapentin 100 milligrams (mg) at bedtime and Xtampza (an abuse deterrent Oxycodone) 9 mg twice a day for chronic pain. In addition, she frequently receives Acetaminophen and or Oxycodone for pain. The current care plan identifies the resident's alterations in comfort related to acute pain and neuropathic pain but lacks resident specific non-pharmacological interventions to utilize for pain relief. During an interview on 02/28/23 at 12:30 PM, Registered Nurse (RN) #38 agreed the care plan lacks resident specific non-pharmacological interventions to assist R#42 with pain relief.

Based on observation, medical record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards or practice, the comprehensive care plan, and the resident's choices, related to pain management. Resident #47 was not offered an as needed (prn) pain medication before or during pressure wound treatment prior to surveyor intervention. This resulted in actual harm to the resident. Also, the facility demonstrated a pattern of not assessing Resident #47's pain prior to prn pain medication and/or assessing its effectiveness following the prn pain medication administration. These practices were evident for one (1) of eighteen (18) sampled residents. Resident identifier: #47. Facility census: 60. Findings included: a) Resident #47 On 09/11/18 at at 11:30 AM, registered nurse (RN) #39 began treatment on a Stage 4 pressure wound to the resident's right buttock. She washed the right buttock wound with soap and water. The resident jumped when touched with the washcloth during cleansing, and complained of pain. RN #39 then applied Sureprep to the peri-wound surrounding skin. Next, she applied Santyl (an enzymatic debrider) to the wound bed by using the tip of her gloved index finger. The resident winced and complained of pain again when the wound bed was touched. Her facial expression was distorted and gave further evidence of pain beyond her stated words. RN #39 said it always hurts her like this during the dressing change. RN#39, when asked when she most recently received or was offered pain medication, said this resident received a scheduled dose of pain medication around 9:00 AM this morning. She said it is scheduled twice per day (at 9:00 AM and 9:00 PM). RN #39 said she wanted to get this dressing done before the resident left at 12:15 PM today for an appointment out of the facility. She said she got a bit behind today due to being observed with morning medication pass. Upon inquiry as to whether she gets as needed (prn) pain medication [MEDICATION NAME] prior to the pressure wound treatment, RN #39 replied that the resident does have a prn (as needed) pain medication order. At this time the resident verbalized that she thought the wound was supposed to be packed. RN #39 assured her that was no longer the case, but would go out to see if the physician who made rounds this morning may have changed the order. This writer asked if she also might want to check about prn pain medication while she was at the desk, to which the resident replied yes. RN #39 left the room, then returned quickly with a pain pill for the resident. Upon inquiry, she said it was a [MEDICATION NAME]. The resident took the [MEDICATION NAME]. RN #39 told the resident there were no new physician's orders [REDACTED]. RN #39 then covered the wound with an [MEDICATION NAME] dressing. RN #39 did not ask the resident to rate her pain level. The surveyor asked the resident the level of pain she was experiencing at this time. The resident said it was an eight (8) or nine (9) out of a scale of one (1) to ten (10). The resident then asked why a number was needed. It was explained that this would help the nurse understand the severity level of the pain, and would help the nurse assess how effective the pain medication was at treating her pain. An interview was conducted with the resident on 09/11/18 at 12:10 PM. She said it would be helpful if she could get her dressings changed soon after her scheduled pain medication. She said nurses sometimes are busy and cannot get to her dressing changes timely after the medication. She said sometimes the dressings become soiled and have to be removed at times other than around her scheduled 9:00 AM and 9:00 PM pain medications. She said sometimes nurses offer her pain medication before the dressing changes, and other times they just arrive in her room with the treatment supplies and ready to go. The medical record was reviewed on 09/11/18. According to the Medication Administration Record [REDACTED]. Of that number, nursing staff assessed the severity level of the pain prior to the pain medication only six (6) times out of sixty (60) opportunities. Nursing assessed the effectiveness of the prn [MEDICATION NAME] on only one (1) occasion out of sixty (60) opportunities. This resident also had physician orders [REDACTED]. every six (6) hours as needed for pain or fever. She received this medication four (4) times in August, (YEAR). On one (1) occasion the nurse assessed the pain level of nine (9) out of ten (10). There was no evidence of pain assessment following any of the four (4) doses. Review of the narcotic sign-out sheets for September, (YEAR), found she received [MEDICATION NAME] 5/325 mg. a total of sixteen (16) times. Review of the prn pain management flow sheet for (MONTH) found the [MEDICATION NAME] was recorded only eight (8) out of the sixteen (16) dose opportunities on the flow sheet. Of that total, those eight (8) did have a pre-medication pain level assessment, but only five (5) times was the post prn pain medication level assessed. Also in (MONTH) (YEAR), the resident received one (1) dose of [MEDICATION NAME] which was ordered at every six (6) hours prn for mild pain. There was no pre- or post- administration pain assessment. The resident also had physician orders [REDACTED]. every four (4) hours prn for moderate to severe pain. Per the MAR, this resident received twelve (12) doses of [MEDICATION NAME] in (MONTH) of (YEAR). Nursing completed one pain rating assessment out of twelve (12) opportunities, and did no post prn pain medication rating assessments. Page seventeen (17) of the care plan addressed pain related to a recent surgical procedure, stage 4 pressure ulcer, and [DIAGNOSES REDACTED]. -Evaluate pain characteristics of quality, severity, location, precipitating/relieving factors. -Utilize pain scale -Medicate resident as ordered for pain and monitor for effectiveness. -Complete pain assessment per protocol. An interview was conducted with the director of nursing (DON) on 09/12/18 at 2:30 PM. She said she would look to see if they have a policy about what is expected of a nurse related to assessing pain severity before and after prn pain medication. She wrote down the number of times in (MONTH) and (MONTH) (YEAR) where there were no assessments evident for pain relief following the prn medication, or for pain assessment prior to the prn pain medication. She said she would look elsewhere within the medical record, and would direct the ADON to do likewise, to try and produce evidence of pre- and post- prn pain medication assessments. On 09/12/18 at 4:20 PM another interview was conducted with the DON. She provided the facility's policy on pain management, with revision date of 03/01/18. Item number five (5) on the policy stated that if prn medications are given, to document on the back of the MAR indicated [REDACTED]. Item number eight (8) of the policy stated that patient receiving interventions for pain will be monitored for the effectiveness in providing pain relief. Staff are to document the effectiveness of PRN (pain) medications. The DON said this is typically done on the pain flow record. She agreed that for this resident, staff had dropped the ball and had not consistently assessed her pain before and/or after pain medication doses. She further stated that their policy does not specify how they would determine effectiveness, such as a lichter scale. She agreed that they would need to use some type of scale before treatment with pain medication, and then after the pain medication, as a measure of the change in comfort level. An interview was conducted with the administrator, the DON, and the corporate/regional administrator employee #500 (E#500) on 09/12/18 at 5:00 PM. No further information was provided related to the lack of pain assessments pre- and/or post- prn pain medication administration for this resident. E#500 asked if it would be considered harm when the resident was not given and/or offered prn pain medication prior to the pressure wound treatment and dressing change when observed on 09/11/18. Replied in the affirmative since the resident did have pain during the treatment, and the prn pain medication was not suggested prior to surveyor intervention.

Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to be a suprapubic catheter). Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. Hospital #1 Records Review of the resident's hospital records revealed he arrived in the emergency room (ER) of Hospital #1 on 11/17/10. Notes written by the ER nursing staff stated, "2240 (10:40 p.m.) Pt (patient) arrives /c (with) multi layers of Blankets (sic). Hot, moist skin Red (sic) in color. ... 11/17 (sic) 0040 (12:40 a.m. on 11/18/10) [MEDICATION NAME] (L) (left) D/C'd (discontinued) per physician, Blue (sic) tip sent to lab for culture. ..." Review of the form titled "ED Nursing Record - Adult Male - PRIMARY ASSESSMENT", in the section titled "EENT" (ears, eyes, nose, throat) was written: "Dried oral secretions (sic) oral membrane". In the section titled "Skin" were circled the words "diaphoresis" and "hot". In the section titled "Cardiovascular" was written (next to the printed word "[MEDICAL CONDITION]") "mild Bilat(eral) leg & arm". Above the nurse's signature was written: "hands / fingers swelled (sic) ..." Documentation on the form titled "ED Nursing Record - Adult Male - General Documentation", under the heading "I & O" (fluid intake and output), noted the resident received 1000 cc of fluid (elsewhere identified as normal sterile saline - NSS) and voided 50 cc of urine while in the ER of Hospital #1. Documentation by the ER physician on a form titled "Physical Exam" identified the resident was lethargic, his abdomen was distended and tympanic, "decubiti" (pressure sores) were present "multi site", and the resident had a [MEDICATION NAME] central line with a dressing labeled "11/9/10". "Patient much more alert /p (after) NS (normal saline) [MEDICATION NAME]." In addition to a culture of the [MEDICATION NAME] central line catheter tip, the physician ordered urine and blood cultures. The physician reviewed the results of a urine culture and sensitivity from a previous admission, found the organism previously cultured was E. coli that was positive for extended spectrum beta lactamase (which was resistant to [MEDICATION NAME] and sensitive to Imipenem), and ordered intravenous [MEDICATION NAME] and Imipenem ([MEDICATION NAME]). The [MEDICATION NAME] was started, and the [MEDICATION NAME] was sent with him ("Start [MEDICATION NAME] when [MEDICATION NAME] complete") when he was transferred to Hospital #2 at 0350 (3:50 a.m.) on 11/18/10. -- 3. Hospital #2 Records The resident was transferred from Hospital #1 to Hospital #2 related to the lack of a bed at Hospital #1, and the resident a direct admit into Hospital #2's intensive care unit "because [MEDICAL CONDITION] secondary to urinary tract infection". The resident arrived at Hospital #2 on the early morning of 11/18/10. The resident's Hospital #2 "History and Physical" revealed under the heading "History of Present Illness": "This is a [AGE] year-old Caucasian male with a history of end-stage [MEDICAL CONDITION], depression, chronic [MEDICAL CONDITION], gastroparesis, [MEDICAL CONDITION] bladder, [MEDICAL CONDITION] reflux disease, [MEDICAL CONDITION], and recurrent urinary tract infection who was transferred (sic) (Hospital #1) to (Hospital #2) for direct admission to (sic) intensive care unit because [MEDICAL CONDITION] secondary to urinary tract infection. ... It seems the patient used to have a recurrent urinary tract infection in the past, but the last time he was found to have a urinary tract infection and got admitted to the hospital was in early 2010. Since the placement of (sic) cystostomy tube (a suprapubic catheter) in early 2010, the patient did not get admitted to the hospital because of urinary tract infection (sic). ..." "In the emergency room , the patient was evaluated by the ER physician who found the patient to [MEDICAL CONDITION] with temperature 101.8 degrees, heart rate in excess of 110 per minute and also respiratory rate in excess of 24 per minutes. His white blood cell count also was high at 14,600. Because he needed to be admitted and there was no hospital bed in the (name of Hospital #1), the patient has been transferred to (name of Hospital #2). I admitted the patient to the intensive care unit for close monitoring, because of his complicated previous history and also serious hospital admission." Under the heading "Impressions" were noted: "1. High fever, secondary [MEDICAL CONDITION]. 2. Urinary tract infection. ..." Under the heading "Plans" were noted: "1. Admit to ICU. 2. Blood and urine cultures which were done in the (Hospital #1) emergency room . Will send wound culture from cystostomy (suprapubic) tube area. 3. Empiric IV antibiotics with Imipenem, [MEDICATION NAME] (sic) and [MEDICATION NAME] will be continued, which were started in the emergency room in (name of Hospital #1). 4. IV hydration will be given cautiously. 5. Will continue home medications." - The resident's Hospital #2 "Discharge Summary" revealed the following discharge Diagnoses: [REDACTED]. [MEDICAL CONDITION]. 2. Urinary tract infection. 3. [MEDICAL CONDITION] surrounding his suprapubic catheter and [MEDICAL CONDITION] tube site. 4. Catheter line associated bacteremia with Staphylococcus epidermis, all subsequent cultures negative." Under the heading "Hospital Course" was noted, "The patient was sent to (name of Hospital #1) from his nursing home for high fevers. He was found to have a highly positive urinary tract infection as well as pus surrounding his suprapubic catheter and [DEVICE] as well as some small scattered pressure sores. The patient is a known chronic quadriplegic from end-stage MS and has a history of recurrent urosepsis and ESBL positive organisms. The patient's ultimate infectious sources included a single blood culture positive for staph epidermidis, also listed from his catheter tip although I am not sure which catheter this was as it was not documented. Presumably it was some type of a central line. He also had both areas of [MEDICAL CONDITION] positive for cultures with [MEDICAL CONDITION]-resistant Staphylococcus aureus as well as pseudomonas and ESBL positive Escherichia coli. Urine culture was positive for [MEDICATION NAME] which was [MEDICATION NAME] sensitive but [MEDICATION NAME] resistant, also positive for the ESBL. Escherichia coli as well. ... The patient resolved with routine treatment of [REDACTED]. -- 4. Elevated Temperatures (a) Vitals Summary Report (VSR) A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11/09/10 at 3:37 a.m. - 97.2 (tympanic) - 11/09/10 at 9:52 p.m. - 97.2 (axilla) - 11/10/10 at 2:28 a.m. - 98.3 (axilla) - 11/10/10 at 11:45 a.m. - 98.2 (axilla) - 11/11/10 at 5:55 a.m. - 100.1 (axilla) - High of 99.0 exceeded - 11/11/10 at 5:56 a.m. - 97.8 (axilla) - 11/11/10 at 10:01 p.m. - 98.2 (axilla) - 11/12/10 at 4:41 a.m. - 98.7 (axilla) - 11/13/10 at 3:52 a.m. - 99.7 (axilla) - High of 99.0 exceeded - 11/13/10 at 2:07 p.m. - 97.4 (axilla) - 11/13/10 at 9:37 p.m. - 96.7 (axilla) - 11/14/10 at 4:59 a.m. - 97.8 (axilla) - 11/14/10 at 9:48 p.m. - 97.9 (axilla) - 11/15/10 at 2:50 a.m. - 97.5 (axilla) - 11/16/10 at 4:02 a.m. - 98.4 (axilla) - 11/17/10 at 5:08 a.m. - 99.5 (axilla) - High of 99.0 exceeded - 11/17/10 at 9:52 p.m. - 101.7 (axilla) - High of 99.0 exceeded - 11/17/10 at 10:54 p.m. - 102.4 (axilla) - High of 99.0 exceeded According to the VSR, between 09/11/10 and 11/05/10, Resident #28 had only one (1) temperature reading that was flagged for review as "High of 99.0 exceeded". This occurred at 2:37 p.m. on 09/23/10, at which time his axillary temperature measured 99.5 degrees F. -- (b) Nursing Notes Further review of the resident's electronic medical record at the nursing facility revealed the following consecutive nursing notes: - 10/13/10 at 5:45 p.m. - "Temp: 98.7. zero (sic) signs or symptoms of distress (sic) will cont(inue) to monitor." - 10/14/10 at 1:47 p.m. - "Peg (sic) tube pulled out during care, scant amount of bleeding notes at site. Cleansed area with [MEDICATION NAME] (sic), replaced with 20Fr 15cc magna port (sic) Proper placement noted, flushes without difficulties. [MEDICATION NAME] 1.5cal (sic) running at 85cc/hr. no (sic) problems noted." - 10/17/10 at 11:30 a.m. - "REsident (sic) g tube (sic) flushed with ease and proper placement. 60cc (sic) of residual noted." - 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) given vie (sic) peg tube. Will continue to monitor." - 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). Contacted Dr. (name). Verbal order for [MEDICATION NAME] 1gram IM (intramuscular injection) qd (everyday) x 3 days for UTI. Will continue to monitor." - 11/05/10 at 10:53 p.m. - "Resident showing s/s (sign and symptoms of) illness as temp cont(inues) to rise. Tylenol via GT ([DEVICE]) given with decrease of temp at this time. ... Will continue to monitor." ?- 11/06/10 at 9:54 p.m. - "Temp 98.9 Axillary (sic) Resident continues on an ABT (antibiotic therapy) for UTI, no adverse reactions noted." - 11/07/10 at 2:12 a.m. - "Temp 97.2 axillary. Continues ABT related to UTI. ... No signs and symptoms of distress. Will monitor." - 11/07/10 at 9:21 p.m. - "Temp 98.1 (sic) Completed ABT today for UTI. 0 (no) adverse reactions noted." - 11/09/10 at 3:36 a.m. - "S/P (status [REDACTED]." - 11/11/10 at 6:00 a.m. - "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245." - 11/11/10 at 4:36 p.m. - "97.9 (sic) continues with tube feed of [MEDICATION NAME] ,flushes (sic) with ease. ... exhibits no signs of distress." - 11/14/10 at 12:01 p.m. - "VS (vital signs): 97 20 100/70 97.8. alert. Total care. Suprapubic cath patent. [DEVICE] flushed with each ... Zero signs or symptoms of distress noted. Will continue to monitor." - 11/15/10 at 2:42 p.m. - "Residents (sic) mothers (sic) was in today to visit ..." - 11/16/10 at 6:57 a.m. - "resident (sic) alert. total (sic) care.area (sic) around suprapubic cath.cleaned, (sic) temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. resting (sic) at this time." - 11/16/10 at 2:11 p.m. - "Resident heard moaning from hallway (sic) Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). Called Dr. (name) (sic) verbal order given from [MEDICATION NAME] 1gram (sic) IM QD x3days (sic). Meds ordered from pharmacy. Resident resting quietly now." - 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). New order [MEDICATION NAME] IV (intravenously) x3days (sic), ordered stat from pharmacy along with flushes and IV pump. [MEDICATION NAME] 1gram IV (intravenous) given via PICC at 1:30pm (sic) without difficulty. No adverse reactions noted. No s/s (signs / symptoms) IV complications noted." - 11/17/10 at 6:01 p.m. - "Resident moaning loudly, when asked if uncomfortable he said 'yeah'. V/S (vital signs) stable, tylenol (sic) given for apparent discomfort. GT turned off for time r/t (related to) abd (abdominal) discomfort. ... Will cont to monitor. Urinary output >200cc at this time. ABT [MEDICATION NAME] IM (sic) continues for UTI. No adverse effect noted. Fluid tolerated via GT." - 11/17/10 at 8:28 p.m. - "Monitoring resident frequently, no futhur (sic) moaning noted. Resting quietly. V/S remain stable, afebrile. T&P (turn and position) frequently. HOB (head of bed) ele (elevated) for comfort. Will continue to monitor." - 11/17/10 at 9:48 p.m. - "(Resident #28) transferred to hospital-unplanned (sic) for evaluation and treatment via ambulance to (name of Hospital #1). Physician notified of transfer. Physician called 2145 (9:45 p.m.) with info of condition change, order to send to (Hospital #1) for eval and tx (treat). Responsible party notified of transfer ..." -- (c) Medication Administration Record (MAR) Review of the resident's November 2010 MAR revealed staff initialed having administered "Tylenol 650 mg via GT ([DEVICE]) for temp > 101 Q 4 hours PRN (as needed)" to Resident #28 on the following dates: - 11/05/10 at 11:45 p.m. - 11/09/10 at 6:00 p.m. - 11/11/10 at 2:45 a.m. - 11/11/10 (this second entry on 11/11/10 is illegible) - 11/13/10 at 2:30 a.m. - 11/13/10 at 5:00 p.m. - 11/14/10 at 5:00 p.m. - 11/15/10 at 8:00 p.m. - 11/16/10 at 5:00 a.m. - 11/16/10 at 11:00 a.m. - 11/17/10 at 5:45 p.m. -- (d) Comparison of VSR, Nursing Notes, and MAR Record review, including a comparison was made of documentation found in the nursing notes, in the VSR, and on the November 2010 MAR related to the administration of Tylenol for elevated temperatures, revealed the following: (1) From 09/25/10 until 11/04/10, the resident had no temperatures recorded in the VSR that exceeded a pre-established threshold that triggered further assessment. Beginning on the early morning of 11/04/10, the resident had a fever of 100.6 degrees F (axillary) for which he was medicated with Tylenol 650 mg. He continued to have an elevated temperature on 11/05/10, at which time the nurse contacted the physician, who ordered the antibiotic [MEDICATION NAME] 1 gram IM everyday for three (3) days. On the telephone order, the indication for use of the [MEDICATION NAME] was "UTI". According to the nursing notes, the last dose of this 3-day course of [MEDICATION NAME] was administered on 11/07/10. According to the November 2010 MAR, a nurse administered Tylenol 650 mg for an elevated temperature at 6:00 p.m. on 11/09/10, although there were no corresponding entries in either then nursing notes or the VSR to state what the temperature was. Per documentation on the MAR, additional doses of Tylenol 650 mg were administered for elevated temperatures on 11/11/10 (possibly twice, although one (1) entry was illegible), 11/13/10 (twice), 11/14/10, 11/15/10, and 11/16/10 (twice). All entries in the nursing notes between 11/04/10 and 11/16/10 were made by licensed practical nurses (LPNs). There was no evidence of any nursing assessment having been completed by an RN and recorded in the resident's nursing notes. Staff did not notify the physician that Resident #28 continued to have intermittent fevers (beginning on 11/09/10) after completion of the first 3-day course of [MEDICATION NAME] on 11/07/10. Once notified of the resident's elevated temperature on 11/16/10, the physician ordered a second 3-day course of [MEDICATION NAME] 1 gram IM everyday for three (3) days for "UTI". The physician examined the resident on 11/16/10, recorded a [DIAGNOSES REDACTED]. No labs were ordered during this period of intermittent fevers beginning on 11/04/10, in an effort to identify the infectious organism(s) and/or what antibiotic(s) would be effective in treatment. (According to labs collected at Hospitals #1 and #2, the resident had multiple infectious organisms at multiple sites (central line catheter tip, urine, blood, and at the insertion sites of his suprapubic catheter and gastrostomy tube), all of which were resistant to [MEDICATION NAME], meaning the [MEDICATION NAME] that was administered prior to the resident's transfer to Hospital #1 was ineffective in treating these infections.) The only entry made by an RN prior to his transfer to the hospital was recorded at 9:48 p.m. on 11/17/10. It contained no assessment information but stated the resident was transferred to the hospital "unplanned" for evaluation and treatment, after the physician was notified of a "condition change" at 2145 (9:45 p.m.), and an attempt was made to notify the resident's responsible party. -- (2) Not all temperatures were recorded in a single location in the resident's medical record where the user could access and review all temperature readings for analysis, tracking, and trending. On thirteen (13) occasions between 11/04/10 and 11/17/10, temperatures were recorded in the nursing notes (NN) and/or nurses initialed the MAR to indicate Tylenol was given for an elevated temperature, but no corresponding entry of a temperature reading was found on the VSR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." - MAR on 11/09/10 at 6:00 p.m. - Tylenol was given for elevated temperature - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - MAR on 11/11/10 at 2:45 a.m. - Tylenol was given for elevated temperature. (A corresponding entry was also found in a NN at 6:00 a.m. on 11/11/10 as follows: "temp (sic) 100.1 ax. tylenol (sic) 350mg (sic) per g.t. (sic) @ 0245.") - MAR on 11/13/10 at 2:30 a.m. - Tylenol was given for elevated temperature - MAR on 11/13/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/14/10 at 5:00 p.m. - Tylenol was given for elevated temperature - MAR on 11/15/10 at 8:00 p.m. - Tylenol was given for elevated temperature - NN on 11/16/10 at 6:57 a.m. - "... temp 102.2 ax at 0500.tyleol (sic) 650mg per [DEVICE] given. ..." (A corresponding entry was also found on the MAR for 11/16/10 at 5:00 a.m.) - NN on 11/16/10 at 2:11 p.m. - "... Temp 100.6ax (sic). Gave tylenol (sic) 650mg via gt (sic). ..." - MAR on 11/16/10 at 11:00 a.m. - Tylenol was given for elevated temperature - NN on 11/17/10 at 3:34 p.m. - "Temp 98.1ax (sic). ..." - MAR on 11/17/10 at 5:45 p.m. - Tylenol was given for elevated temperature -- (3) Two (2) instances of elevated temperatures (greater than 100.0 degrees F axillary, which would be equivalent to 101 degrees F orally), which were recorded either in the VSR or NN, were not treated with Tylenol in accordance with standing orders: - NN on 11/05/10 at 1:59 p.m. - "Resident extremely sweaty (sic) temp taken 100.4ax (axillary). ..." - VSR on 11/17/10 at 9:52 p.m. - 101.7 (axilla) -- (4) Not all instances when Tylenol was administered were recorded on the MAR. On one (1) occasion between 11/04/10 and 11/17/10, a nurse recorded (in the nursing notes) having administered Tylenol to Resident #28, for which there was no corresponding entry in the MAR: - NN on 11/04/10 at 5:14 a.m. - "Increased temp. (temperature) of 100.6 axillary ,skin (sic) warm and moist. 650 mg. tyneol (sic) ..." -- (5) One (1) entry on the MAR (on 11/11/10) was illegible; therefore, it could not be ascertained whether a second dose of Tylenol was given or, if a second dose was given, at what time it was administered. -- (6) No documentation was found on the reverse side of the MAR, when Tylenol was given for an elevated temperature, of an assessment of the effectiveness of the PRN Tylenol in reducing the resident's temperature after administration. -- (e) References Obtained Via Internet (1) According to Medline Plus (a service of the U.S. National Library of Medicine <http://www.nlm.nih.gov> / National Institutes of Health <http://www.nih.gov>), in an article titled "Fever": "Fever is the temporary increase in the body's temperature in response to some disease or illness. "... An adult probably has a fever when the temperature is above 99 - 99.5 ?F (37.2 - 37.5 ?C), depending on the time of day. "... Call your doctor right away if you are an adult and you: - Have a fever over 105 ?F (40.5 ?C), unless it comes down readily with treatment and you are comfortable - Have a fever that stays at or keeps rising above 103 ?F - Have a fever for longer than 48 - 72 hours - Have had fevers come and go for up to a week or more, even if they are not very high - Have a serious medical illness, such as a heart problem, [MEDICAL CONDITION] cell [MEDICAL CONDITION], diabetes, [DIAGNOSES REDACTED], [MEDICAL CONDITION], or other chronic lung problems - Have a new rash or bruises appear - Have pain with urination - Have trouble with your immune system (chronic steroid therapy, after a bone marrow or organ transplant, had spleen removed, HIV-positive, were being treated for [REDACTED]. - Have recently traveled to a third world country" (URL: http://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm) -- (2) According to the Mayo Clinic, in an article titled "Fever: First aid": "Fever is a sign of a variety of medical conditions, including infection. "... Under the arm (axillary) "Although it's not the most accurate way to take a temperature, you can also use an oral thermometer for an armpit reading: - Place the thermometer under your arm with your arm down. - Hold your arms across your chest. - Wait five minutes or as recommended by your thermometer's manufacturer. - Remove the thermometer and read the temperature. "... An axillary reading is generally 1 degree Fahrenheit (about 0.5 degree Celsius) lower than an oral reading. ..." (URL: <http://www.mayoclinic.com/print/first-aid-fever/FA >) -- (3) According to Drugs.com, in an article titled "How To Take An Axillary Temperature": "What is it? "An axillary (AK-sih-lar-e) temperature (TEM-per-ah-chur) is when your armpit (axilla) is used to check your temperature. A temperature measures body heat. A thermometer (there-MOM-uh-ter) is used to take the temperature in your armpit. An axillary temperature is lower than one taken in your mouth, rectum, or your ear. This is because the thermometer is not inside your body such as under your tongue. "Why do I need to check an axillary temperature? "An axillary temperature may be done to check for a fever. 'Fever' is a word used for a temperature that is higher than normal for the body. A fever may be a sign of illness, infection or other conditions. A normal axillary temperature is between 96.6? (35.9? C) and 98? F (36.7? C). The normal axillary temperature is usually a degree lower than the oral (by mouth) temperature. The axillary temperature may be as much as two degrees lower than the rectal temperature. Body temperature changes slightly through the day and night, and may change based on your activity. ... "How do I use a digital thermometer? "Wait at least 15 minutes after bathing or exercising before taking your axillary temperature. - Take the thermometer out of its holder. - Put the tip into a new throw-away plastic cover. If you do not have a cover, clean the pointed end (probe) with soap and warm water or rubbing alcohol. Rinse it with cool water. - Put the end with the covered tip securely in your armpit. Hold your arm down tightly at your side. - Keep the thermometer in your armpit until the digital thermometer beeps. - Remove the thermometer when numbers show up in the 'window'. - Read the numbers in the window. These numbers are your temperature. Add at least 1 degree to the temperature showing in the window. ..." (URL: <http://www.drugs.com/cg/how-to-take-an-axillary-temperature.html>) -- (f) Facility Policy Review of the facility's policy titled "3.5 Vital Signs" (revision date 10/01/10) revealed it was silent to how staff was to take a resident's temperature (e.g., route; device to be used; etc.). Review of the facility's document titled "Clinical Competency Validation - Skill: Measuring Temperature, Pulse, and Respiration" (revision date of 10/2009) revealed the steps to be taken by staff to measure and record a resident oral temperature. This document did not address how to measure a resident's axillary temperature. There was no policy or procedure available to address the difference between an axillary temperature reading and an oral temperature reading, such as whether to add 1 degree F when reading an axillary temperature or when an axillary temperature was elevated enough to require treatment with medication. -- (g) Care Plans Addressing Vital Signs A review of the resident's care plan revealed the following: (1) A problem statement related to UTIs stated: "(Resident #28) is at risk for complications of current UTI." (This problem statement had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) The goal associated with this problem statement was: "Infection will be resolved within 14 days." (This goal had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, was revised on 11/17/10, and had a "Target Date" of 12/01/10.) The interventions developed to achieve this goal were: - "Monitor vital signs and report to physician as indicated." (This intervention had a "Date Initiated" of 11/05/10, was "Created on" 11/11/10, and was revised on 11/17/10.) - "Administer [MEDICATION NAME] as ordered." (This intervention had a "Date Initiated" of 11/17/10, was "Created on" 11/11/10, and was revised on 11/17/10.) There was no mention anywhere in this 13-page care plan of the need to measure Resident #28's temperature via the axilla due to an inability to obtain a temperature reading via another route (e.g., oral, rectal, tympanic). Given that the resident's standing physician orders [REDACTED]. -- (2) Another problem statement was: "Triple lumen PICC line due to need for IV antibiotics for urosepsis." (This problem statement had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, and was revised on 10/11/10.) The goal associated with this problem statement was: "(Resident #28) will have no complication related to IV therapy by (sic) x 60 days." (This goal had a "Date Initiated" of 09/23/10, was "Created on" 01/20/10, was revised on 11/17/10, and had a "Target Date" of 12/11/10.) One (1) intervention developed to achieve this goal was: "Vital signs q (every) shift." (This intervention had a "Date Initiated" of 01/20/10, was "Created on" 01/20/10, and was revised on 10/11/10.) - Review of the VSR found no evidence to reflect this resident's temperature was measured and recorded on every shift in accordance with this care plan intervention. -- 5. Fluid Balance / Hydration Status (a) Physician Orders Review of the physician's orders [REDACTED]. - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." - "Hand irrigate foley (sic) with 60 cc sterile H2O every 8 hours or as needed for output less than 200cc (sic)." - "Suprapubic cath eter (sic) check every shift for placement and function. May change cath when dysfunctional." -- (b) Care Plan Addressing Hydration / Fluid Balance Review of his care plan revealed the following problem statement: "I have an enteral feeding tube to meet nutritional needs due to impaired swallowing secondary to [MEDICAL CONDITION] MS." (This problem statement had a "Date Initiated" of 04/30/10, was "Created on" 04/30/10, and was revised on 07/21/10.) Interventions associated with this problem statement included: "Free H2O, 250ml q 4 hrs, as ordered." (This intervention had a "Date Initiated" of 04/30/10 and was "Created on" 04/30/10.) Review of this 13-page care plan found no other problem statements, goals, or interventions addressing the resident's hydration status / fluid balance, although the resident was totally dependent on others to meet his nutrition and hydration needs. There was also no care plan developed to address the need to hand irrigate the catheter with 60 cc of sterile water if the resident's urinar