Every finding on record at Clayton Nursing and Rehab Center

Based on observation, and interviews, the facility failed to properly store medications located in the facility medication storage room when the staff failed to ensure medication fridge temperature log is being monitored routinely. This deficient practice is likely to result in medications being used in resident care at risk of not receiving the full benefits of medication. The findings are: A. On 02/10/26 at 12:55 pm, during an observation of the locked medication storage room, the vaccine fridge temperature log form for the months of January 2025 through February 2026 was not complete, the following dates on vaccine fridge temperature log were left blank: 1. Day Shift: 01/01/25 through 01/18/25, 01/20/25 through 06/01/25, 06/03/25 through 07/23/25, 07/25/25 through 09/12/25, 09/15/25 through 09/31/25, 10/04/25, 10/19/25, 10/21/25, 10/26/25, 10/27/25, 11/01/25 through 11/12/25, 11/15/25, 11/18/25, 11/20/25, 11/21/25, 11/23/25 through 11/30/25, 12/04/25 through 12/12/25, 12/15/25 through 01/02/26, 01/06/26 through 01/08/26, 01/12/26 through 01/16/26, 01/19/26 through 01/25/26, 01/30/26 through 02/01/26, and 02/06/26 through 02/08/26. 2. Night Shift: 01/11/25, 01/18/25, 02/01/25, 02/24/25, 03/01/25, 03/18/25, 03/19/25, 04/04/25, 04/08/25, 05/10/25, 05/19/25, 07/27/25, 08/01/25, 08/15/25, 08/16/25, 09/12/25, 09/26/25, 10/05/25, 10/17/25, 11/13/25, 11/22/25, 12/17/25, 12/19/25, and 12/27/25.B. On 02/10/26 at 12:56 pm, during an interview with Licensed Practical Nurse (LPN) #2, she confirmed the vaccine medication fridge temperature log is not getting done routinely. LPN #2 stated that nurses are responsible for completing all temperature log. C. On 02/11/26 at 1:38 pm, during an interview with Director of Nursing (DON), she confirmed that there has been inconsistency with the vaccine fridge temperature log not being checked routinely. DON stated that fridge temperature should be checked once per shift and should be documented on the appropriate log and it did not occur.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly store dishes in sanitary conditions.2. Keep the stove and oven clean.These deficient practices are likely to affect all 36 residents listed on the resident census list provided by the Administrator on 02/09/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and food stored properly. The findings are:A. On 02/09/26 at 1:10 pm, a random observation of the kitchen revealed the following:1. Dried food particles, dried liquid splashes and trash in the plate warmer (a device designed to keep clean plates warm and ready to be used for serving meals).2. The stove had what appeared to be dirty, dried food particles and dried liquid splash marks covering the front side. The back of the stove had dirt and grease covering it.3. The oven had baked on food stains throughout the inside. B. On 02/09/26 at 1:43 pm, during an interview with the Dietary Manager (DM), he confirmed the plate warmer, stove, and oven were dirty and did not meet his expectations.

Based on observation and interviews, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by1. Not ensuring Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) was used for residents with required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities).2. Not ensuring that shared resident-care equipment, specifically a mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another), was cleaned and disinfected between use. These failed practices have the potential to affect all 36 residents living in the facility as identified by the census provided by the Administrator 02/09/26. These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are: PPE A. On 02/09/26 at 11:25 am a random observation of the 200 hall revealed the following: 1. R #1 had an EPB sign posted on her door. 2. Certified Nurse Aide (CNA) #1 was in the room with R #1 and was not wearing any PPE. 3. R #1 was sitting on the bed when CNA #2 walked into R #1's room without putting on PPE and closed the door behind her. 4. Approximately five minutes after closing the door, CNA #1 and CNA #2 opened the door to R #1's room and assisted R #1 out of her room in her wheelchair. B. On 02/09/26 at 11:39 am during an interview with CNA #2, she confirmed that CNA #1 and herself were providing direct care to R #1. She confirmed neither wore PPE and stated they should have been. Disinfecting equipment C. On 02/12/26 at 1:03 pm, during an observation, R #4 was transferred from wheelchair to bed using a mechanical lift. CNA #2, and #3 provided a brief change immediately after the transfer. R #4 is on Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities), all staff providing direct resident care donned with mask, gown and gloves as ordered. CNA #2 & #3 donned off their Personal Protective Equipment (PPE), performed hand-hygiene and immediately took the mechanical lift to another room without cleaning or sanitizing the medical equipment. D. On 02/12/26 at 1:18 pm, during an interview with CNA #2 and CNA #3, they both confirmed that they did not follow protocol by not cleaning the medical equipment after using it for direct resident care. CNA #2 and #3 stated they are to clean and wipe down all medical equipment after use with bleach after each use and it did not happen. E. On 02/12/26 at 1:29 pm, during an interview with Director of Nursing (DON), she confirmed she is the Infection Preventionist of the facility. DON stated that all nursing staff after to perform hand hygiene before and after patient care including medication administration. DON stated that nursing staff are to follow all infection control precautions to prevent the spread of infection. DON also stated all medical equipment is cleaned and disinfected after each use.

Based on observations and interviews, the facility failed to ensure a safe, clean, and homelike environment for 3 (R #9, R #13, and R #15) of 9 (R #3, R #4, R #5, R #9, R #13, R #15, R #16, R #33, and R #39) residents reviewed for dining when staff: -Administered medications in the dining area during mealtimes.-Used an overhead paging system to call facility staff.-Maintain the vents in the kitchen to ensure they are free from dirt and dust build up.These deficient practices could likely affect all 30 residents that eat their meals in the dining area, as identified by the list identified by the Dietary Manager on 02/09/26 by creating an uncomfortable and sanitary living environment. The findings are: Administering medications in the dining area during mealtimes:A. On 02/10/26 at 11:45 am, an observation of the lunch meal revealed the following:1. R #13 was seated at a table in the dining area eating lunch when Licensed Practical Nurse (LPN) #2 walked up to him and handed R #13 a medicine cup (a small plastic cup used in the administration of medications). After R #13 took the medicine that was in the cup, LPN #2 told him to put his head back and administered eye drops (liquid medication applied in the eyes). Once LPN #2 was done administering medications, R #13 finished his meal.2. R #9 was seated at a table with R #4 and R #39 in the dining area eating lunch when LPN #2 walked up and handed R #9 a medication cup. R #9 stopped eating his meal to take his medication.3. R #15 was seated at a table with R #5, R #16, and R #33 eating lunch when LPN #2 walked up and handed R #15 a medication cup. R #15 stopped eating his meal to take his medication.B. On 02/10/26 at 12:33 pm, during an interview with LPN #2, she stated that she usually administers medications in common areas and mealtimes because that is where all the residents are. Use of an overhead paging system to call facility staff:C. On 02/12/26 at 8:37 am, a random observation of the dining area revealed an announcement using the overhead paging system asking LPN #1 to contact another staff member. D. On 02/13/26 at 8:14 am, a random observation of the dining area revealed an announcement using the overhead paging system asking LPN #1 to contact another staff member. Maintain the vents in the kitchen to ensure they are free from dirt and dust build up:E. On 02/29/26 at 1:13 pm, a random observation of the kitchen serving area revealed the ceiling vents to be covered with dust and dirt making a portion of the vents and surrounding ceiling appear to be brownish black in color instead of the white they were supposed to be.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 2 (R #8 and R #9) of 4 (R #4, R #8, R #9, and R #28) residents reviewed for care plans. This deficient practice could likely result in residents not getting the needed care and services. The findings are:R #8A. Record review of R #8's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; lung disease),2. Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills),3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation,4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Essential (primary) hypertension (HTN; high blood pressure). B. Record review of R #8's physician orders revealed an order dated 08/05/25 for R #8 to utilize oxygen at two liters per minute via nasal cannula as needed for respiratory distress. C. Record review of R #8's care plan dated 08/04/25 revealed no indication that R #8 utilizes oxygen as needed. D. On 02/13/26 at 9:20 am, during an interview with the Director of Nursing (DON), she confirmed that R #8 does utilize oxygen as needed. The DON confirmed that R #8's care plan does not indicate that she utilizes oxygen, and it should. R #9 E. Record review of R #9's Face Sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Parkinsonism (a syndrome characterized by uncontrolled movements),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe,3. Obstructive and reflux uropathy (a blockage in the urinary track that stops urine from flowing),4. Wasting disease (severe, involuntary weight loss, loss of muscle, and fatigue),5. Sarcopenia (age-related progressive loss of muscle mass, strength, and function). F. On 02/10/26 at 10:30 am, during an observation of R #9 in the dining area revealed R #9 asleep in his wheelchair. R #9's legs and ankles appeared red and swollen. G. Record review of R #9's Physician Progress Note dated 08/21/24 revealed a diagnosis of ankle edema (swelling due to fluid backup). H. Record review of R #9's care plan revised on 07/31/25 revealed no indication of R #9 having ankle edema. I. On 02/13/26 at 9:30 am, during an interview with the DON, she confirmed that R #9 does have ankle edema. The DON confirmed R #9's care does not meet her expectation because it should include his ankle edema and it does not.

Based on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 3 (R #4, R #8, and R #9) of 5 (R #4, R #6, R #8, R #9, and R #11) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: R #4 A. Record review of R #4's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin) with other diabetic neurological complications, 2. Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), 3. Quadriplegia (paralysis of all four limbs) C1 to C4, C5 to C7 (spinal cord levels), 4. Encounter for fitting and adjustment of urinary device, 5. Other obstructive (blockage in the urinary tract that impedes urine flow) and reflux uropathy (involves the backward flow of urine from the bladder into the kidneys), 6. Need for assistance with personal care. B. Record review of R #4's physicians order revealed an antibiotic order dated 08/07/23 Nitrofurantoin Macrocrystal oral (antibiotic) capsule 100 milligrams (mg) for urinary tract infection prophylaxis (to prevent disease). C. Record review of R #4's MDS assessment dated [DATE] revealed antibiotic use was not checked. D. On 11/25/25 at 12:08 pm, during an interview with MDS Coordinator (MDSC), she confirmed R #4 is currently taking an antibiotic. MDS coordinator confirmed that she failed to capture this antibiotic in this assessment. R #8 E. Record review of R #8's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), 3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation, 4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 5. Essential (primary) hypertension (HTN; high blood pressure). F. On 02/10/26 at 9:05 am, an observation of R #8 in her room revealed an oxygen concentrator plugged in next to R #8's bed. G. Record review of R #8's physician orders revealed an order dated 08/05/25 for R #8 to utilize oxygen at two liters per minute via nasal cannula as needed for respiratory distress. H. Record review of R #8's MDS assessment dated [DATE] revealed no indication that R #8 utilizes oxygen. I. On 02/13/26 at 9:20 am, during an interview with the Director of Nursing (DON), she confirmed that R #8 does utilize oxygen as needed. The DON stated that R #8's MDS assessment does not meet her expectations because it is not accurate. R #9 J. Record review of R #9's Face Sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Parkinsonism (a syndrome characterized by uncontrolled movements), 2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), severe, 3. Obstructive and reflux uropathy (a blockage in the urinary track that stops urine from flowing), 4. Wasting disease (severe, involuntary weight loss, loss of muscle, and fatigue), 5. Sarcopenia (age-related progressive loss of muscle mass, strength, and function). K. On 02/10/26 at 10:30 am, during an observation of R #9 in the dining area revealed R #9 asleep in his wheelchair. R #9's legs and ankles appeared red and swollen. L. Record review of R #9's Physician Progress Note dated 08/21/24 revealed a diagnosis of ankle edema (swelling due to fluid backup). M. Record review of R #9's MDS assessment dated [DATE] revealed no indication of R #9 having ankle edema. N. On 02/13/26 at 9:30 am, during an interview with the DON, she confirmed that R #9 does have ankle edema. The DON confirmed R #9's MDS assessment does not meet her expectation because it is not accurate.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #8) of 1 (R #4, R #8, and R #28) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:A. Record review of R #8's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; lung disease),2. Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills),3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation,4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Essential (primary) hypertension (HTN; high blood pressure). B. Record review of R #8's physician orders revealed an order dated 08/05/25 for R #8 to utilize oxygen at two liters per minute via nasal cannula as needed for respiratory distress. C. Record review of R #8's baseline care plan dated 08/04/25 revealed no indication that R #8 utilizes oxygen as needed. D. On 02/13/26 at 9:20 am, during an interview with the Director of Nursing (DON), she confirmed that R #8 does utilize oxygen as needed. The DON confirmed that R #8's baseline care plan does not indicate that she utilizes oxygen, and it should.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #1) of 3 (R #1, R #3, and R #8) residents reviewed for respiratory care when the facility failed to ensure medical orders indicated the frequency of when to administer R #1 oxygen. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are:A. Record review of R #1's admission record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Chronic respiratory failure (a life-term condition where the lungs cannot maintain adequate oxygen levels) with hypoxia (a condition characterized by insufficient oxygen reaching the tissues of the body),2. Chronic obstructive pulmonary disease (COPD; lung disease),3. Obstructive sleep apnea (OSA; a common sleep disorder),4. Emphysema (a respiratory disorder that results in the reduction of air intake),5. Carrier or suspected carrier of Methicillin Resistant Staphylococcus Aurea's (MRSA; bacteria that are resistant to treatment with semi-synthetic penicillin).B. Record review of R #1's physician orders revealed an order dated 09/14/25 for R #1 to use supplemental oxygen at two liters per minute (L/min). C. On 02/10/26 at 10:05 am, during an observation of R #1's room, she was observed lying in her bed wearing a nasal cannula (a medical device used to deliver supplemental oxygen through their nostrils) that was connected to an oxygen concentrator (a medical device that concentrates oxygen and delivers it to someone that needs supplemental oxygen) that was located next to her bed.D. On 02/13/26 at 9:47 am, during an interview with the Director of Nursing (DON), she confirmed the order for R #1's oxygen should specify the frequency of when it should be administered, and it does not.

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 30 residents listed on the facility census provided by the Administrator on 10/28/24 when staff failed to: 1. Serve the food items listed on the menu. 2. Provide residents with an alternate meal menu. If the facility is not providing meal as listed on the menu, an alternative meal or offering an alternate meal menu to residents, then residents are likely to experience weight loss, frustration, and depression. The findings are: Meal Service: A. On 10/28/24 at 4:52 pm, a dinner observation revealed the following: 1. Dinner Menu: Glazed meatloaf, French green beans, garlic seasoned potatoes, herbed dinner roll with margarine, and French orange cheesecake. 2. Staff did not serve the residents cheesecake. Staff served the residents Jell-O with whipped topping. 3. Residents meatloaf did not have a glaze as indicated on the menu. B. On 10/28/24 at 5:06 pm and 5:17 pm, during an interview with Licensed Practical Nurse (LPN) #1, she stated the kitchen informed her they did not have all the ingredients for the cheesecake so they served Jell-O instead. She stated there was not a glaze on the meat loaf, but there should have been according to the menu. C. On 10/28/24 at 5:08 pm during an interview with R #6, he stated he would prefer to be served the cheesecake instead of the Jell-O and was not okay with the substitution nor was R #6 informed of the menu change. D. On 10/28/24 at 5:10 pm during an interview with R #12, she stated she would have loved to have the cheesecake and would have also enjoyed a glaze on the meatloaf. R #12 confirmed that she was was not aware of the change. E. On 10/28/24 at 5:14 pm during an interview with R #30, he stated he would have preferred to eat the cheesecake instead of Jell-O. F. On 10/28/24 at 5:18 pm during an interview with the Dietary Manager (DM), he stated the facility did not have supplies for cheesecake. He stated the meatloaf did not have a glaze on it, because they did not have ketchup or a glaze available. DM stated the food order had not come in therefore items were not available. G. On 10/31/24 at 1:42 pm during an interview with the Registered Dietitian (RD), he stated the residents should be served what was posted on the menu. The RD stated the kitchen did not have supplies for several meals during the week, but they should have. RD further stated that residents should have meals available as posted or she should be informed so that all meals have the same nutritional value as what is posted. Alternate Menu Posting: H. On 10/31/24 at 12:25 pm during an interview with Dietary Manager, he stated they did not make an alternate meal or offer an alternate meal. DM further stated I talked to my Manager (Regional) and I was told that because the census is low here and we only get one, two, maybe three alternate requests, alternates are not made. I. On 10/31/24 at 1:45 pm during an interview with the RD, he stated the posted menu should include the alternate menu choices, and the posted menus should match the meals that are being served. 47031

Based on observation and interview the facility failed to store food in a manner that prevented cross contamination when staff failed to label and date open food items. These failures have the potential to result in cross contamination, the growth of food borne pathogens, and food borne illness (foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi). This failure had the potential to affect all 30 residents who ate food from the kitchen. The findings are: A. On 10/28/2024 at 1:38 PM, observation of the Dietary Department refrigerators and freezers revealed the following: - One, four-quart plastic container with an unidentified substance not labeled or dated. - Two, five-pound bags of slightly black colored stalks open to air, not labeled or dated. - One, two-inch pan of a red liquid uncovered and not labeled or dated. - One, six-quart plastic container of unidentified food not labeled or dated. - One tray of 6 oz. glasses of yellow liquid not labeled or dated. - One, ten-pound bag of frozen diced chicken open to air and not dated. -Two, one-pound bags of beef patties open to air and not dated. -Two, one-pound bags of boiled eggs not dated with opened date and were open to air. -Two, ten-pound rolls of Provolone cheese not dated. - One, fifty-pound bag of bread crumbs bag open to air, not labeled or open date. - One, four-inch soiled steel pan with a two-ounce scoop in refrigerator open to air containing crusted, crumbly food unidentified item not labeled or dated. B. On 10/28/24 at 1:41 PM during an interview with the Healthcare Group Services Operationalist (HCGS), he stated it was expected for staff to label and date all items ad should be covered not open to air.

Based on record review and interview, the facility failed to notify 4 (R #3, 21, 24 and 25) residents reviewed of the outcomes/resolutions of their grievances. This deficient practice could likely result in the facility not considering the needs of the residents or adequately resolving their grievances and lead to a decrease in resident quality of life. The findings are: A. Record review of the facility grievance log revealed the following: 1. Dated 08/12/24: R #34's son filed a grievance regarding the resident's clothes not changed and snacks thrown out. Staff marked the Resolution of Grievance section Yes The section did not contain the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. 2. Dated 08/19/24: R #35 filed a grievance regarding cold air from air conditioner blew on the residents at meal time. Staff marked the Resolution of Grievance section Yes The section did not contain the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. 3. Dated 09/04/24: R #3 filed a grievance regarding a missing candy dish. Staff marked the Resolution of Grievance section Yes The section did not contain the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. 4. Dated 09/30/24: R #21 filed a grievance regarding a Certified Nursing Assistant (CNA) talking on phone during shower. Resolution of Grievance section was answered and no resolution documented and without confirmation of R #21 knowing the outcome. B. On 10/29/24 at 12:57 pm during an interview with the Resident Council (RC), they stated they are not always told about the facility findings for their grievances. C. On 10/31/24 at 1:17 pm during an interview with the Administrator (ADM), she stated staff did not complete the grievance form. She stated staff should complete the entire grievance form so residents know the resolution of each grievance.

Based on record review and interview, the facility failed to ensure the care plan was revised for 1 (R #3) out of 1 (R #3) residents reviewed when staff failed to conduct a quarterly care plan meetings as required. These deficient practices are likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's nursing progress notes revealed R #3's last care plan meeting occurred on 04/30/24. C. On 10/28/24 at 3:26 pm during an interview with R #3, he stated he did not recall having a care plan meeting in awhile. D. On 10/30/24 at 5:00 pm during an interview with the Minimum Data Set Coordinator (MDSC), she stated she was responsible for to schedule and conduct resident care plan meetings. The MDSC stated R #3 did not have his last two quarterly care plan meetings, but he should have.

Based on record review and interview, the facility failed to ensure the resident's ability to perform activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) was maintained for 2 (R #6 and R #25) of 2 (R #6 and R #25) residents reviewed for restorative therapy (RT; therapy in which a resident trains on abilities they already have to perfect them and help maintain the physical abilities to perform ADLs.) If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer (move from one place to another), and do other activities of daily living. The findings are: R #6: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. Record review of R #6's physician orders, dated 02/16/23, revealed R #6 was to receive Restorative Nursing Program (RNP) services two to three times a week for passive range of motion (the movement of a joint when an out-side force moves the body part while the person receiving the exercise is relaxed) to both of his arms. C. Record review of R #6's Documentation Survey Report (ADL tracking document) revealed the following: - Dated 09/01/24 through 09/30/24, staff completed RNP services with R #6 one time during the month on 09/27/24. - Dated 10/01/24 through 10/30/24, staff did not complete any RNP services with R #6. D. On 10/29/24 at 9:18 am during an interview with R #6, he stated he use to receive RNP services for his arms, but he has not received the services for awhile. R #6 confirmed he would like to continue with RNP services. E. On 10/29/24 at 5:53 pm during an interview with the Restorative Certified Nursing Assistant (RCNA), he stated he provided RNP services to residents in the facility. The RCNA stated he worked on the floor often and transported residents to appointments. He stated this prevented him from providing RNP services to R #6. RCNA stated R #6 should receive RNP services two to three times a week, but he did not. F. On 10/30/24 at 5:47 pm during an interview with CNA #1, she stated R #6 used RNP services and liked them. G. On 10/31/24 at 10:08 am during an interview with Registered Nurse (RN) #1, she stated RNP services gave R #6 a sense of purpose. RN #1 stated R #6 should receive RNP services, and he enjoyed the services. H. On 10/31/24 at 1:11 pm during an interview with the Director of Nursing (DON), she stated the RCNA was the only Restorative Aide in the facility. The DON stated R #6 should receive RNP services two to three times a week, but he did not. 47031 R#25: I. Record review of R # 25's face sheet revealed R #25 was admitted into the facility on [DATE]. J. Record review of R #25's physician orders, dated 10/16/24, revealed R #25 was to receive RNP services for passive range of motion to upper and lower extremities (arms and legs), three times a week. K. On 10/29/24 at 5:53 pm during an interview with the Restorative Certified Nursing Assistant (RCNA), he stated he provided RNP services to residents in the facility. The RCNA stated he worked on the floor often and transported residents to appointments. He stated this prevented him from providing RNP services to R #25. RCNA stated R #25 should have received RNP services three times a week, but she did not. L. On 10/31/24 at 1:25 pm during an interview with the Director of Nursing (DON), she stated the RCNA was the only Restorative Aide in the facility. The DON stated R #25 should receive RNP services two to three times a week, but she did not.

Based on observation, record review, and interview, the facility failed to ensure enhanced barrier precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were put into place for 6 (R #3, #15, #28, #29, #8 and #7) of 6 (R #3, #15, #28, #29, #8 and #7) residents who had an open wound or a urinary catheter (a thin, flexible tube that is inserted into the bladder through the urethra which is used to drain urine from the bladder when a person is unable to urinate on their own). If EBP are not put in place for residents with sources of multi-drug resistant organisms (MDRO; germs that are resistant to many antibiotics and can cause serious infections.) then the chance of spreading those organisms to all residents in the facility increases. MDROs can have a negative effect on the health of residents and lead to adverse outcomes. The findings are: A. Record review of the facility's Procedure for EBP, revised 05/01/24, revealed staff to use EBP during high contact patient care activities, such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs. assisting with toileting, and device care, to include urinary catheters. Further review of record revealed PPE should be accessible and located outside of the patients room. B. On 10/29/24 at 4:25 pm during random observation of the 200 hallway, R #3, R #6, and R #28 did not have personal protective equipment (PPE-specialized clothing or equipment that protects the wearer from injury or the spread of infection or illness) outside of their rooms or any posted signs to indicate to staff that they should wear PPE when providing direct care to the residents. The residents had PPE stations inside their rooms. Findings for residents identified to have urinary catheters: Findings for R #3 C. Record review of R #3's physicians orders, dated 10/28/24, revealed R #3 had an order for an indwelling catheter. D. Record review of R #3's physicians orders, dated 08/06/24, revealed the following orders for catheter care: - Empty catheter drainage bag at least once every eight hours when it becomes 1/2 to 2/3 full. - Replace drainage system if disconnections or leakage occur, as needed. - Perform indwelling catheter care (includes cleaning tubing and inspecting the catheter for any problems) every day and night shift. Findings for R #6 E. Record review of R #6's physicians orders, dated 10/14/24, revealed the following: - An order for an suprapubic catheter (a device that drains urine from your bladder through your belly button). - Change when occluded(blocked and not draining) as needed. - Catheter care every morning and at bedtime. Findings for R #28 F. Record review of R 28's physicians orders, dated 10/01/24, revealed R #28 had an order for an indwelling catheter. G. Record review of R #28's physicians orders, dated 08/14/24, revealed the following orders for catheter care: - Change indwelling catheter when occluded (blocked) or leaking, as needed. - Empty catheter drainage bag at least once every eight hours when it becomes 1/2 to 2/3 full, every 8 hours and as needed. - Replace drainage system if disconnections or leakage occur, as needed. - Perform indwelling catheter care every day and night shift. Findings for residents identified to have wounds: H. On 10/30/24 at 1:00 pm during random observation of the 100 hallway, R#29, R #8, and R #7 did not have any PPE in their rooms or any signage to signify to staff that they should wear PPE when providing direct care to the residents. The residents had PPE stations inside their rooms. The residents had wounds. Staff were observed providing care to the residents and were not observed using PPE. Findings for R #29 I. Record review of R #29's skin and wound evaluation, dated 10/30/24, revealed R #29 had a [NAME] terminal pressure ulcer (a skin wound that appears in some people during their final weeks of life and can an appear and develop over a few hours) to her right heel. Findings for R # 8 J. Record review of R #8's wound evaluation, dated 10/28/24, revealed R #8 had an open hematoma (a localized area of swelling resulting from broken blood vessels under the skin) on the front of her left, lower leg. Findings for R # 7 K. Record review of R #7's wound evaluation, dated 10/28/24, revealed R #7 is being treated for a Stage 2 pressure injury (a partial-thickness skin loss that appears as a shallow open wound with a red or pind wound bed) to the left gluteus (buttock ). L. On 10/30/24 at 1:17 pm during interview with Skin Care team lead (SHTL) nurse, when asked why R #'s 29. 8 & 7 did not have EBP in place she stated it was just recently brought to her attention that the guidelines for EBP have been updated. M. On 10/30/24 at 1:19 pm during interview with the Director of Nursing/ Infection Preventionist (DON/IP), she stated there was available PPE in the closet in her office, and the nurses could access it at any point if there was an outbreak. She stated We are in-servicing our staff on the use of EBP.

Based on observation, record reviewtyg, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 1 (R #6) of 1 (R #6) residents reviewed when staff did not ensure R #6 had access to his call light. These deficient practice is likely to result in residents being unable to request assistance in times such as needing help with transferring, after falling, or other acute distress. The findings are: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE]. B. Record review of R #6's care plan, dated 06/12/24, revealed R #6 had decreased mobility due to a history of a stroke, left and right sided weakness, and impaired balance which required R #6's call light to be placed within his reach at all times. C. On 10/29/24 at 9:26 am during an observation and interview, R #6's call light pad was on a chair behind R #6's bed and out of the resident's reach. R #6 appeared anxious as evidence by moving back and forth and he stated that he could not reach the call light to ask staff for more water and to take him to a shower. D. On 10/29/24 at 9:34 am during an interview with Nurse Aide (NA) #1, she stated R #6's call light should be placed next to him on the bed. NA #1 confirmed R #6's call light was out of reach for R #6. E. On 10/31/24 at 1:14 pm during an interview with the Director of Nursing (DON), she stated R #6's call light should be near him and within his reach at all times when he was in his room.

Based on interview, the facility failed to ensure foods were palatable (pleasant to taste) and to the resident's satisfaction for 1 (R #21) of 1 (R #21) residents. This deficient practice is likely to affect residents' ability to eat and enjoy meals, and is likely to cause unplanned weight loss. A. On 10/28/24 at 2:47 PM, during an interview with R #21, R #21 stated that on 10/27/24 during dinner the previous night the macaroni salad was extreme. The resident stated the macaroni salad smelled burnt. R #21 stated the peach cobbler had salt instead of sugar. B. On 10/30/24 at 9:05 am during interview, [NAME] #1 stated they came to work on 10/29/24, and there was burnt pasta in the refrigerator from the dinner the night before (10/28/24). C. On 10/30/24 at 9:16 am during an interview with Food Service Director, he stated the facility hired some new dietary staff, and he was currently training them. He stated the new staff needed a lot of supervision. The Food Services Director stated the nighttime dietary staff were all new, and he was aware of the burnt pasta and the mistake with the peach cobbler. D. Record review of Grievance/concern form dated 10/28/24 revealed. Resident compaint regarding dinner the previous day (Sunday 10/27/24) the cook scorched the pasta for the minestrone soup and it tasted burnt; served the coleslaw without dressing just raw cabbage and added salt instead of sugar to the peach cobbler, totally ruinng the dessert.

Based on observation and interview, the facility failed to ensure that medications were stored safely and securely. This deficient practice is likely to affect all 31 residents identified on the alphabetical census list provided by the Director of Nursing on 10/2/23. This deficient practice is likely to put residents at risk of overdosing/taking medication that is not prescribed to them if residents have access to unsecured medications. The findings are: A. On 10/02/23 at 5:13 pm, during random observation, the medication cart for the East Side unit was by the dining area, where multiple residents were dining. The medication cart was unlocked and unattended. B. On 10/02/23 at 5:25 pm, during an interview, Licensed Practical Nurse(LPN) #1 confirmed the medication cart was left unlocked and unattended, and it should have been locked. C. On 10/04/23 at 2:00 pm during an interview, Director of Nursing (DON) stated it was her expectation that when the nurse stepped away from the medication cart that they should lock the cart.

Based on observation, record review, and interview, the facility failed to ensure the nutritional needs and preferences were met for all 31 residents listed on the facility census provided by the Director of Nursing (DON) on 10/02/23 by not following Dietitian approved menu's, and not communicating with Dietitian when there is a meal substitution. These deficient practices are likely to result in resident weight loss, frustration, and not meeting their nutritional needs. The findings are: A. Record review of the facility dining menu revealed the following: 1. 10/02/23 dinner- Butter Crumb Topped Fish Fillet, Tartar Sauce, Dinner Roll, Frosted Brownie, Assorted Beverage, Au Gratin Potatoes, and Seasoned Peas. B. On 10/02/23 at 5:19 pm, during an dinner observation, staff served all residents cauliflower instead of peas. C. On 10/02/23 at 5:35 pm, during an interview with R #22, he confirmed he did not know about any meal substitutions for dinner. D. Record review of the facility menu substitution log revealed that the Registered Dietitian (RD) was not notified of the following substitutions: 1. 09/13/23: oatmeal-substitution grits, no oatmeal. Not initialed by RD. 2. 09/15/23: glazed cinnamon rolls- substitution cinnamon toast, no cinnamon rolls. Not initialed by RD. 3. 09/19/23: potato wedge- substitution pasta salad, no potatoes. Not initialed by RD. 4. 09/21/23: ham- substitution sausage, no ham. Not initialed by RD. 5. 09/21/23: pot beef on roll- substitution chicken pot pie, no beef thawed. Not initialed by RD. 6. 09/21/23: blueberries- substitution vanilla pudding, no blueberries. Not initialed by RD. 7. 10/02/23: peas- substitution cauliflower, no peas. Not initialed by RD. 8. 10/03/23: oats- substitution grits, no oats. Not initialed by RD. 9. 10/04/23: zucchini- substitution broccoli, no zucchini. Not initialed by RD. 10. 10/04/23: pork chops- substitution pork loin, no pork chops. Not initialed by RD. E. On 10/05/23 at 10:50 am, during an interview, the Dietary District Manager (DDM) stated, We filled out the substitution log, called the Dietitian [of all menu substitutions], and we let the residents know [of the meal changes]. F. On 10/05/23 at 12:31 pm, during an interview, the RD stated, He [Dietary Manager] has called me on a couple of those [meal substitutions, but not all of them]. The menu was created by the corporation, but I approve it. We have had difficulties with supplies. They [dietary staff] write it [foods being substituted] down and I will look over the substitutions and if they are not appropriate, I will do training and teaching [with dietary staff]. RD confirmed she was not aware of all meal substitutions and should have been made aware.

Based on interview and record review, the facility failed to treat and communicate resident's pain levels with their physician for 1 (R #22) of 1 (R #22) resident reviewed for pain management. If facility fails to communicate pain levels to physicians, then residents are likely to experience exacerbated (make worse) pain. The findings are: A. Record review of R #22's face sheet revealed resident was admitted to facility on 01/14/21 with following diagnosis. 1. Low back pain. (Pain between lower edge of ribs and the buttock) 2. Spondylolysis. (Stress fracture in part of the spinal bone) 3. Major Depressive Disorder. (Persistent feelings of sadness and loss of interest) B. On 10/03/23 at 2:21 PM, during an interview, R #22 stated, My back has been broken twice. I only get Tylenol [pain medication], but I wish I had something stronger. It hurts all the time. C. Record review of R #22's physician orders, dated 01/19/21, revealed an order for Tylenol Extra Strength tablet, 500 Milligrams (mg). 2 tablets by mouth twice a day as needed (PRN). D. Record review of R #22's care plan dated 03/12/23 revealed, Focus: [Name of R #22] exhibits or is at risk for alterations in comfort related to chronic pain, new DX [diagnosis] CPPD - Calcium pyrophosphate deposition disease [a form of arthritis characterized by sudden, painful swelling in one or more of the joints]. C/o [complains of] pain to knees, shoulders, hands, wrist. Interventions: Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors, Utilize pain scale, Advise [Name of R #22] to request pain medication before pain becomes severe, and Medicate [Name of R #22] as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. E. Record review of R #22's pain level summary page, documenting pain scale of resident (0 = no pain at all, 10 = worst pain imaginable) dated 08/01/23 through 10/04/23, revealed the following: 1. R #22 rated his pain a 9/10 on pain scale for the dates 08/10, 08/11, 08/12, 08/13, 08/17, 08/18, 08/21, 08/22, 08/23, 08/27, 08/28, and 08/31. 2. R #22 rated his pain a 10/10 on pain scale for the dates 08/02, 08/09, and 08/13. 3. R #22 rated his pain a 9/10 on pain scale for the dates 09/05, 09/09, 09/10, 09/11, 09/13, 09/14, 09/15, 09/18, 09/20, 09/23, 09/24, 09/25, 08/28, and 09/29. 4. R #22 rated his pain a 10/10 on pain scale for the dates 09/05, 09/19, and 09/28. 5. R #22 rated his pain a 9/10 on pain scale for the date 10/03. 6. R #22 rated his pain a 10/10 on pain scale for the date 10/04. F. Record review of R #22's August 2023, Medication Administration Record (MAR) revealed R #22 was given 2 tablets of PRN Tylenol Extra strength tablet 500 mg a total of 55 times between 08/01/23 and 08/31/23 G. Record review of R #22's September 2023, MAR revealed R #22 was given 2 tablets of PRN Tylenol Extra strength tablet 500 mg a total of 50 times between 09/01/23 and 09/30/23. H. Record review of R #22's October 2023, MAR revealed R #22 was given 2 tablets of PRN Tylenol Extra strength tablet 500 mg a total of 5 times between 10/01/23 and 10/04/23. I. On 10/04/23 at 12:10 pm during an interview, Director of Nursing (DON) stated if a resident is having breakthrough pain [pain that is being experienced between doses of administered medication], her expectation would be for nursing staff to provide the resident with breakthrough pain medication (Medication intended to treat pain which has reoccurred) and notify the provider that the resident was still experiencing pain. She confirmed that R #22 did not have an order for breakthrough pain medication. J. On 10/05/23 at 12:50 pm during an interview, the Facility Medical Director (FMD) he stated, Maybe [nursing staff should alert the FMD of R #22's increase in pain medication use and elevated pain scale numbers], but I know this guy [R #22] very well. I do not know if the pain scale applies to him [R #22]. I'm not going to start him [R #22] on narcotics [pain medication].

Based on record review, interviews, and observations the facility failed to honor resident meal preferences for 2 (R #'s 1 and 22) of 2 (R #'s 1 and 22) residents by not providing the meal selected by the residents on their meal tickets. This deficient practice is likely to result in weight loss due to the resident not eating and/or an allergic reaction to the food being served to the resident. The findings are: Findings for R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's dinner meal ticket, dated 10/02/23, revealed, Lasagna roll up-1, Dinner roll-1, and Seasonal Fresh Fruit- 1. C. On 10/02/23 at 5:39 pm, during an observation and interview, staff served R #1 butter crumb topped fish fillet, tartar sauce, dinner roll, and cauliflower. R #1 stated, I didn't know they [facility] didn't have lasagna, but I would have liked that. R #1 confirmed she would have preferred the lasagna roll-up that was on her meal ticket. D. On 10/05/23 at 10:51 am during an interview, the Dietary Manager (DM) stated R #1 was served the fish, and she should have been served according to her preference. 48690 Findings for R #22: F. Record review of R #22's face sheet revealed R #22 was admitted into the facility on [DATE]. G. Record review of R# 22's meal ticket, dated 10/02/23, revealed seasoned peas was the vegetable on the meal ticket for that day. H. On 10/02/23 at 5:43 pm, during a dinner observation, staff served R #22 cauliflower instead of peas which was on his meal ticket. I. On 10/02/23 at 5:44 pm, during an interview with the Restorative Aide (RA), RA confirmed staff served R #22 cauliflower instead of peas. J. On 10/05/23 at 12:31 pm during an interview with the Registered Dietitian (RD), she stated, This [not serving resident's according to their meal tickets] appears as an error. I need to figure out why they[dietary staff] didn't make it [food on R #1's and #22's meal tickets]. I need to analyze and work though. It sounds like she [R #1] was disappointed and we need to address that.

Based on observation and interview, the facility failed to ensure that 1 (R # 24) of 1 (R # 24) resident reviewed during random observation was provided the necessary care and services to maintain the highest practicable physical well being by not assessing and treating R #24's pain. The facility did not evaluate R #24's pain level after she was administered pain medication, therefore the nurse was unaware that the pain medication was ineffective. After being informed by the CNA (Certified Nurse Aide) that the resident was still in pain, the nurse failed to provide any additional pain medication for 1 hour and 45 minutes. This resulted in R #24 experiencing intense pain with no relief. The findings are: A. Record Review of R # 24's care plan dated 03/21/16 revealed, (R #24) Experiences alteration in level of comfort AEB (as evidenced by) pain reported by resident during interview. Res (resident) did state her pain is always a 5-7 on scale of 1-10, res states this is her normal, and the most comfortable she gets. Res does c/o (complain of) RT (right) hip pain due to recent surgery for [REDACTED]. Approaches instructs staff to Identify the location and rate of pain prior to and after any interventions. B. Record Review of the Controlled Drug Administration Record for R # 24 revealed that she was administered [MEDICATION NAME] (Narco/[MEDICATION NAME]: pain reliever) 7.5/325 milligram (mg) tablet by Registered Nurse (RN) # 1 on 09/27/16 at 7:00 pm. C. On 09/27/16 at 8:16 pm, during interview with R # 24, she stated that she told Certified Nursing Assistant (CNA) # 1 that she was in pain 30 minutes ago (approximately 7:45 pm) and CNA # 1 told her that she would tell the nurse. D. On 09/27/16 at 8:44 pm, during an interview with R # 24, when asked what her pain level was on a scale of 0 (no pain) to 10 (extreme pain) she stated she was about a 7-8. E. On 09/27/16 at 8:49 pm, during observation, CNA #1, CNA #2, and CNA #3 entered R # 24's room to reposition her. F. On 09/27/16 at 8:52 pm, during observation, CNA #1 went to RN #1 to tell her that R # 24 was requesting pain medication and RN # 1 stated, It is too early, I will go tell her. RN # 1 entered R # 24's room. G. On 09/27/16 at 8:57 pm, during an interview with RN # 1, when asked how often R # 24 receives pain mediation, she stated Every 4 hours and I medicated her at 7:00 pm with a Narco ([MEDICATION NAME]) 7.5 mg, she (R # 24) doesn't need them very often, they are given as needed. I just reminded her that she had a pain medication less than 4 hours ago, the CNA's just turned her so hopefully that will help her pain. H. On 09/27/16 at 9:13 during an interview with RN # 1, when asked, when do you check the effectiveness post PRN (as needed) medication, RN # 1 stated, Whenever I get a chance to ask. When asked if she assessed R # 24's level of pain, RN # 1 stated, I just popped my head in and see if she was ok, I did not specifically ask her what her pain level was. RN # 1 confirmed that she did not know what R # 24's pain level was when she checked on her. When asked if there was anything else to give her if she is still in pain, RN # 1 stated I will give her a tylenol to cover the pain. I. Record review of the Medication Administration Record [REDACTED]. J. On 09/28/16 at 10:36 am, during interview with R # 24, she stated that she just couldn't remember last night (09/27/16) when she received her last pain pill (when asked by the surveyors on 09/27/16) and that her mind kept telling her that she hadn't had any medicine because she was still in so much pain. K. Record review of the Pain Management Process dated 09/2013 revealed Post intensity evaluation will be assessed and documented in a timely manner. Upon follow-up, if the intervention is ineffective, process should be repeated until resident indicates adequate relieve and/or functional goals are met.

Based on record review, observation and interview, the facility failed to ensure that 1 (R # 24) of 1 (R # 24) resident reviewed during random observation was assessed pre (before) and post (after) administration of the prn pain medication. The facility did not evaluate R #24's pain level after she was administered pain medication, therefore the nurse was unaware that the pain medication was ineffective likely resulted in R #24 experiencing intense pain with no relief. The findings are: A. Record Review of R # 24's care plan dated 03/21/16 revealed (R #24) Experiences alteration in level of comfort AEB (as evidenced by) pain reported by resident during interview. Res (resident) did state her pain is always a 5-7 on scale of 1-10, res states this is her normal, and the most comfortable she gets. Res does c/o (complain of) RT (right) hip pain due to recent surgery for [REDACTED]. Approaches instructs staff to Identify the location and rate of pain prior to and after any interventions. B. Record Review of the Controlled Drug Administration Record for R # 24 revealed that she was administered [MEDICATION NAME] (Narco/[MEDICATION NAME]: pain releiver) 7.5/325 milligram (mg) tablet by Registered Nurse (RN) # 1 on 09/27/16 at 7:00 pm. C. On 09/27/16 at 8:16 pm during interview with R # 24, she stated that she told Certified Nursing Assistant (CNA) # 1 that she was in pain 30 minutes ago (approximately 7:45 pm) and CNA # 1 told her that she would tell the nurse. D. On 09/27/16 at 8:44 pm during an interview with R # 24, when asked what her pain level was on a scale of 0 (no pain) to 10 (extreme pain) she stated she was about a 7-8. E. On 09/27/16 at 8:49 pm during observation, CNA #1, CNA #2, and CNA #3 entered R # 24's room to reposition her. F. On 09/27/16 at 8:52 pm during observation, CNA #1 went to RN #1 to tell her that R # 24 was requesting pain medication and RN # 1 stated, It is too early, I will go tell her. RN # 1 entered R # 24's room. G. On 09/27/16 at 8:57 pm during an interview with RN # 1, when asked how often R # 24 receives pain mediation, she stated Every 4 hours and I medicated her at 7:00 pm with a Narco ([MEDICATION NAME]) 7.5 mg, she (R # 24) doesn't need them very often, they are given as needed. I just reminded her that she had a pain medication less than 4 hours ago, the CNA's just turned her so hopefully that will help her pain. H. On 09/27/16 at 9:13 during an interview with RN # 1, when asked, when do you check the effectiveness post PRN (as needed) medication, RN # 1 stated, Whenever I get a chance to ask. When asked if she assessed R # 24's level of pain, RN # 1 stated, I just popped my head in and see if she was ok, I did not specifically ask her what her pain level was. RN # 1 confirmed that she did not know what R # 24's pain level was when she checked on her. When asked if there was anything else to give her if she is still in pain, RN # 1 stated I will give her a tylenol to cover the pain. I. Record review of the Medication Administration Record [REDACTED]. J. Record review of the PRN Flowsheet for [MEDICATION NAME] (pain releiver) for R # 24 dated 09/26/16 to 09/28/16 did not document the problem, pre-treatment intesity scale, non-medication interventions, medication given, post treatment (tx) time results of tx and post tx pain intesity scale for [MEDICATION NAME] 200 mg tablet that was administered on 09/27/16 at 9:30 pm. K. On 09/28/16 at 10:36 am during interview with R # 24, she stated that she just couldn't remember last night (09/27/16) when she received her last pain pill (when asked by the surveyors on 09/27/16) and that her mind kept telling her that she hadn't had any medicine because she was still in so much pain. L. Record review of the Pain Management Process dated 09/2013 revealed Post intensity evaluation will be assessed and documented in a timely manner. Upon follow-up, if the intervention is ineffective, process should be repeated until resident indicates adequate relieve and/or functional goals are met.

Based on observation, record review and interview, the facility failed to provide care needed to maintain dignity for 1 resident (R #44) when a call light triggered to request assistance to the restroom was ignored. This deficient practice likely resulted in embarrassment and shame for R #44, after she urinated on herself. The findings are: A. On 08/12/15 from 8:05 to 8:15 pm during an observation, the call light in R #44's room was visually and audibly going off and could be heard throughout the facility. At 8:10 pm, Certified Nursing Assistant (CNA) #1 was in the common hallway. At 8:14 pm CNA #1 walked by resident R #44's room, looked into the room and continued to walk away while the call light was still going off. At 8:15 pm CNA #1 turned around in the hallway and came back to R #44's room to answer the call light. From 8:05 to 8:15 pm, Housekeeping/Laundry Supervisor (HLS) passed by the resident's room [ROOM NUMBER] times while the call light was going off and did not notify nursing staff. B. On 08/12/15 at 8:39 pm during and interview with R #44, when asked if she had called for help a little while ago, she confirmed that she had. When asked if she waited a long for help, she stated, Yes, I am not sure how long, but long enough for me to leave them a layer of shame all over the bed. I have a very weak bladder and I can't wait that long. When asked if she waits a long time after hitting her call light often she stated, I just got here on Monday, but this time of night I do. They are busy getting everybody in the shower. I understand why, but I just can't hold it and I can't get up without help, so they will have something to clean up when they do get here. During the interview, R #44 was visibly upset, not making eye contact and looking away when talking about what happened. C. On 08/13/15 at 2:34 pm during and interview with LPN #1, when asked how quickly call lights should be answered, she confirmed 3 minutes or sooner. When asked if it would be ok for someone to not address a call light when they knew it was going off, she confirmed that it would not be ok. D. On 08/14/15 at 1:32 pm during an interview with the Administrator (ADM), when asked how quickly call lights should be answered when they are going off, she confirmed that they try to answer call lights in under 3 minutes. When asked if someone is doing something not patient related, should they answer the call light immediately, she confirmed that they should. E. Record review of Policy and Procedure on Call Lights with no date given by ADM in the morning of 08/14/15 revealed, It is the policy of (name of facility) to respond to resident's request and needs in a prompt and courteous manner .5. Answer call promptly . 9. Respond to request. If the person who responded to the light is unable to fulfill the request, because it is out of the scope of his/her job, then he/she should notify the charge nurse. Return to resident with prompt reply . F. Record review of Policy and Procedure on Quality of Life-Dignity dated 08/2009 revealed, 10.Staff shall promote dignity and assist residents as needed by: .b. Promptly responding to the resident's request for toileting assistance .

Based on record review and interview, the facility failed to follow the plan of care by not providing one-to-one toilet assistance for 1 (R #8) of 1 (R #8) residents. This deficient practice caused the resident to fall, which resulted in a [MEDICAL CONDITION]. The findings are: A. Record review of R #8's care plan dated 07/19/11 revealed the following: 1. Problem: Resident has history of falling and at risk for falls due to resident has impaired cognitive status, poor safety awareness, doesn't like to wait for assist from staff, tries to transfer self. Resident has impaired balance moving from surface to surface, turning around, moving on an (and) off toilet, ambulating not stable without human assistance. W/c (wheelchair) and bed alarm in place, Velcro release seat belt on while in wheelchair only, released 2-3 hours. Resident has had multiple falls in the 3 months. DX (Diagnosis): Dementia. 2. Approach: Provide toileting assistance 1-2 for all toileting needs. Resident not to be left alone on toilet on her own, 1 staff member with resident. B. Record review of Nursing Note dated 08/30/11 at 12:30 am for R #8 revealed "Resident ambulated to BR (bathroom) with one assist and used walker. Certified Nursing Assistant (CNA) #1 was removing wet linen from bed when CNA heard thump.. Resident was on the floor. CNA #1 called for LN (Licensed Nurse). During assessment noted severe pain on the R (right) leg/hip/pelvis area. Transferred onto chair-bed. Holding (R) (right) leg, and crying out." C. Record review of emergency room Consultation dated 08/30/11 for R #8 revealed the following, "HPI: This [AGE] year-old female is a resident of the nursing home and sustained a fall with right hip trauma. X-ray shows [MEDICAL CONDITION]." D. On 08/31/11 at 10:49 am, during interview, the Director of Nursing (DON) stated "That CNA #1 took R #8 to the restroom and got her ready to use the restroom. R #8 had her shoes on for ambulation that were brought by the family for better ambulation. CNA #1 left R #8 using the restroom to change her linen, but had the door to the restroom open. That is when she heard her crying and was laying on the floor. She immediately called for the charge nurse (name of LPN #1). (Name of LPN #1) did her assessment and did her incident report and documentation is done in the nurses notes. After a fall, we talk about the incident in the morning stand up meeting. We also have weekly meeting on falls, weights, meds. etc. " E. On 08/30/11 at 6:37 pm, CNA #1 was interviewed. When asked what happened on the day of the incident, CNA #1 stated "during our rounds I went to her (R#8) room, placed (name of R #8) on the toilet then continued to take off the linen from her bed, then walked out to get clean linen from the cart that was placed outside the door. I walked back into her room and had started to replace her linen at which time she fell . I had my back toward the bathroom door where she was located at the time. The door was slightly opened, I could see her. I then ran for the charge nurse to get her to check her vitals. We then got her up on the wheelchair. The charge nurse called the family and stuff, we waited for them to come and stuff." CNA #1 confirmed leaving the resident unsupervised while she (R #8) was on the toilet.

The facility failed to ensure that Resident #8 was not left unsupervised when toileting and the resident fell and broke her hip. This resulted in an Immediate Jeopardy (IJ) with actual harm being identified on 09/01/11 at 2:30 pm. The Administrator was notified of the findings for the IJ on 09/01/11 at 3:07 pm. The facility took corrective action by providing an acceptable Plan of Removal on 09/01/11 at 5:20 pm. This resulted in the scope and severity of the deficiency being lowered to a Level 3, Scope G. The Plan of Removal indicated that the facility action plan was to: 1. Upon return to the facility affected resident will be reassessed and resident's care plan will be updated. Staff will be in-serviced and re-educated to resident's new plan of care. The affected Certified Nursing Assistant (CNA) will be re-educated and in-serviced on affected resident's care plan, the falling leaf program and all identified resident that can- not be left alone on the toilet. CNA will be suspended and receive counseling and training before returning to work schedule. 2. All residents identified as being unsafe to leave alone on the toilet have the potential to be affected. Director of Nursing (DON) will audit the review all care plans and identify all residents whose care plan indicates that they are not to be left alone on the toilet. All staff will be in-service and re-educated on those identified residents that are not to be left alone on the toilet. Will also review the falling leaf program and read the care plan for each resident is, and shift to shift report for reporting any new care plan interventions. 3. The CNA Orientation checklist will be updated to include the falling leaf program, identified high risk residents for falls, care plans and location of care plans and location of care plans and CNA review of care plans and will be completed on all new hires and/or rehires. Any new care plan interventions or changes to resident care plans will be communicated to all staff during the shift to shift report. 4. Care plans will be reviewed and updated as needed based on resident changes. Information will be communicated to staff during shift to shift report. Staff development and/or charge nurses will ensure that CNA's are compliant with following resident's plan of care. If non-compliance is found, CNA will be reeducated and counseled at time of noncompliance by Charge Nurse and/or staff development and reported to Director of Nursing. Monitoring results will be reviewed and discussed at daily stand up meeting. 5. Completion date is 09/01/11. Based on record review and interview the facility failed to ensure that one (R #8) of one (R #8) resident's was adequately supervised while toileting. This deficient practice resulted in the resident falling and fracturing her hip. The findings are: A. Record review of R #8's medical record revealed the following: 1. Minimum Data Set Assessment Section G Functional Status dated 07/11/11 showed that for toilet use, R #8 needs extensive assistance and one person physical assist. When moving on and off toilet, R #8 is not steady, only able to stabilize with human assistance. 2. Assessment of Fall Risk dated 07/05/11 showed that R #8 is a high risk for falls. 3. Care plan dated 07/11/11 showed: a. Problem: Resident has history of falling and at risk for falls due to resident has impaired cognitive status, poor safety awareness, doesn't like to wait for assist from staff, tries to transfer self. Resident has impaired balance moving from surface to surface, turning around, moving on an (and) off toilet, ambulating not stable without human assistance. W/c (wheelchair) and bed alarm in place, Velcro release seat belt on while in wheelchair only, released 2-3 hours. Resident has had multiple falls in the 3 months. DX (Diagnosis): Dementia. b. Approach: Provide toileting assistance 1-2 for all toileting needs. Resident not to be left alone on toilet on her own, 1 staff member with resident. 4. Nursing Note dated 08/30/11 at 12:30 am for R #8 showed "Resident ambulated to BR (bathroom) with one assist and used walker. Certified Nursing Assistant (CNA) #1 was removing wet linen from bed when CNA heard thump.. Resident was on the floor. CNA #1 called for LN (Licensed Nurse). During assessment noted severe pain on the R (right) leg/hip/pelvis area. Transferred onto chair-bed. Holding (R) (right) leg, and crying out. B. Record review of emergency room Consultation dated 08/30/11 for R #8 revealed the following, "HPI: This [AGE] year-old female is a resident of the nursing home and sustained a fall with right hip trauma. X-ray shows fractured hip." C. On 08/31/11 at 10:49 am, during interview, the Director of Nursing (DON) stated "That CNA #1 took R #8 to the restroom and got her ready to use the restroom. R #8 had her shoes on for ambulation that were brought by the family for better ambulation. CNA #1 left R #8 using the restroom to change her linen, but had the door to the restroom open. That is when she heard her crying and was laying on the floor. She immediately called for the charge nurse (name of LPN #1). (Name of LPN #1) did her assessment and did her incident report and documentation is done in the nurses notes. After a fall, we talk about the incident in the morning stand up meeting. We also have weekly meeting on falls, weights, meds. etc. " D. On 08/30/11 at 6:37 pm, CNA #1 was interviewed. When asked what happened on the day of the incident, CNA #1 stated "during our rounds I went to her (R#8) room, placed (name of R #8) on the toilet then continued to take off the linen from her bed, then walked out to get clean linen from the cart that was placed outside the door. I walked back into her room and had started to replace her linen at which time she fell . I had my back toward the bathroom door where she was located at the time. The door was slightly opened, I could see her. I then ran for the charge nurse to get her to check her vitals. We then got her up on the wheelchair. The charge nurse called the family and stuff, we waited for them to come and stuff." CNA #1 confirmed leaving the resident unsupervised while she (R #8) was on the toilet.