Every finding on record at Chardon Woods

Based on observation, record review, and interview, the facility failed to protect Resident #6 from resident to resident abuse. This affected one resident (#6) of three residents reviewed for abuse prohibition. The facility census was 95. Findings include: Record review for Resident #6 revealed he was admitted to the facility on [DATE] with diagnoses including unspecified intracranial injury, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was rarely or never understood. Review of a social worker note dated 04/01/25 revealed there had been an incident of Resident #6 being kissed by another resident (Resident #80) and Resident #6 did not respond when asked about being kissed by another resident. Review of the initial physician assessment, dated 04/01/25, revealed Resident #6 was being seen for the admission assessment. The incident regarding Resident #6 being kissed by another resident was not noted in this assessment, and there were no notations regarding any negative behaviors or expressed concerns for Resident #6. The physician noted Resident #6 resided on an all male behavior unit. Review of the psychiatric note, dated 05/09/25 and authored by Psychiatric Nurse Practitioner (PNP) #900 revealed Resident #6 was being seen for a comprehensive psychiatric evaluation and he was inattentive and selectively non-verbal and when he did choose to speak it was in a soft, drawn out voice with few words. Resident #6's mood was stable and there was nothing noted in this assessment regarding the incident on 04/01/25 when Resident #6 was kissed by another resident. Record review for Resident #80 revealed he was admitted [DATE] and had diagnoses including paranoid schizophrenia, unspecified psychosis, and other sexual disorders. Review of Resident #80's care plan revealed the care plan noted behaviors including throwing food, walking around naked, and approaching staff asking them to have sex with him (dated 08/11/24). Record review of progress notes for Resident #80 revealed on 03/25/25 Resident #80 attempted to touch another resident and on 04/01/25 Resident #80 was witnessed approaching another male resident and kissing him on the lips so he was hospitalized that day. Resident #80 returned to the facility on [DATE]. Review of a psychiatric note for Resident #80, dated 04/01/25 and authored by PNP #900, revealed staff reported he kissed another resident without consent and a 'pink slip' was completed for safety same day as incident. Resident #80 would not answer any questions about the kissing incident stating multiple times you can leave now. Record review of the Self-Reported Incident (SRI) dated 04/01/25 revealed on that date Certified Nurse Aide (CNA) #401 witnessed Resident #80 approach and kiss Resident #6 on the lips while Resident #6 was sitting in his wheelchair in a common room. Resident #80 then went back to his room. CNA #401 notified Licensed Practical Nurse (LPN) #402 then interviewed Resident #80, who said he wanted to know what it felt like. LPN #402 educated Resident #80 his behavior was inappropriate, and Resident #80 was sent to the hospital. Psychosocial support was given to Resident #6 with no adverse findings. The facility assessed or interviewed all other residents on the unit with no findings and educated staff on abuse prohibition. The facility categorized the incident as alleged physical abuse and concluded abuse did not occur. Record review of the related facility investigation for the SRI dated 04/01/25 revealed an application for emergency hospital admission, dated 04/01/25 and authored by PNP #900, which said Resident #80 was noted to be sexually inappropriate towards another resident by kissing them on the lips without consent. Per staff, the victim had to push a table to get away. An emergency psychiatric evaluation was needed to promote safety because his impulsiveness posed an immediate risk to others. In addition, a witness statement by CNA #401 stated he saw Resident #80 kiss Resident #6, who shoved his tray to get him away. CNA #401 then told the nurse, and together they interviewed Resident #80 who said he kissed Resident #6 because he wanted to know what it felt like. A witness statement by LPN #402 said the aide told them of the kiss, and LPN #402 interviewed Resident #6 who laughed and said yes, and confirmed he 'only' was kissed. An interview form with Resident #6 revealed he mouthed yes when asked if he felt safe here. An interview with Resident #6 on 05/22/25 at 9:59 A.M. revealed he was asleep in the common area and was woken up by another resident kissing him. He said he no longer wanted to reside on the same unit with Resident #80 because he hated Resident #80. When the surveyor specifically asked if he felt abused Resident #6 answered yes. Observation of Resident #6 during this interview revealed he laughed before answering multiple questions, then presented with a distraught facial expression when asked if he felt abused by the event. Resident #6 did not report any further incidents with Resident #80 since the incident on 04/01/25 and he did not report telling the staff he did not want to reside on a unit with Resident #80. An interview with Regional Nurse (RN) #502 on 05/22/25 at 10:41 A.M. revealed Resident #6 had not mentioned anything to the staff about not wanting to reside in the same unit as Resident #80. RN #502 said now aware and in response, the facility would assess to see if Resident #6 was appropriate to move to a different unit. An interview with LPN #402 on 05/22/25 at 12:54 P.M. revealed he sent Resident #80 to the hospital after he kissed Resident #6. When LPN #402 interviewed Resident #6, Resident #6 revealed Resident #80 stuck his tongue in his mouth. Resident #6 did not seem distraught at the time of the interview. LPN #402 stated Resident #80 had a history of behaviors including urinating on the floor, walking around naked, and pulling the common room television off the wall. LPN #402 stated Resident #80 was currently hospitalized so was not available for interview. An interview was conducted with the Administrator on 05/22/25 at 1:22 P.M. to review the SRI involving Resident #6 and Resident #80. The Administrator verified the SRI and related facility investigation, and reviewed the above findings including that an event of resident-to-resident abuse occurred at the facility between Resident #80 and Resident #6.

Based on observation, interview, record review and policy review, the facility did not provide structured and routine activities on the memory care unit as scheduled. This affected all 27 residents (#1, #10, #11, #31, #32, #35, #37, #41, #42, #45, #54, #59, #62, #63, #74, #76, #77, #79, #83, #87, #90, #91, #92, #93, #99, #103, #108) that resided on the memory care unit. The facility census was 99. Findings include: Review of the activities calendar for January 2024 through November 2024 revealed no concerns with the scheduled activities; however, there was no activity calendar specific to the residents residing on the memory care unit. Review of the December 2024 activity calendar revealed on Tuesdays and Wednesdays only one activity was listed for the day between 10:30 A.M. and 11:00 A.M. and there were no activities after 3:00 PM on Saturdays. Review of the January 2025 activity calendar revealed there was no activity calendar specific to the residents residing on the memory care unit (unit G). The calendar reflected exercise took place on weekdays Monday through Friday at 11:00 A.M. On 01/16/25 and 01/30/25 exercise was the only activity listed on the calendar. On Tuesday and Wednesday 01/14/25, 01/15/25, 01/21/25, 01/22/25, 01/28/25, and 01/29/25 TBA (to be announced) listed on the calendar at 3:00 P.M. Religious services were scheduled for three Sundays, but on Sunday 01/26/25, the calendar listed self-directed activities with no specified time. Tuesday through Saturday there were no activities listed after 3:00 P.M. Observation on 01/13/25 at 10:02 A.M. revealed a dry erase board behind the nurse's station that listed the activity for the day before that stated Sunday, 01/12/25, ice cream social. The board did not list any other activities for that day. Observation on 01/13/25 at 10:13 A.M. revealed Resident #90 had an outdated activity calendar from December 2024 hung on the wall of his room. Observations on 01/13/25 at 11:00 A.M. and 3:33 P.M. revealed no activities were conducted on the memory care unit at the scheduled time. Observations on 01/14/25 at 3:08 P.M. revealed no activities were conducted on the memory care unit at the scheduled time. Observation on 01/15/25 at 11:09 A.M. revealed no activities were conducted on the memory care unit at the scheduled time. Interview on 01/13/15 at 9:49 A.M. with Resident #92 revealed there were rarely any activities on the memory care unit. Observation at the time of the interview revealed Resident #92 did not have an activity calendar posted. Interview on 01/13/25 at 10:02 A.M. with Certified Nurse Assistant (CNA) #505, who worked on the memory care unit, revealed there were no activities for that day. She also stated, they don't push activities here and reported a band usually came on Thursdays. On 01/15/25 at 11:02 A.M. surveyor met with residents and Activity Director #604 during a resident council meeting where Resident Council President #16 expressed a desire to see more activity staff as there is only the Activity Director during the week and one activity assistant on the weekends. Interview on 01/15/25 at 11:07 A.M. with Licensed Practical Nurse (LPN) #540 revealed a coloring activity was held after lunch on 01/14/25. Interview on 01/15/25 at 12:27 P.M. with Activity Director (AD) #604 revealed there was only one activity staff daily which included herself on weekdays and an Activity Assistant #625 on Saturdays and Sundays. AD #604 further explained she did two activities in memory care (Unit G) and two activities upstairs and would do room visits in between activities when she had time. AD #604 would take activities to the memory care unit and the staff would work with them on activities if they had time; however, most of the residents on the memory care unit required one-on-one. She then reported that she invited residents to activities as she walked around and wrote that day's activity on the dry erase board. Review of the policy titled Activities with an implementation date of 02/01/24 revealed the program included facility-sponsored group, individual, and independent activities would be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being.

Based on observation, interview, record review and review of the facility policy, the facility did not ensure medications were administered utilizing proper infection control standards including not touching medications with ungloved hands and hand hygiene between residents. This affected two residents (Resident #69 and #102) out of five residents reviewed for medication administration. The facility census was 99. Findings included: 1. Review of the medical record for Resident #69 revealed an admitted [DATE] with diagnoses including chronic kidney failure, pulmonary embolism, and protein-calorie malnutrition. 2. Review of medical record for Resident #102 revealed an admitted [DATE] with diagnoses including hypertension, allergic rhinitis, and congestive heart failure. Observation on 01/14/25 at 8:37 A.M. revealed Resident Nurse (RN) #553 was preparing Resident #102's medications, and the following infection control issues were identified: RN #533 reached into the ascorbic acid (vitamin C) bottle with her ungloved fingers to obtain two 500 milligram (mg) tablets and then placed the two tables in the plastic medication cup. RN #533 poured one aspirin 81 mg chewable tablet into her ungloved hand and then placed it in the plastic medication cup. RN #533 took the potassium chloride extended release10 milliequivalent (mEq) tablet and broke the tablet in half with her ungloved hands and placed it in the plastic medication cup. RN #533 took the propranolol (medication for hypertension) 60 mg tablet out of the packet and laid it onto the medication cart. She then picked up the tablet off the medication cart with her ungloved hand and placed it in the plastic medication cup. RN #533 took the Risperdal 0.5 mg (anti-psychotic medication) out of the packet and laid it onto the medication cart. She then picked up the tablet off the medication cart with her ungloved hand and placed it in the plastic medication cup. RN #533 took the torsemide (diuretics used for congestive heart failure) 20 mg three tablets and laid them onto the medication cart. She then picked up the tablet off the medication cart and placed it in the plastic medication cup. Observation on 01/14/25 at 8:50 A.M. revealed RN #533 then proceeded into Resident #102's room obtained his blood pressure, temperature, and oxygen saturation. She then proceeded to administer Resident #102's medications as prepared. She then proceeded out of his room and did not perform hand hygiene. Observation on 01/14/25 at 8:59 A.M. revealed RN #533 proceeded then to prepare Resident #69's medication (still without performing hand hygiene). She prepared Eliquis (blood thinner medication) 5 mg tablet and went into Resident #69's room and administered the medication. Interview on 01/14/25 at 9:10 A.M. with RN #533 verified she did reach into the containers with her ungloved hand to obtain medications, pour medications out of the container into her ungloved hand, break medication in half with her ungloved hand and place medications out of the packet onto the medication cart and pick up with her ungloved hand. She stated, what else we supposed to do as she revealed she came from the hospital and that was what they do there and did not know she could not do that at this facility. She revealed she thought she did use hand sanitizer between the administration of Resident #102 and Resident #69's medications. Interview on 01/15/25 at 1:03 P.M. with Regional RN #630 verified nurses should perform hand hygiene between each resident they administer medications to. She also verified that a nurse should not touch the medication with her ungloved hands including reaching into medication bottles, pouring medications into her hand out of medication bottle, breaking medication in half and picking medications up off the medication cart. Review of the facility policy labeled, Medications Administration, dated 02/10/24, revealed medications were to be administered in accordance with professional standards to prevent contamination or infection. The policy revealed after administration of medication the nurse was to wash hands. There was nothing in the policy regarding not touching medications with bare hands.

Based on observations, record reviews, interviews and reviews of the facility policy revealed the facility did not ensure the Physician's Order and the Care Plan for the use of oxygen were in place for Resident #94. This affected one resident #94 out of four. This had the potential to affect 14 Resident's(#3, #14, #17, #20, #27, #44, #46, #48, #51, #65, #68, #70, #71, #100) that was identified by the facility utilizing oxygen. Findings Include: Review of medical record for Resident #94 revealed an admitted [DATE] and his diagnoses included chronic kidney disease, vascular dementia without behavioral or psychotic disturbance, heart failure, fluid overload, primary hypertension, and atrial fibrillation. Review of Quarterly Minimum Data Set (MDS) 3.0 dated 12/16/24 revealed that in Section O - Special Treatments, Procedures and Programs, Letter C1 Oxygen Therapy was marked that resident was not receiving oxygen therapy. Review of undated comprehensive care plan revealed Resident #94's care plan did show the focus, goals and interventions for oxygen use. Review of January, 2025 Physician orders revealed no order for oxygen for Resident #94 Observation on 01/13/25 at 09:54 A.M. revealed Resident #94 sitting on the edge of his bed and to the left of the resident, next to his bed was an oxygen concentrator. It was running at 2.5 liters, which was connected via nasal cannula which was on the floor not attached to the resident and not labeled. Interview on 01/13/25 at 9:54 A.M. with Resident #94 stated he removed the nasal cannula sometimes because it is irritating. Interview on 01/13/25 at 09:58 A.M. with Registered Nurse (RN) #584 and verified that the oxygen tubing was not labeled and on the floor. RN #584 stated that it is the policy to label and date oxygen tubing. She revealed the procedure for changing the tubing was to be changed every 72 hours. Observation on 01/13/25 at 11:05 A.M. revealed Resident #94 with new oxygen tubing and he continued to have oxygen at 2.5 liters per nasal cannula that was labeled, dated and verified with RN #584. Interview on 01/14/25 at 9:45 A.M. with Regional RN #630, Assistant Director of Nursing (ADON) #599 and the Administrator. And verified there were no physicians order for oxygen for Resident #94 Interview on 01/15/25 at 02:00 P.M. with MDS Coordinator #576 verified that the Care Plan for Resident #94 had not been updated with the focus, goal and interventions for oxygen. Review of facility policy labeled, Oxygen Administration dated 02/01/24 revealed under the policy Explanation and Compliance Guidelines that Oxygen was administered under orders of a physician, except in case of an emergency. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident Care Plan shall identify the interventions for oxygen therapy based on the resident's assessment and orders.

Based on observation, interview, record review and review of the facility policy, the facility did not ensure Resident #102 was offered to rinse his mouth after administration of steroidal (anti-inflammatory) based respiratory inhaler. This affected one resident (#102) out of one resident observed for respiratory inhaler use. This had the potential to affect eight residents (#2, #6, #19, #20, #33, #65, #82 and #102) identified by the facility with orders for respiratory inhalers. The facility census was 99. Findings include: Review of the medical record for Resident #102 revealed an admitted [DATE] with diagnoses including hypertension, allergic rhinitis, and congestive heart failure. Review of the care plan dated 11/18/24 revealed Resident #102 had altered health maintenance related to progressive physical and mental status including congestive heart failure. Interventions included administering medications as ordered and monitoring for signs of distress including respiratory symptoms. There was nothing in the care plan regarding rinsing the resident's mouth after inhaler use. Review of the January 2025 physician's orders revealed Resident #102 had the following order: Pulmicort Flexhaler (corticosteroid respiratory inhaler) inhalation aerosol powder breath activated 108 microgram (mcg) one inhalation orally two times a day. There was nothing in the order regarding rinsing the resident's mouth after inhalation. Observation on 01/14/25 at 9:04 A.M. revealed Registered Nurse (RN) #553 administered Pulmicort Flexhaler one inhalation to Resident #102. After administration, he was not encouraged to rinse his mouth out. Interview on 01/14/25 at 9:10 A.M. with RN #553 verified she had not offered Resident #102 to rinse his mouth after administration of his inhaler as she had never heard of that as a prevention for the formation of a fungal infection of the mouth. She revealed that the facility would just treat with Nystatin (anti-fungal medication used to treat fungal infections) instead if a resident developed a fungal infection. Interview with 01/15/25 at 1:03 P.M. with Regional RN #630 verified each time a steroidal inhaler was administered, the nurse was to offer the resident to rinse his mouth to prevent the development of a fungal infection. Interview on 01/14/25 at 10:42 A.M. with Pharmacist #700 contracted by the facility verified after administration of a steroidal based inhaler, it was recommended to encourage a resident to rinse their mouth to prevent the development of a fungal infection. Review of the undated package insert guidelines labeled, Pulmicort Flexhaler (Budesonide) revealed after administration of the inhaler, the guidance was to rinse the resident's mouth with water and spit to prevent infection in the mouth. Review of the Administration of Metered-Dose Inhaler, dated 02/01/24, revealed the facility was to administer medications as prescribed and in accordance with professional standards. If the inhaler was a corticosteroid the nurse was to allow the resident to rinse and gargle with water to remove the medication from the back of the throat.

Based on record review, interview and facility policy review, the facility failed to ensure residents and/or resident representatives were able to participate in quarterly care plan conferences for Residents #10 and #62. This affected two residents (#10 and #62) of two resident records reviewed for participation in care planning. The facility census was 99. Findings include: 1. Review of Resident #62's medical record revealed an admitted [DATE]. Diagnoses included Alzheimer's disease with late onset, generalized anxiety disorder, major depressive disorder, and fracture of right ulna styloid process. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 meaning she was severely cognitively impaired. Resident #62 required partial to moderate assistance with toileting, transfers, and bed mobility, maximal assistance with dressing and personal hygiene. Review of the current care plan revealed Resident #62 was prone to behavior problems including yelling, screaming, and agitation and had a care plan in place which included intervening to protect the rights of others, diverting his attention, and monitoring medications for effectiveness. Review of the progress notes from May 2024 through November 2024 revealed Resident #62 had a care plan meeting 05/06/24 and did not have the next care plan meeting until 11/08/24. Interview on 01/14/25 at 3:25 P.M. with the Social Service Designee (SSD) #513 confirmed Resident #62 did not have a quarterly care plan meeting between 05/06/24 and 11/08/24. 2. Review of Resident #10's medical record revealed an admitted [DATE]. Diagnoses included paranoid schizophrenia, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder single episode, severe with psychotic features. Review of the annual MDS assessment dated [DATE], revealed Resident #10 had a BIMS score of 15 meaning she was cognitively intact; however, an attempted interview on 01/13/25 at 3:33 P.M. revealed she had impaired thought processes due to paranoid schizophrenia. Resident #10 required partial to moderate assistance with toileting showers, transfers, personal hygiene, lying to sitting, and sitting to stand. Resident #10 was compliant with all medications, including psychotropic medications, during the review period. Review of the current care plan revealed Resident #10 had a care plan in place for behavioral health needs and use of psychotropic medication. The care plan reflected interventions that targeted behaviors which resulted from disorganized and delusional thinking and false beliefs. Review of the Interdisciplinary Team (IDT) Plan of Care Review Summary dated 11/15/24 revealed an annual care plan meeting for Resident #10 was scheduled for that day with SSD #513. The IDT Plan of Care Review Summary noted only SSD #513 was in attendance and participated in the review of Resident #10's plan of care and did not include the resident or anyone else from the IDT. Interview on 01/14/25 at 3:25 P.M. with the SSD #513, confirmed the care plan meeting was a scheduled quarterly/annual and the conference was not held with the IDT, Resident #10, or the resident's representative. Review of the Care Planning-Resident Participation Policy, implemented 02/01/24, revealed it was the facility's policy to discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences and allow them to see the care plan initially, at routine intervals, and after significant changes.

Based on observation and interview the facility failed to maintain a clean and sanitary environment. This affected all the residents in the facility. The facility census was 138. Findings include: The following observations of the G nursing unit were verified with State tested Nursing (STNA) #153, Licensed Practical Nurse (LPN) #165, LPN #166, Registered Nurse (RN) #167 on 01/11/23 between 9:45 A.M. and 10:`15 A.M.: a. The floor in the common dining room and hallways were dull, scuffed with food debris and dried liquid puddles in several area around the tables and chairs where the residents ate their meals. b. The counters in the kitchenette area were sticky with dried red liquid droplets. c. Resident #33's room had food ground in to the carpet d. Resident #28's room had gouges in the plaster in the bathroom and food crumbs and an empty cup with dried liquid in the bottom located on her bed. e. Observation of the storage room used to store the microwave, resident food, and snacks revealed the floor and shelves covered with food crumbs, dust and other debris. The microwave oven was covered in dried food build up, grease build-up inside and outside the oven. RN #167 and LPN #166 were unable to state when the microwave had been cleaned. LPN #166 indicated the microwave was used to heat up resident and staff food. An interview with Housekeeper #169 and Housekeeper #170 on 01/12/23 at 7:28 A.M. indicated there were not enough housekeepers working each day to ensure all areas of the facility were cleaned appropriately. Both housekeepers stated they tried hard to ensure all the residents' rooms, storage areas and common areas of the facility were cleaned everyday. The housekeepers stated the facility needed one housekeeper for each nursing unit every day to ensure all areas were cleaned and disinfected properly according to their training. The housekeepers worked eight hour shifts five days a week and there were currently only two housekeepers scheduled to clean the resident care areas of the facility. Housekeepers indicated a floor technician was responsible for cleaning al the hallways in the common areas of the facility and there was one floor technician hired to ensure all the hallways were cleaned daily. The housekeepers indicated there were no housekeeping staff working weekends and they were not sure who was responsible to ensure the nursing units were cleaned and disinfected. An interview with the Housekeeping Manager (HM) on 01/12/23 at 11:13 A.M. indicated she employed a total of six full time housekeeping staff. The HM stated she had two open positions and was in the process of hiring one housekeeper who would be starting orientation soon. The HM indicated none of the resident rooms or common areas were deep cleaned on a routine schedule. Rooms were deep cleaned prior to a resident admission to the facility. The HM indicated the floors were really old and in need of replacement and no wax was applied to the floors. This deficiency represents non-compliance investigated under Complaint Number OH00138888.

Based on observation, record review and interview the facility failed to ensure food was served at a safe and appetizing temperature. This affected 124 residents who ate meals in the facility. The facility census was 138 Findings include: Medical record review revealed Resident #139 was admitted to the facility on [DATE] with diagnoses including pulmonary fibrosis with chronic respiratory failure with hypoxia and hypercapnea, diabetes mellitus, dementia, hypertensive heart disease with heart failure, cerebral vascular disease and anxiety with a history of breast cancer and removal of left breast. Resident #139's physician orders dated 11/08/22 indicated a diet order for a no added salt, regular texture diet with thin liquids. An observation of the kitchen staff serving the residents their meal on 01/11/23 at 12:00 P.M. revealed the temperature of the food items including meatloaf, mashed potatoes and corn were measured prior to serving the food items to the residents. The meatloaf was cooked to an internal temperature of greater than 160 degrees Fahrenheit, the mashed potatoes at 170 degrees Fahrenheit and the corn was cooked to an internal temperature of 155 degrees Fahrenheit. After the temperature was measured the food items were then placed in the steam table prior to plating the food items on the resident's plate. The kitchen staff placed the food on the resident's warmed plate and covered with a plastic lid prior to placing the resident's meal in the meal cart. A test tray was placed on the last meal cart to leave the kitchen to serve the residents their lunch. After all the residents were served their lunch meal the test tray was tested for palatability. The food taste was adequate but the food items were not hot. The temperature was measured with the facility thermometer and verified with Dietary Technician #159. The meatloaf temperature measured 127 degrees Fahrenheit, temperature of the mashed potatoes and the temperature of the corn measured 106 degrees Fahrenheit. An interview with Resident #139 on 01/11/23 at 3:20 P.M. indicated the facility food was often served cold. The United States Department of Agriculture (USDA) guidelines dated 08/09/2018 for holding food indicated all hot food should be held at a minimum of 140 degrees Fahrenheit to ensure food safety. This deficiency represents non-compliance investigated under Complaint Number OH00138888 and Complaint Number OH00138785.

Based on observation and interview the facility failed to maintain a clean and sanitary kitchen. This affected 124 residents who ate food prepared in the kitchen. The facility census was 138. Findings include: 1. A tour of the kitchen, storage areas and dishwashing area on 01/11/23 from 11:35 to 12:00 P.M. revealed concerns with the cleanliness of the kitchen which were verified with the Kitchen Supervisor (KS) as indicated below: a. Soiled bed blankets on top of the meal cart at the entrance of the kitchen and on the food preparation table. b. Meal carts with thick lime scale dripping down the sides of the meal carts and ice machine. c. Floors with build-up of grease, food debris, individual cream condiment cups laying on the floor and general dirt and grime on the floors throughout the kitchen. d. The three sink sanitizer solution which was in use to sanitize cookware at the time of the tour was tested by the KS and revealed a 150 parts per million of chlorine concentration reading using a litmus test. The KS stated the sanitizer solution needed changed and re-tested to ensure the litmus test reading was in the range for sanitization of the cookware. e. The hand washing sink was coated in a thick brown film and the KS stated the sink had not been cleaned appropriately. KS obtained a cleaning/disinfesting product and was able to clean the sink to the appropriate cleanliness and was unable to state when the last time the sink was cleaned. KS stated the staff used the sink to wash their hands while performing their assigned duties. f. In the equipment storage room the blast chiller and double oven slow cooker was coated with grease build-up and food debris, sticky dried liquid on the outside stainless steel panels of the equipment and the floor had grease/food build-up and had a large round area in the corner of the storage room with a rust stain on the floor and vinyl flooring was worn away. g. The floors in the equipment storage area was generally dull and dirty with dried liquids, food crumbs and build-up of food and grease. A review of the manufacturer guidance for appropriate parts per million of chlorine via litmus test paper indicated the test should read between 50 and 100 ppm of chlorine. 2. Observation during the breakfast meal service on 01/12/23 between 7:00 A.M. and 8:00 A.M. revealed on the B nursing unit a dark brown plastic cart was used to deliver food trays to the residents on the B nursing unit. Licensed Practical Nurse (LPN) #158 and LPN #168 verified the meal cart was caked with built-up dried food debris and had food crumbs covering the two shelves on the cart. This deficiency represents non-compliance investigated under Complaint Number OH00138888.

Based on observation, record review and interview the facility failed to provide incontinence care as needed for Resident #139. This affected one out of three residents reviewed for incontinence care. The facility census was 138 Findings include: Medical record review revealed Resident #139 was readmitted to the facility on [DATE] with diagnoses including pulmonary fibrosis with chronic respiratory failure with hypoxia and hypercapnea, diabetes mellitus, dementia, hypertensive heart disease with heart failure, cerebral vascular disease and anxiety with a history of breast cancer and removal of left breast. Resident #139's Minimum Data Set (MDS) assessment dated [DATE] indicated she was always incontinent of bowel and bladder and was not a candidate for a toileting program. The MDS assessment indicated Resident #139 was dependent on staff for her toileting needs. A plan of care was initiated to address her incontinence upon admission to the facility. Interventions included to provide incontinence care as needed and perform perineal care after each incontinence episode. An interview with Resident #139 on 01/12/23 at 6:10 A.M. revealed she had not been provided incontinence care recently within the last few hours. Resident #139 indicated she was wet with urine and needed changed. An observation and interview on 01/12/23 at 6:15 A.M. with Sate tested Nursing Assistant (STNA) #163 indicated she had checked all the residents on her assignment and changed them if needed. STNA #163 was asked to check Resident #139 for incontinence. STNA #163 entered the room and found Resident #139's incontinence brief soaked with urine and urine leaking on to the bed pad placed underneath Resident #139. STNA #163 indicated she was assigned to provide direct care for Resident #139 and verified Resident #139 had not been checked at 6:00 A.M. for incontinence care. Review of the facility policy and procedure titled Skin: Incontinence Care Protocol dated 01/14/05 indicated the facility would provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort an self-esteem for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00138785.

Based on observation and interview the facility failed to ensure staff performed hand hygiene during incontinence care for Resident #139 to prevent possible cross contamination of infections. This affected one out of three residents reviewed for incontinence care. The facility census was 138. Findings include: Medical record review revealed Resident #139 was readmitted to the facility on [DATE] with diagnoses including pulmonary fibrosis with chronic respiratory failure with hypoxia and hypercapnea, diabetes mellitus, dementia, hypertensive heart disease with heart failure, cerebral vascular disease and anxiety with a history of breast cancer and removal of left breast. Resident #139's Minimum Data Set (MDS) assessment dated [DATE] indicated she was always incontinent of bowel and bladder and was not a candidate for a toileting program. The MDS assessment indicated Resident #139 was dependent on staff for her toileting needs. A plan of care was initiated to address her incontinence upon admission to the facility. Interventions included to provide incontinence care as needed and perform perineal care after each incontinence episode. An observation of State tested Nursing Assistant (STNA) #163 on 01/12/23 at 6:15 A.M. revealed STNA #163 entered Resident #139's room and checked her for incontinence and found Resident #139's incontinence brief was soaked with urine leaking through to the bed pad placed underneath Resident #139. STNA #163 donned a pair of disposable gloves and proceeded to clean Resident #139's perineal area with soap and water. Upon completion of the perineal care STNA #163 applied moisture barrier cream. STNA #163 did not remove her soiled disposable gloves used during the task. STNA #163 proceeded to adjust Resident #139's bed touching the bed control buttons, placing pillows under Resident #139, pulling the light cord and placed the moisture barrier cream in Resident #139's bedside table drawer without removing the disposable gloves and performing hygiene prior to touching the various items in Resident #139's room. An interview with STNA #163 upon completion of the task on 01/12/23 at 6:30 A.M. verified she failed to remove her gloves and perform hand hygiene prior to touching the various items in Resident #139's room. STNA #163 stated she would do better next time. Review of the facility policy and procedure titled Hand Hygiene revised on 11/28/17 indicated hand hygiene would be performed to assist in the prevention of spreading infections. Item number six on the policy indicated staff perform hand hygiene (even if gloves were used) in the following situations: - Before and after contact with a resident. - After contact with blood, body fluids, or visibly contaminated surfaces or other objects and surfaces in the resident's environment. - After removing personal protective equipment. - Before performing a procedure such as a aseptic task. This deficiency represents non-compliance investigated under Complaint Number OH00138888 and Complaint Number OH00138785.

Based on observation, interview, and record review, the facility failed to ensure the kitchen and nursing unit refrigerators were maintained in a clean and sanitary manner. This had the potential to affect 117 of 127 residents as eleven residents (#2, #8, #17, #29, #68, #73, #85, #103, #104, #118, and #132) received nothing by mouth. The facility census was 127. Findings include: Observations during the initial tour of the kitchen on 10/03/22 from 9:05 A.M. through 9:20 A.M. with Dietary Supervisor (DS) #504 revealed a large white bin with a clear lid that was dirty with food splatter and the scoop was stored inside of the bin with the oatmeal. There was black, dirty scum-like substance dried on the floor under the prep table near the oatmeal bin and under the stove across from the prep table. On the prep table next to the stove there were three clear containers of scoops stored on the top shelf of this prep table that had various food crumbs on inside bottom. Observation of the ice machine had whitish drippings and blackish stains on the front, side, and back of it. Observation of the dish machine appeared dirty with lime scale and a dead bug on top of it and the front of the dish machine appeared dirty with splashes of whitish lime scale. Linen was observed on the floor near the entrance into the kitchen. Interview on 10/03/22 between 9:05 A.M. through 9:20 A.M. with DS #504 verified the identified findings. DS #504 stated the linen on the floor was from the meal carts to capture spillage during transport back to the kitchen, but there was usually a bin that they could put the soiled linen in. Observation of the nursing unit D refrigerator on 10/04/22 at 8:55 A.M. with Unit Manager (UM) #505 revealed food splatter, purple in color and food crumbs, two frozen dinner boxes not labeled, and a yellow plastic bag of food also not labeled or dated in the freezer. Interview at this time with UM #505 verified the identified findings and stated staff try to label and date items but believed the kitchen was responsible for the cleaning. Observation on 10/04/22 at 9:41 A.M. of the nursing unit C refrigerator with State tested Nurse Aide (STNA) #506 revealed an opened fruit cup with no label, a bluish stain on the inside door shelf, and strand of hair inside of the freezer and on the door shelf. Observed in the refrigerator portion was various food splatter in both shelves of the inside door, bottom of fridge, and inside the clear bin at the bottom of the refrigerator. Interview at this time with STNA #506 verified the identified findings. Review of a list of resident diets revealed Resident #2, #8, #17, #29, #68, #73, #85, #103, #104, #118, and #132 received nothing by mouth.

Based on observation, interview, and record review, the facility failed to ensure staff properly wore personal protective equipment (PPE) while entering a resident room that was positive with COVID-19 and while in resident care areas. This had the potential to affect 46 residents (#2, #5, #8, #10, #17, #20, #21, #23, #27, #29, #33, #34, #36, #37, #39, #48, #50, #51, #53, #55, #59, #65, #66, #68, #71, #73, #75, #83, #85, #93, #103, #104, #105, #110, #116, #117, #118, #121, #125, #128, #129, #130, #131, #132, #133, and #378) who all resided on units C and D. The facility census was 127. Findings include: Observation on 10/03/22 at 11:18 A.M. of Licensed Practical Nurse (LPN) #507 sitting at nurses' station on unit C with no mask on face but wearing goggles. Observed in the common area near the nurse's station but greater than six feet were Residents #34 and #116. Interview at this time with LPN #507 verified the identified finding and stated she will put it on when around residents. Observation on 10/03/22 at 11:45 A.M. of State tested Nurse Aide (STNA) #508 don a gown and gloves but already had on goggles and a black mask, enter Resident #128's room and close the door behind him. Observed outside of Resident #128's room a sign for contact precautions and a sign on a cart with PPE that read Use Personal Protective Equipment (PPE) when caring for patients with confirmed or suspected COVID-19). Observed STNA #508 exit Resident #128 's room with the gown and gloves doffed. Interview at this time with STNA #508 verified he was wearing a black surgical mask when he entered the resident's room and did not put on a N95. STNA #508 stated he was supposed to put on a N95 mask prior to entering the resident's room. Observation on 10/03/22 at 12:09 P.M. of LPN #507 exiting Resident #128's room wearing only a black cloth mask and goggles. Interview at this time with LPN #507 stated she put gloves on and entered the resident's room to hand him his pills and doffed the gloves prior to exiting the room. LPN #507 stated she did not don a gown or put on a N95 mask. LPN #507 stated Resident #128 was in transmission-based precautions due to being positive for COVID-19. Interviews on 10/03/22 at 12:20 P.M. and 12:45 P.M. with the Director of Nursing (DON) who was also the infection control preventionist revealed staff should have a mask on while at nurses' station unless drinking or eating. DON stated when staff enter resident rooms that were positive with COVID-19 they should wear eyewear, N95 mask, gown, and gloves. DON stated they did not have a policy for what staff should wear while at nursing station but stated they followed Centers for Disease Control and Prevention (CDC) guidance for community transmission. DON stated since they were in a county that was in the red indicating high transmission rate for COVID-19 staff were to wear a mask and eye protection. Observation on 10/03/22 at 3:04 P.M. of Maintenance Staff (MS) #509 walking down the hall on unit D with his facemask and goggles not properly on, exposing his mouth and eyes. Observed MS #509 then enter Resident #50's room. Interview at this time with MS #509 verified the observation and had pulled up his mask and goggles properly. Review of the facility policy titled, Donning and Doffing PPE for COVID-19, revised 02/02/22, revealed the policy did not specify the use of a N95 mask or higher respirator when entering a resident's room with confirmed or suspected COVID-19. The policy did indicate to put on isolation gown, respirator and/or facemask, eye protection, gloves and enter the isolation area/room. Review of the CDC website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/23/22 revealed when [CONDITION(S)]-CoV-2 Community Transmission levels are high, source control is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. HCP could choose not to wear source control when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms) if they do not otherwise meet the criteria described below and Community Levels are not also high. Source control options for HCP include: A NIOSH-approved particulate respirator with N95 filters or higher; A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated); A barrier face covering that meets ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus masks; OR A well-fitting facemask. When Community Levels are high, source control is recommended for everyone. HCP who enters the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on observation, record review, and interview, the facility failed to ensure all resident rooms had call lights in place. This affected two of ten residents on the secured G unit reviewed for accessible call lights (Resident #4 and #40). The total census was 127. Findings include: 1. Record review of Resident #40 revealed she was admitted [DATE] and had diagnoses including dementia, major depressive disorder, and unspecified [CONDITION(S)]. Review of her care plan revealed no mention of any prohibition against keeping a call light in the room. Observation of Resident #40's room on 10/03/22 at 9:36 A.M. revealed she had no bedside call light or cord either plugged into the bedside socket or visible elsewhere in the room. Observation of Resident #40 at this time revealed she was not interviewable. The surveyor confirmed the above observation with Licensed Practical Nurse (LPN) #401 on 10/03/22 at 9:40 A.M. 2. Record review of Resident #4 revealed she was admitted [DATE] and had diagnoses including dementia, paranoid [CONDITION(S)], and depression. Review of her care plan revealed no mention of any prohibition against keeping a call light in the room. Observation of Resident #4's room on 10/05/22 at 10:08 A.M. revealed she had no bedside call light or cord either plugged into the bedside socket or visible elsewhere in the room. Observation of Resident #40 at this time revealed she was not interviewable. The surveyor confirmed the above observation with LPN #401 on 10/05/22 at 10:21 A.M. Interview with her at this time revealed she believed Resident #4 was able to use a call light and had done so in the past. She did not believe Resident #40 was able to use a call light.

Based on interview, observation, and record review the facility failed to ensure Resident #47 was free from significant medication error. This affected one resident (Resident #47) of five residents (Resident's #14, #47, #59, #61 and #98) observed for medication administration. The facility census was 168. Finding include: Review of the medical record for Resident #47 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy form labeled, Do Not Crush-Drug Guide, dated March 2022, revealed [MEDICATION(S)] Extended Release (ER) was on the list not to crush. Review of the care plan dated 04/15/22 revealed Resident #47 had altered health maintenance related to progressive physical and mental status as Resident #47 was admitted with congested heart failure and cardiovascular disease. Interventions included administer medications as ordered and monitor for signs of cardiac distress including [CONDITION(S)], fatigue, [CONDITION(S)], shortness of breath, and nausea. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 was cognitively impaired. Observation of medication administration on 05/20/22 at 8:57 A.M. revealed Licensed Practical Nurse (LPN) #600 crushed Resident #47's [MEDICATION(S)] ER 25 mg tablet, placed it in pudding and administered it to Resident #47. Interview on 05/20/22 at 9:15 A.M. with LPN #600 verified she crushed Resident #47's [MEDICATION(S)] ER and verified she should not have since the medication was in an extended-release form. Review of the nursing note dated 05/20/22 at 9:52 A.M. and authored by LPN #600 revealed Nurse Practitioner (NP) #900 was notified Resident #47's [MEDICATION(S)] ER was crushed during medication administration. NP #900 ordered no new orders. Interview on 05/20/22 at 12:50 P.M. with the Director of Nursing (DON) verified [MEDICATION(S)] ER should not be crushed as the medication was on the do not crush medication list that was provided to the facility from the pharmacy. Interview on 05/20/22 at 1:18 P.M. with Pharmacy Consultant #612 revealed [MEDICATION(S)] ER should not be crushed for Resident #47 since it is extended release unless approved by a physician. He revealed dizziness could be an adverse effect if the medication was crushed. Review of facility policy labeled Crushing of Medication, dated 08/07/12, revealed all medication which do not lose effectiveness or produce side effects when crushed may be crushed per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed medications that were extended release should not be crushed. This deficiency substantiates Complaint Number OH 381.

Based on observation, interview and facility policy review, the facility failed to ensure linens were properly stored or maintained. This had the potential to affect all 146 residents residing in the facility. Findings include: Observation on 06/29/21 at 4:14 P.M. during the initial facility tour revealed unfolded linen sitting on top of the clean linen cart on E unit, which could not be identified as clean or soiled. Interview at the time of the observation with Registered Nurse (RN) #214 confirmed the unfolded linen was on top of the clean linen cart and indicated uncertainty whether it was clean or dirty. Observation on 06/29/21 at 4:32 P.M. during the initial facility tour revealed unfolded linen sitting on the top of the clean linen cart in C unit's hallway. Interview at the time of the observation with State tested Nursing Assistant (STNA) #209 confirmed the unfolded linen on top of the cart was soiled. Review of facility policy titled Infection Prevention and Control Program (ICPC), revised 11/28/17, revealed staff handle store and transport linens appropriately including but not limited to bagging/containing contaminated linen where collected; and clean linens are transported by methods that ensure cleanliness e.g. protect from dust and soil. Review of facility policy titled Infection Control - Laundry Linen Isolation Room Cleaning Practice, revised May 2015, revealed soiled and clean linen must be kept separate and all times; all soiled linen must be placed directed into covered a hamper; and soiled linen is brought into the soiled room - do not leave in hall or near clean linen. This deficiency substantiates Complaint Number OH 364.

Based on interview, record review and review of facility self-reported incidents (SRI), the facility failed to ensure a comprehensive investigation of physical abuse was completed for Resident's #24, #86 and #132. This affected three Resident's (#24, #86 and #132) of three residents reviewed from facility self-reported incidents for abuse, neglect, and exploitation. The facility census was 146. Findings include: 1. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 06/14/21 revealed alteration of mood and behavior due to cognitive decline/deficit. Interventions included provide one to one with resident as needed and offer activities of interest. Review of the SRI file dated 05/25/21 revealed Resident #24 during lunch pushed Resident #132 which caused Resident #132 to fall and sustain a fracture. The file contained a copy of the Self-Reported Incident Form # 5, a copy of Resident #24's profile sheet, a copy of Resident #24's progress notes from 05/25/21 to 06/02/21, a copy of Resident #132's profile sheet, a copy of Resident #132's progress notes from 05/25/21 to 05/28/21, and a report titled Quick Response for Resident #132. The file did not contain a comprehensive investigation which would include witness statements, resident interviews, staff interviews, or assessments. Interview with the Administrator on 06/29/21 at 5:14 P.M. confirmed the SRI file dated 05/25/21 was incomplete, and the victim, the alleged perpetrator, witnesses, and staff were not interviewed. 2. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 06/14/21 revealed alteration of mood and behavior due to cognitive decline/deficit. Interventions included provide one to one with resident as needed and offer activities of interest. Review of the SRI file dated 05/30/21 revealed Resident #24 pushed Resident #86 which caused Resident #86 to fall and hit head. The file contained a copy of the SRI Form # 9, a copy of Resident #24's profile sheet, a copy of Resident #24's progress notes from 05/25/21 to 06/02/21, a copy of Resident #86's profile sheet, a copy of Resident #86's progress notes from 05/30/21 to 06/01/21, and a report titled Quick Response for Resident #86. The file did not contain a comprehensive investigation which would include witness statements, resident interviews, staff interviews, or assessments. Interview with the Administrator on 06/29/21 at 5:14 P.M. confirmed the SRI file dated 05/30/21 was incomplete, and the victim, the alleged perpetrator, witnesses, and staff were not interviewed.

Based on observation and interview the facility failed to ensure the kitchenette on the G unit was maintained in a clean and sanitary manner and in good repair to prevent contamination and/or food borne illness. This had the potential to affect 30 residents (#3, #9, #10, #12, #22, #25, #30, #35, #37, #38, #39, #40, #50, #67, #69, #70, #73, #76, #77, #78, #79, #80, #85, #88, #92, #94, #113, #114, #118 and #123) of 142 residents residing in the facility. Findings include: During a kitchen tour on 11/20/19 at 9:24 [NAME]M. two kitchenette were observed on the G unit. The left side which contained higher room numbers had a toaster with loose debris and water mark type stains, the outside of the microwave had smears of food residue on the top and sides The counter tops in both kitchenettes were stained with multiple round brown and red stains and the finish on the top of the counter had worn away leaving an unclean surface. In addition, a refrigerator with a broken off door handle that left behind sharp broken hard plastic was also observed. The dish washing and storage area contained an ice machine with a clogged drain in the spill reservoir leaving 1/4th of an inch of standing water beneath the ice shoot. There was a side by side freezer which Cook #207 stated hadn't worked since (MONTH) of (YEAR). The refrigerator on right side read 46 degrees on the outside thermometer, but, there wasn't a thermometer on the inside. The above concerns were verified with State tested nursing assistant (STNA) #370, STNA #356 and Cook #207 at the time of the observation. On 11/21/19 at 8:42 [NAME]M. the observation of the right side refrigerator revealed there still was no thermometer inside the refrigerator and the outside thermometer again read 46 degrees. The refrigerator was noted to be running loudly with a slight knocking noise. A pool of standing water was observed on the bottom of the refrigerator with two cases of canned soda sitting in the standing water. Cook #210 verified the temperature and standing water . He stated the refrigerator was defrosting and that was why it made that loud rattling noise. During an interview on 11/21/19 at 10:50 [NAME]M. Dietary Manager (DM) #223 revealed he would check the refrigerator to ensure a thermometer had been placed inside and to check on the standing water. At 11:12 P.M. DM #223 revealed he had placed a thermometer in the refrigerator and it had also read 46 degrees indicating the supplements and perishable food inside were not stored at the proper temperature and had been disposed of. He stated the refrigerator had malfunctioned. The facility identified 30 residents, Resident #3, #9, #10, #12, #22, #25, #30, #35, #37, #38, #39, #40, #50, #67, #69, #70, #73, #76, #77, #78, #79, #80, #85, #88, #92, #94, #113, #114, #118 and #123 who resided on the G unit.

Based on observation, record review and interview the facility failed to ensure Resident #118, who sustained significant weight loss, was cued to eat or offered a substitute during meals. This affected one resident (#118) of four residents reviewed for nutrition. Findings include: Record review revealed Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/17/19 revealed the resident was cognitively impaired and required the assistance of one staff for eating. The assessment also indicated the resident had a weight loss of 5% or more in one month and or a loss of 10% over six months. Review of the resident's care plan, dated 10/17/19 revealed the staff were to offer meal substitutes when foods were refused. Review off the physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. The supplement of a frozen treat was eaten 100% of 22 times and less than 25% 18 times. Review of the resident weights revealed the resident had a six month weight loss of 13.67% between 06/17/19 and 11/18/19 and a three month weight loss of 14.29% between 09/03/19 and 11/18/19. On 11/18/19 at 12:00 P.M. an observation of the lunch meal revealed Resident #118 pushed away the plate of cabbage, buttered noodles, ham and corn bread that had been served to her. At 12:08 P.M. the resident had eaten half the ham and a couple of forks of cabbage, approximately 10% of the total meal. At no time was the resident cued to continue eating or offered a substitute. On 11/20/19 at 8:30 [NAME]M. observation of the breakfast meal revealed the resident refused the breakfast meal and was not offered a meal substitution. Review of the State tested nursing assistant (STNA) documentation for breakfast reflected the resident had refused the meal. Interview on 11/21/19 at 10:44 [NAME]M. with Dietitian (RDLD) #222 revealed she monitored the intake of the supplements and revealed Resident #118 was on weekly weights. When asked if substitutes were brought down on the steam cart and made available to the residents she stated she wasn't sure if the substitutes were on the steam table. Interview on 11/21/19 at 10:50 [NAME]M. with Dietary Manager (DM) #223 revealed staff ask the residents the day before if they want to substitute meals, and if they do, he makes sure they are on the steam table. In regards to residents who had dementia and might not know or remember if they wanted a meal substitution, he stated there were always substitutes in the kitchen and the staff only needed to call the kitchen. He stated substitutes were not automatically placed on the steam cart.

Based on record review and interview the facility failed to ensure confidential medical information was maintained in a safe and secure manner. This affected one resident (#137) of one resident reviewed for privacy. Findings include: Review of the medical record for Resident #137 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of most current Minimum Data Set (MDS) 3.0 assessment, dated 11/06/19 revealed the resident exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS)score of three. Interview on 11/18/19 at 10:54 [NAME]M. with Resident #137's daughter revealed when she arrived to take her mother to a cardiologist appointment her packet of information was not available. Licensed Practical Nurse (LPN) #269 told her it was given to the family that left earlier to another appointment. Resident #137's information was printed again and she left to the appointment with her mother. Interview on 11/21/19 at 9:03 [NAME]M. with the Director of Nursing (DON) reported being present when the information needed printed out again for Resident #137's daughter and she thought that was unusual. The DON revealed the printed information that had been printed prior had been given to another resident's family. Interview on 11/21/19 at 9:44 [NAME]M. with Office Personnel #290 revealed she scheduled the appointments, printed out the required documents prior to the appointment, placed the information in an envelope and delivered the envelopes to the units the day before the appointment date. She reported on this date, Resident #137's envelopes was stuck to another resident's information and both packets were given to the other resident's family member. Interview on 11/21/19 12:18 P.M. LPN #269 revealed she worked the day the information was given to the wrong family. She did not realize she had given Resident 137's envelope of information to the wrong family. She discovered it was not available when she could not find it for Resident #137 and her daughter. LPN #269 left the floor to print out the required documents and while she was gone, the pharmacy tech was able to print out the information after confirmation from the DON. She stated both parties returned to the facility but did not know what happened to the documents. Review of the Notice of Privacy Practices policy, reprinted from the HIPAA Privacy Reference Manual, revealed how medical information may be used and disclosed and how you can get access to this information. Included were sections on: Understanding your health record and information, How we may use and disclose protected health information, Other allowable uses of your health information, Other uses if health information, Your rights regarding health information about you, Our responsibilities, Changes to this notice and Complaints.

Based on observation, record review, facility policy and procedure review, and staff and resident interviews, the facility failed to provide effective administration of residents, resulting in Actual Harm and Substandard Quality of Care in regards to appropriate administration of pain medication to four residents (Resident #205, #208, #228, #235). This affected four of 12 residents reviewed for pain management. Findings include: The facility failed to administer necessary pain medication as ordered by the physician to four residents (Resident #205, #208, #228, #235). These included Resident #205 who on 10/10/12 at 10:00 P.M. had an onset of extreme neck pain and remained in extreme, incapacitating pain throughout the entire night until 10/11/12 at 12:20 P.M. when he was sent to the hospital by ambulance because the facility was unable to provide pain medication for over 14 hours; Resident #228 who expressed buttock pain and had to wait 34 hours before being medicated for pain; Resident #208 who on 10/10/12 at 11:15 A.M. was observed frequently squirming in the chair, occasionally yelling out and crying with complaints of back pain; and Resident #235 who was unable to participate in physical therapy because she did not receive her pain medication as ordered. See F309 for details.

Based on observation, clinical record review, staff and resident interviews and review of facility policy and procedure for Management of the Resident in Pain, the facility failed to administer necessary pain medication as ordered by the physician to eight residents (Resident #205, #208, #228, #224, #235, #223, #236 and #40). This caused Actual Harm to four residents - Resident #205 who on 10/10/12 at 10:00 P.M. had an onset of extreme neck pain and remained in extreme, incapacitating pain throughout the entire night until 10/11/12 at 12:20 P.M. when he was sent to the hospital because the facility was unable to provide pain medication to the resident; Resident #228 who expressed buttock pain and waited 34 hours before being medicated for pain; Resident #208 who was observed frequently squirming in the chair, occasionally yelling out and crying with complaints of back pain; and Resident #235 who was unable to participate in physician ordered physical therapy because she did not receive her pain medication as ordered. The facility failed to prevent avoidable pain for four of the eight residents to allow them to reach his/her highest practicable ability resulting in Substandard Quality of Care. The facility also failed to assess four residents (#223, #224, #236, and #40) before giving them pain medication. The deficient practice affected eight of 12 residents reviewed for pain management. Findings include: 1. Resident #205 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders dated 10/05/12 revealed the resident was ordered nothing by mouth (NPO) and a nutritional intravenous (IV) infusion infused continuously at 125 milliliters (ml) per hour. The resident had a [MEDICAL CONDITION] bag and [MEDICAL CONDITION] drainage system for bowel and bladder function. The resident was not ordered any type of pain medication upon admission. On 10/10/12 the physician ordered the resident to receive Tylenol suppository 650 milligrams (mg) every six hours as needed for elevated temperature and on 10/11/12 around 3:00 A.M., the physician ordered [MEDICATION NAME] 30 mg IV every six hours as needed for pain. Review of a pain assessment for Resident #205 dated 10/05/12 revealed the only section completed indicated the resident was not verbal, nonverbal, unresponsive or had altered consciousness, did not have dementia and had no pain. No other section of the assessment was completed and no pain assessment was completed when the resident was experiencing pain. No nursing progress notes were noted regarding the resident experiencing pain on 10/11/12 at 3:00 A.M. or why the call to the physician or the faxing of the ordered [MEDICATION NAME] IV to the pharmacy. Review of an interim plan of care dated 10/06/12 for alteration in comfort related to status [REDACTED]." On 10/11/12 at 8:25 A.M. upon entering Resident #205's room for an observation of a dressing change, the resident was lying in his bed, flat, in a very stiff position, with grimacing on his face. The resident said "I have been in severe pain all night, I have never had pain this bad in my life, It's greater than a 10 scale. " The resident was unable to turn to allow observation of his back. Interview with Registered Nurse (RN) #303 at this time revealed "we faxed an order to the pharmacy at 3:00 A.M. and they have not as of yet sent us the medication for the resident." On 10/11/12 at 10:55 A.M. Resident #205 observed lying in his bed with Physical Therapy Technician (PTT) #15 in his room, next to the bed doing range of motion to the resident ' s legs. PTT #15 stated he was aware the resident was having severe pain in his neck. He stated, "I can ' t do any more than careful range of motion with the resident ' s legs until the resident receives a pain medication and maybe I can come back later and continue." The resident stated he had not received anything for pain. The resident was unable to participate in the physical therapy and PTT #15 stopped the range of motion exercises. During interview with RN #303 on 10/11/12 at 11:00 A.M., she stated she called Resident #205's physician and he ordered something else for the resident. She stated the pharmacy just called her and said the resident ' s [MEDICATION NAME] IV would be here in two hours. She stated it was very hard to wait for pain medication for a resident. She stated, " the wait is unacceptable, it ' s hindering their ( the resident ' s ) recovery." On 10/11/12 interview with the two other nurses working on the A Unit revealed the following information. At 11:15 A.M., Licensed Practical Nurse (LPN) #305 stated "it is not easy to give a resident a pain medication here. The length of time is bad between the order of a medication and getting the medication from pharmacy." . She stated, "Patients have to wait a very long time, a very poor system here, it ' s sad." At 11:35 A.M. LPN #306 stated, "the wait time for residents to get pain medication is upsetting to us and the residents and their families." She stated, "the residents lose confidence in us." On 10/11/12 at 4:05 P.M. the director of nursing confirmed it could take up to 24 hours for a resident to receive their prescribed narcotic pain medication. On 10/11/12 at 4:00 P.M. review of the facility policy and procedure on Management of the Resident in Pain dated 10/18/01 and revised in March 2011 revealed the following: Nursing Expectations: a. Implement interventions for all residents in pain. Implement protocol appropriate treatment. b. Evaluate response to interventions, recognize side effects and adjust according to resident condition, physician order, nursing judgment. Side effects include but are not limited to: respiratory depression, changes in mental status, [MEDICAL CONDITION], nausea and vomiting, [MEDICAL CONDITION], puritis. c. Document assessments, interventions, evaluations and resident care provided accordingly. Expected Outcome: The patient will experience maximal pain relief with minimal side effects. Pain Management Policy: Assessment of pain will be completed with admission process to facility. Assessment of verbal complaints and non-verbal signs or symptoms of pain will be completed. Non-verbal indicators of pain include but are not limited to moaning, crying, irritability, and anxiety. Assessment of pain for residents who are unable to report pain will be monitored through activities of daily living and during care be delivered by nursing staff. Assess level of pain including intensity of pain if reportable by resident on numeric pain scale; 0=no pain, 10=the worst pain imaginable. Identify pharmacological and non-pharmacological methods to reduce pain in a resident. Document assessments, interventions, evaluations and resident care accordingly. Provide medication in accordance with physician order. Evaluate the resident ' s response to interventions. Notify the physician if interventions are ineffective. 2. Resident #208 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #208 ' s October 2012 orders revealed physician orders dated 10/08/12 for a narcotic pain medication ([MEDICATION NAME]) 50 mg two times a day as needed, [MEDICATION NAME] 5% (700 mg patch) one patch topically to lower back daily as needed for pain and Tylenol 650 mg every six hours as needed. Review of an interim plan of care dated 10/08/12 revealed the resident was at risk for pain due to [DIAGNOSES REDACTED]. During interview with Resident #208 on 10/10/12 at 11:15 A.M. the resident was seated in her wheelchair in her room, next to her bed. The resident ' s family member was visiting. During the entire interview, the resident frequently squirmed in the chair. Occasionally she yelled out and began crying and complained of back pain. She stated " I have been having low back pain for days. " LPN #304 entered the resident ' s room. The resident and family member requested the resident receive a pain medication. The nurse left the room. At 12:00 P.M., LPN #304 returned to the resident ' s room and informed her that she "has to call pharmacy for them to send a pain medication for her." LPN #304 verified the [MEDICATION NAME] medication was in the facility starter box. She stated " I am not allowed to take it out for the resident until pharmacy faxes me an authorization. " The resident did not receive the [MEDICATION NAME] medication until 1:00 P.M. 3. Resident #228 was admitted to the facility on [DATE] at 1:00 P.M. with [DIAGNOSES REDACTED]. The medications listed on the hospital discharge sheet indicated she received Tylenol 650 mg every six hours as needed for mild pain and [MEDICATION NAME] (a narcotic pain reliever) every four hours as needed for moderate pain. A facsimile from the hospital dated 10/08/12 at 10:52 P.M. listed prescriptions including [MEDICATION NAME]. The physician's orders dated 10/08/12 included [MEDICATION NAME] 5/500 mg every four hours as needed for pain and Tylenol 650 mg every six hours as needed for pain. On 10/09/12 at 11:00 P.M. an order was written for [MEDICATION NAME] (a narcotic like pain reliever for moderate to moderate/severe pain) 50 mg every four hours as needed for pain. Handwritten on the order was "send med STAT". Review of the pain assessment dated [DATE] at 4:06 P.M. indicated Resident #228 had acute, ache and tender type pain. The assessment identified wound care as aggravating the pain. Review of the admission care plan dated 10/08/12 indicated the focus was the resident had alteration in comfort related to an open coccyx. The interventions were to medicate as ordered, assess for pain, proper body alignment, monitor response to pain, offer back rubs and offer quiet environment. Review of the history and physical dated 10/10/12 at 11:00 A.M. signed by the nurse practitioner indicated the resident's chief complaint was "my foot and my butt hurt". The nurse practitioner noted that pain was present in the left foot and sacrum. Review of the narcotic book indicated [MEDICATION NAME] was administered to Resident #228 on 10/09/12 at 11:00 P.M., 10/10/12 at 1:10 P.M. and on 10/11/12 at 12:30 A.M. Tylenol and [MEDICATION NAME] were not administered. Resident #228 and her husband were interviewed on 10/09/12 at 3:45 P.M. Resident #228 voiced having pain. The husband was in the room and confirmed she had pain. The resident voiced seeing people in her room that were not there. Interview with RN #301 on 10/10/12 at 6:45 A.M. indicated Resident #228 was without pain medication for over 24 hours and has been in pain the entire time. RN #301 stated she had no pain medication to give the resident because the pharmacy would not send the pain medication without a written physician order, facsimile of a written order or until the physician called the pharmacy and gave a verbal order over the telephone. The pharmacy would not accept verbal orders given by nurses over the telephone. Interview with RN #302 on 10/11/12 at 10:40 A.M. revealed she completed Resident #228's wound treatments on 10/10/12 and the resident expressed pain during the treatment. She stated 10/11/12's dressing change would have to wait about 20 more minutes for the pain medication to take effect. She verified she did not write a note about the resident's pain during the dressing change on 10/10/12. She stated she would write a note. The note dated 10/11/12 at 10:41 A.M. for 10/10/12 at 1:39 P.M. indicated RN #302 completed Resident #228's dressing change to the coccyx. The resident had no complaints of pain with repositioning but did moan while the nurse packed the coccyx wound. RN #302 would let nursing know so the resident could be medicated prior to dressing changes to coccyx. Interview with LPN #300 on 10/11/12 at 10:25 A.M. verified Resident #228 was not given pain medication from her admission on 10/08/12 at 1:00 P.M. until 10/09/12 at 11:00 P.M. The resident had waited 34 hours to receive her pain medication. 4. Resident #224 was admitted on Friday 10/05/12 at 8:00 P.M. following a hospital admission for exacerbation of [MEDICAL CONDITIONS]. The resident's [DIAGNOSES REDACTED]. The physician orders dated 10/05/12 indicated the resident had [MEDICATION NAME]-[MEDICATION NAME] 5 mg/500 mg ([MEDICATION NAME]) ordered every six hours for pain. On 10/05/12 at 11:10 P.M. the physician orders were faxed to the pharmacy. A review of the resident's pain intervention log for as needed (PRN) medication for October 2012 revealed it was blank. A review of the resident's admission care plan implemented on 10/05/12 revealed the resident had chronic back pain, medication was to be given as ordered and pain assessments and pain scales were to be completed. A review of the progress notes since the resident was admitted did not reveal any documentation related to pain. The pain rating data completed on 10/05/12 at 11:27 P.M. revealed the resident's pain was an eight out of ten, and it was a daily aching pain that affected her sleep and rest. What alleviated the resident's pain was medication. The first documented dose of pain mediation was 10/06/12 at 2:35 PM which was taken from the contingency box (back up supply of medications). On 10/12/12 at 10:15 A.M. an interview with LPN #309 revealed that on 10/05/12 at 10:56 A.M. the facility faxed the prescription for the resident's [MEDICATION NAME] to the pharmacy and again on 10/06/12 at 12:33 A.M. because the pharmacy stated they didn't receive the first fax. LPN #309 verified the first documented dose of as needed [MEDICATION NAME] was given at 10/06/12 at 2:55 P.M. which was approximately 14 hours after the second fax to the pharmacy requesting the medication. On 10/11/12 at 10:25 A.M. an interview was conducted with the resident who revealed that she requested her as needed for pain medication, [MEDICATION NAME] at 6:30 A.M. and still had not received it. The resident stated that they told her they were waiting for the medication to come from somewhere but she wasn't sure where. The resident stated she came back from therapy about 30 minutes ago and again asked for her pain medication but was told her pain medication had not come in yet. The resident stated her pain was 8.5 out of ten and felt like a hot poker in her back. The resident stated that she had blown out her disks in her back and no matter how she sat, laid or walked; when the medication wore off she was in pain. The resident stated at times tears would roll down her eyes because of pain. The resident stated she wanted to work harder in therapy today and do more but could not because of pain. The resident stated at home she was on [MEDICATION NAME] 10 milligrams every six to eight hours for pain. The resident stated that she did without pain medication for hours when she was first admitted . On 10/11/12 at 10:38 A.M. an interview was conducted with LPN #308 who stated that they did not have any [MEDICATION NAME] designated for the resident in stock right now and LPN #309 was following up with pharmacy. LPN #308 stated she thought pharmacy received the prescription but they were waiting for permission to pull it from contingency. LPN #308 stated the resident had a card for [MEDICATION NAME] but it was empty and even though she thought pharmacy was notified, they never received the shipment of it. LPN #308 verified the last time the resident received the pain medication was 10/10/12 at 10:50 P.M. LPN #308 stated she had this problem with other residents and their receipt of pain medication. On 10/11/12 at 10:46 A.M. an interview was conducted with LPN #309 who revealed the pharmacy was called last night and the [MEDICATION NAME] was not a new order but a refill. When she came in this morning she found out the pharmacy never sent the medication because they stated the prescribing physician was not in the system. LPN #309 stated she called the pharmacy to get it all taken care of and was told the resident ' s pain medication would be in this afternoon. She stated she faxed the pharmacy for permission to have the medication taken out of contingency. A review of the refill order form for the pharmacy revealed the facility sent a fax to the pharmacy on 10/10/12 at 1:36 P.M. Review of the Scheduled III-Controlled Substance sheet for the pharmacy revealed an order was completed on 10/10/12 at 5:00 P.M. Review of the request for removal of controlled medication from contingency supply was faxed to the pharmacy and per interview with LPN #309 on 10/12/12 at 10:46 A.M. it was faxed over to pharmacy on 10/11/12 at approximately 11:00 A.M. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. which was 12 hours and 30 minutes after she received her last dose of pain medication (10/10/12 at 11:50 P.M.) and was four hours and 50 minutes after the resident requested the pain medication at 6:30 A.M. There was no documentaion of pain assessments related to these dates or any of the dates noted on the October 2012 medication administration record. The residents care plan revealed medication were to be given as ordered, pain assessments and pain scales were to be completed. 5. Review of the physician orders dated 09/08/12 for Resident #40 revealed an order for [REDACTED].#40 revealed the resident received 12 doses of her as needed pain medication. A review of the resident ' s pain intervention log and progress notes for October 2012 revealed the resident received 11 doses of the as needed pain medication without a documented assessment (such as severity and location of pain) and reassessment of her pain. On 10/16/12 at 3:06 P.M. this was confirmed by the director of nursing. 6. A review of the physician orders dated 09/22/12 for Resident #223 revealed an order for [REDACTED].#223 revealed the resident received 40 doses of his as needed pain medication. A review of the resident ' s pain intervention log and progress notes for October 2012 revealed the resident received all 40 doses of the as needed pain medication without a documented assessment and reassessment of his pain. On 10/16/12 at 3:06 P.M. this was confirmed by the director of nursing. 7. A review of the physician orders dated 10/01/12 for Resident #236 revealed an order for [REDACTED].#236 revealed the resident received 49 doses of her as needed pain medication. A review of the resident ' s pain intervention log and progress notes for October 2012 revealed the resident received 33 doses of the as needed pain medication without a documented assessment and reassessment of her pain. On 10/16/12 at 3:06 P.M. this was confirmed by the director of nursing. 8. Resident #235 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #235 had a physician order on 10/04/12 for [MEDICATION NAME]-[MEDICATION NAME] 325/5 mg one to two tablets by mouth to be given as needed every four hours for pain. Interview with Resident #235 on 10/10/12 at 10:48 A.M. revealed she needed ice applied to her knees and pain medication one hour prior to her therapy sessions. Resident #235 stated she had pressed her call light button to inform staff she was in need of ice and pain medication. She stated the staff did not bring her the ice and pain medication in a timely manner. She stated she had to wait over an hour for her request. This occurred every day. Resident #235 stated she had to participate in her therapy sessions while in pain. The resident stated she was unable to participate fully with therapy due to the pain she experienced.

Based on observation, clinical record review, staff and resident interviews and review of facility policy and procedure for Management of the Resident in Pain, the facility failed to administer pain medication prior to a dressing change for one resident (Resident #109) resulting in extreme abdominal pain during her abdominal dressing change. This involved one resident (Resident #109) observed for dressing changes. The facility census was 44. Findings include: Review of Resident #109's physician orders revealed the resident had three narcotics ordered for pain and one anti-anxiety medication. On 10/06/12, the physician ordered a narcotic ([MEDICATION NAME]) 50 milligrams by mouth as needed four times a day for moderate pain. Between 12/01/12 and 12/20/12, Resident #109 received 11 doses [MEDICATION NAME] for moderate pain. On 10/20/12, the physician ordered a narcotic [MEDICATION NAME] ([MEDICATION NAME]) 5/325 one tablet by mouth as needed for severe pain. Between 12/01/12 and 12/20/12, Resident #109 received 36 doses of the [MEDICATION NAME] for severe pain to her abdomen. On 11/21/12, the physician ordered an anti-anxiety medication (Lorazepan) 0.5 mg by mouth twice a day. Between 12/01/12 and 12/20/12, Resident #109 received 12 doses of the Lorazapan for anxiety. On 12/20/12, the physician ordered a scheduled narcotic ([MEDICATION NAME]) extended release 15 milligrams by mouth every 12 hours. Between 12/01/12 and 12/20/12, Resident #109 received her scheduled [MEDICATION NAME] medications. Review of Resident #109's care plan on pain, related to chronic pain and her surgical wound, revealed Resident #109 was to be medicated per the physician's order for pain. Staff were to monitor for increased levels of pain and notify the physician. Review of the risk of impaired skin integrity care plan revealed Resident #109 was to be medicated per the physician's order. Observation made on 12/19/12 at 11:33 A.M., revealed registered nurse (RN) #1 prepared Resident #109 for her dressing change. Resident #109 was lying in her bed awake. Registered nurse #1 lifted Resident #109's shirt and removed a large dressing from her abdomen. Observation revealed a moderate amount of bloody drainage on the dressing. Interview with Resident #109 at this time revealed her abdominal wound hurts "a lot," all of the time. The area to her lower abdomen had a large, bloody, red and raw wound. RN #1 cleaned the area with normal saline and wiped the area with gauze. Resident #109 held her shirt tight, she was observed breathing through her pursed lips and she began to cry. Registered nurse #1 questioned Resident #109 about her pain and asked if she wanted to be medicated for pain. Resident #109 said "yes" and continued to cry and breath through pursed lips. Registered nurse #1 did not leave the room to locate another nurse, nor did she use the call bell for assistance to provided Resident #109's pain medication. Registered nurse #1 continued with the dressing change and again washed the wound with normal saline and dried the wound with a gauze. Resident #109 revealed she would be glad when the wound is better. Registered nurse #1 opened other supplies and applied a Vaseline gauze dressing to the area. RN #1 was unable to open the second dressing, she had to stop, wash her hands and she applied new gloves. The second dressing was applied. At the time of the dressing change, an interview with Resident #109 revealed she did not know the name of her pain medication. Resident #1 continued to lay very still, cry and breath through pursed lips. Registered nurse #1 applied the final gauze dressing and one piece of tape. Registered nurse #1 asked if Resident #109 wanted her to stop the dressing change and provide her with pain medication. Resident #109 revealed that she wanted RN #1 to stop the treatment and wanted her pain medication. Registered nurse #1 re-questioned Resident #109 and then RN #1 informed the resident that she only had to apply a few pieces of tape to the dressing. The nurse asked Resident #1 if she wanted her to stop now or did she want her pain medication. Again, Resident #109 revealed she wanted the pain medication and wanted RN #1 to stop the dressing change. Registered nurse #1 told Resident #109 she would get her pain medication and stated to the resident "I will let it kick in for a half hour" and return and finish the dressing change. RN #1 washed her hands, cleaned up the area and left the room. Resident #109 was still crying and wiping her eyes when RN #1 left the room. Review of the Medication Administration Record [REDACTED]. On 12/19/12 at 11:50 A.M., Resident #109 was medicated for pain. Interview with RN #1 revealed she informed the nursing staff of the dressing change and the nurses should have medicated Resident #109. Review of the medication treatment record revealed Resident #109 had not been medicated for the dressing change until 11:50 A.M. Review of the pain intervention log for the as needed pain medication revealed on 12/19/12 at 11:50 A.M., the resident had pain eight out of ten on a pain scale of one to ten with ten being the highest severity and one being the lowest severity, when the as needed pain medication [MEDICATION NAME] was given. Review of Resident #109's pain assessment dated [DATE] at 2:30 P.M. revealed the resident verbalized the frequency of the pain to her abdomen as frequent. The duration of the pain was intermittent. She rated the pain as moderate. Interview with LPN #3 on 12/19/12 at 11:50 A.M. revealed LPN #3 had not been informed of Resident #109's dressing change by the wound nurse. LPN #3 revealed the residents have medications for pain and should be medicated for treatments. Interview with RN#1 on 12/21/12 at 2:02 P.M., revealed she could not remember who she told about Resident #109's dressing change. Registered nurse #1 revealed she should have covered Resident #109's wound with a wet dressing and provided pain medication; not continued with the dressing. RN #1 revealed that Resident #109 had been under a great deal of stress due to her upcoming surgery, she has been very anxious. Interview with the director of nursing on 12/21/12 at 2:14 P.M., revealed the resident should receive pain medications prior to treatments and there needs to be good communication between the nursing staff and the auxiliary staff. Review of the facility policy and procedure on Management of the Resident in Pain dated 10/18/01 and revised in March 2011 revealed the following: Nursing Expectations: a. Implement interventions for all residents in pain. Implement protocol appropriate treatment. b. Evaluate response to interventions, recognize side effects and adjust according to resident condition, physician order, nursing judgment. Side effects include but are not limited to: respiratory depression, changes in mental status, [MEDICAL CONDITION], nausea and vomiting, [MEDICAL CONDITION], puritis. c. Document assessments, interventions, evaluations and resident care provided accordingly. Expected Outcome: The patient will experience maximal pain relief with minimal side effects. Pain Management Policy: Assessment of pain will be completed with admission process to facility. Assessment of verbal complaints and non-verbal signs or symptoms of pain will be completed. Non-verbal indicators of pain include but are not limited to moaning, crying, irritability, and anxiety. Assessment of pain for residents who are unable to report pain will be monitored through activities of daily living and during care be delivered by nursing staff. Assess level of pain including intensity of pain if reportable by resident on numeric pain scale; 0=no pain, 10=the worst pain imaginable. Identify pharmacological and non-pharmacological methods to reduce pain in a resident. Document assessments, interventions, evaluations and resident care accordingly. Provide medication in accordance with physician order. Evaluate the resident ' s response to interventions. Notify the physician if interventions are ineffective. This citation is a re-cite from the annual survey completed on 10/16/12.