Every finding on record at Crowne Healthcare of North Baldwin

Based on observations, interviews, a review of BinaxNOW COVID-19 Ag CARD, a review of facility policy titled Coronavirus Testing, and a review of facility's staff vaccination status, the facility failed to ensure a licensed staff member performed COVID-19 testing per manufacturer's guidelines for two of three staff who were unvaccinated for COVID-19 and observed being tested for COVID-19. This has the potential to affect all residents and staff. Findings Include: A review of BinaxNOW COVID-19 Ag CARD product insert with copyright date of 2020 revealed: .PRINCIPLES of the PROCEDURE .To perform the test, a nasal swab is collected from the patient, . The patient sample is inserted into the test card .The swab is rotated 3 (three) times clockwise and the card is closed, . PRECAUTIONS . 19. False Negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. A review of facility policy titled Coronavirus Testing with date implemented of 3/2019 and date reviewed 3/2020 and 9/2021 revealed: Policy: .Routine Testing of Staff 1. Routine testing of unvaccinated staff should be based on the extent of the virus in the community. 4. The facility will test unvaccinated staff per the routine testing intervals as follows: . Level of COVID-19 Community Transmission . High (red) . Minimum Testing Frequency of Unvaccinated Staff . Twice a week . Conducting Testing . 4. Specimens will be collected . in accordance with the manufacturer's instructions for use for the test and Centers for Disease Control (CDC) guidelines. A facility provided document of all staff with vaccination status revealed that Employee Identifier (EI) #7, Lead Housekeeper, EI #10, Licensed Practical Nurse (LPN), and EI #12, Dietary Aid were unvaccinated for COVID-19. On 11/18/2021 at 6:42 AM an observation was made of EI #8, LPN performing staff COVID testing. On 11/18/2021 6:54 AM EI #9, Activity Director was observed being tested . EI #8 added solution to the testing card and labeled the card, both nostrils of EI #9 were swabbed with correct technique, swab placed in Abbott Binax NOW COVID-19 Ag Card, not twirled or rotated clockwise after being added to the card, card labeled with time, timer started, and swab/card placed with timer. EI #8 changed gloves and cleaned area. On 11/18/2021 at 7:02 AM EI #10, LPN was observed being tested . EI #8 added solution to the testing card and labeled the card, both nostrils of EI #10 were swabbed with correct technique, swab placed in Abbott Binax NOW COVID-19 Ag Card, not twirled or rotated clockwise after being added to the card, card labeled with time, timer started, and swab/card placed with timer. EI #8 changed gloves and cleaned area. On 11/18/2021 at 7:07 AM EI #11, Certified Nursing Assistant (CNA) was observed being tested . EI #8 added solution to the testing card and card labeled, both nostrils of EI #11 were swabbed with correct technique, swab placed in Abbott Binax NOW COVID-19 Ag Card, not twirled or rotated clockwise after being added to the card, card labeled with time, timer started, and swab/card placed with timer. On 11/18/2021 at 7:09 AM EI #2, Registered Nurse (RN), Assistant Director of Nursing, Infection Preventionist was asked to observe testing and identify any incorrect technique in the procedure being performed by EI #8. On 11/18/2021 07:10 AM EI #12, Dietary Aid was observed being tested by EI #8 with EI #2 observing. EI #8 performed test and did not twirl or rotate the swab after inserting it into the testing card. On 11/18/2021 at 7:11 AM EI #2 was asked, if she recognized what EI #8 was doing incorrectly, and EI #2 said EI #8 was not turning or rotating the swab in the card. On 11/18/2021 at 7:13 AM EI #8 was asked, was she turning the swabs in the card and she stated yes that she thought she was. On 11/18/2021 at 7:14 AM EI #7, Lead Housekeeper was observed being tested by EI #8. EI #8 added solution to the testing card and card labeled, both nostrils of EI #7 were swabbed with correct technique, swab placed in Abbott Binax NOW COVID-19 Ag Card, swab was twirled or rotated clockwise in the card after being added to the card, card labeled with time, timer started, and swab/card placed with timer. On 11/18/2021 at 8:31 AM an interview was conducted with EI #2. EI #2 was asked, what staff members performed testing. EI #2 replied, EI #8, or an RN, occasionally an LPN, and herself. EI #2 was asked, what training had been provided to staff that performed testing. EI #2 replied, the facility trained on the manufacturer's guidance and demonstrated a test procedure. On 11/18/2021 at 8:44 AM an interview was conducted with EI #8. EI #8 reported she had training to perform COVID testing in the summer, she thought in June. EI #8 was asked, what were the steps to perform COVID testing. EI #8 replied, clean area and table with Purple top wipes, prepare supplies, sanitize hands, and put on Personal Protective Equipment (PPE) which was gown, gloves, shield, and mask, take the test out of the package and use package as barrier, label the card, drop six drops of solution into card, swab each nostril by turning the swab five times for 15 seconds in each nostril, put the swab in the card and rotate three swab times in the card, close and seal, and put on barrier with timer for 15 minutes. EI #8 added, after 15 minutes the test results.

Based on observations, interviews, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a housekeeping/laundry staff member, Employee Identifier (EI) #6 did not carry residents' clothing in a manner that caused the clothing to contact her personal clothing, 2) EI #6 sanitized her hands while delivering clean clothes to Room Locaters (RL) #1, RL #2, and RL #3; and 3) EI #6 sanitized her hands after touching a resident's recliner chair in RL #1. These deficient practices were observed in three of 43 rooms at the facility; and involved EI #6, one of one laundry staff member observed delivering residents' personal laundry. Review of a facility polity titled Hand Hygiene , with a revised date of 03/2021, revealed the following: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 3. Alcohol-based hand rub is the preferred method for cleaning hands in most clinical situations. On 11/17/2021 at 4:16 PM, the surveyor observed EI #6 deliver clean laundry to RL #1, RL #2 and RL #3. EI #6 entered RL #1 with hanging clothes in her hands, moved a wheeled reclining chair in the room, opened the closet cabinet door placing the laundry in the closet, then returned to the laundry cart without sanitizing her hands. EI #6 next entered RL #2 with hanging clothes, opened the closet cabinet door, placed the laundry in the closet, and returned to the laundry cart without sanitizing her hands. After returning to the laundry cart EI #6 removed a dress from the laundry cart and walked down hall 300 with the dress touching her clothes. EI #6 returned to the laundry cart, returned the dress to the cart, and pushed the laundry cart to the 100 hall. Once on the 100 hall, EI #6 removed a hanging coat from the laundry cart and walked to RL #3, again holding the hanging clothes where the clothing item was touching her clothes while walking down the hall. EI #6 entered RL #3 with the with the hanging cloths, opened the closet cabinet door, placed the laundry in the closet, then returned to the laundry cart and again failed to perform any type of hand hygiene. On 11/17/2021 at 4:23 PM, the surveyor conducted an interview with EI #6. The surveyor asked EI #6 did she perform hand hygiene after entering RL #1, and before entering RL #2 and RL #3. EI #6 said she did sometime while she passed the laundry. When asked when she should perform hand hygiene, EI #6 said she should change gloves after leaving a resident's room and sanitize hands her hands, but when not wearing gloves, she was not sure. The surveyor asked EI #6 when should she walk with clothes up against her. EI #6 said never. On 11/17/2021 at 4:34 PM, the surveyor conducted an interview with EI #7, the lead housekeeper. When asked how long EI #6 had been a housekeeper and laundry aid, EI #7 said EI #6 had been in housekeeping about a week and this was EI #6 's second day in laundry. The surveyor asked EI #7 how was EI #6 educated to handle and pass clean laundry to residents' rooms. EI #7 said EI #6 was taught to sanitize her hands and put on gloves before entering a resident's room, hang the clothes, remove her gloves, sanitize her hands, and then proceed to the next room. The surveyor asked EI #7 when should a staff member delivering clean clothes to residents enter the resident's room with hanging clothes, move a resident's chair, open the closet cabinet door, place the laundry in the closet, then return to the laundry cart without performing hand hygiene. EI #7 said never. When asked what the potential harm was when that was done, EI #7 said cross-contamination and passing germs. EI #7 said when handling a resident's clothes or laundry staff should sanitize their hands, put on gloves, retrieve the clothes, carry them without the clothes touching their personal clothing, enter the residents' room and hang the clothes, remove their gloves in the residents' room, then sanitize their hands. The surveyor asked EI #7 what was the potential harm when a staff member handled resident's clothes and the clothes touched their personal clothing. EI #7 said cross contamination. On 11/18/2021 at 3:07 PM, the surveyor conducted an interview with EI #2, the Infection Preventionist. When asked how the facility provided education to staff on hand hygiene, EI #2 said through check offs, reading, and signing education, and by staff surveillance. EI #2 said all staff should be educated on hand hygiene the first day of hire and then at least annually. The surveyor asked EI #2 when was EI #6 educated on hand hygiene. EI #2 said on 11/09/2021. A review of EI #6's PPE (Personal Protective Equipment) Training Competency Check-off, revealed EI #6 was checked off on hand hygiene on 11/09/2021. On 11/18/2021 at 5:22 PM, the surveyor conducted an interview with EI #1, the Director of Nursing. When asked by the surveyor what was the potential harm when a staff member entered a resident's room to deliver clean laundry, touched a resident's chair, delivered the laundry, returned to the laundry cart, then entered other residents' rooms without performing hand hygiene, EI #1 said there was a risk of spreading infection. The surveyor asked EI #1 what was the potential harm when staff handled clean resident clothing against their personal clothing. EI #1 said there was a risk of spreading infection.

Based on observation, interviews, record review, and review of a facility policy titled Dining Room Duties, the facility failed to ensure a Certified Nursing Assistant, Employee Identifier (EI) #5 did not stand while feeding Resident Identifier (RI) #51 his/her lunch meal in the dining room on 11/17/2021. This deficient practice affected RI #51; one of four sampled residents observed being fed their meals. Findings Include: A review of a facility policy titled Dining Room Duties, with an effective date of 01/2017, revealed: . PROCESS: . h) When feeding a resident, staff must sit beside or across from the resident. RI #51 was admitted to the facility on [DATE], with diagnoses to include [CONDITION(S)] and Abnormal Weight Loss. RI #51's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 10/08/2021, coded RI #51 as needing extensive assistance with eating. On 11/17/2021 at 11:51 AM, the surveyor observed EI #5 standing while feeding RI #51 his/her lunch meal. On 11/17/2021 at 12:10 PM, RI #5 was observed to have finished his/her lunch meal. EI #5 stood the entire time while feeding RI #51 the lunch meal. On 11/18/2021 at 2:37 PM, the surveyor conducted an interview with EI #5. When asked what position she was in when feeding RI #51 his/her lunch meal on 11/17/2021, EI #5 said she was standing. The surveyor asked EI #5 when she was hired, what position was she taught to be in when feeding a resident. EI #5 said she was taught to sit. When asked why she stood when feeding RI #51 on 11/17/2021, EI #5 said she was just nervous. The surveyor asked EI #5 what type issue it was considered when she stood while feeding a resident. EI #5 said it was a dignity issue. On 11/18/2021 at 5:45 PM, the surveyor conducted an interview with EI #2, the Assistant Director of Nursing/Staff Educator. The surveyor asked EI #2, what position were staff taught to position themselves in when feeding a resident. EI #2 said staff were to be at eye level and sitting down. When asked what type issue it was when staff stood while feeding the resident, EI #2 said dignity. EI #2 said staff were taught this in orientation and annually. A review of EI #5's Continuing Education report, with a completion date of 09/28/2021, revealed EI #5 had received education on the Dining Room Duties policy.

Based on observations, interview, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure the feeding tube containers of Resident Identifier (RI) #27 and RI #31 were labeled appropriately. This deficient practice affected RI #27 and 31, two of five residents receiving tube feeding at the facility. Findings include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, with a copyright date of 2017, page 1092, UNIT VII Physiological Basis for Nursing Practice, revealed the following: . STEP . (2) . Label bag with tube-feeding type, strength, and amount (include date, time, and initials). Change bag every 24 hours. RATIONALE . Helps decrease bacterial colonization. (1) RI #27 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #27's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], coded RI #27 as receiving tube feedings during this assessment period. RI #27's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:02 AM, RI #27's Glucerna 1.5 cal tube feeding was observed infusing by way of a feeding pump at 65 ml per hour. RI #27's tube feeding container was labeled with RI #27's name, dated [DATE], but there was no room number, start time or rate the tubing feeding was to infuse on the container. On [DATE] at 7:43 AM, RI #27's Glucerna 1.5 cal tube feeding was observed infusing at 65 ml per hour. This container was labeled with RI #27's name, dated [DATE], and once again there was no start time or rate the tubing feeding was to infuse on the container. On [DATE] at 5:24 PM, the surveyor conducted an interview with Employee Identifier (EI) #3, the LPN (Licensed Practical Nurse) assigned to care for RI #27 on the 7 AM to 7 PM shift. The surveyor asked EI #3 what information should be on the tube feeding container of a resident who was receiving a continuous tube feeding. EI #3 said the resident's name, the tube feeding name, the rate of the tube feeding, the date hung, and the time that hung or started. When asked what information was missing from RI #27's continuous tube feeding container, EI #3 replied, RI #27's room number, the time the tube feeding was started, and the rate the tube feeding should infuse. The surveyor asked who would be responsible for ensuring the tube feeding container was filled out appropriately. EI #3 said whoever hung the tube feeding, and identified EI #4, another LPN, as working the shift the tube feeding was hung on. When asked why it would be important to ensure the resident's tube feeding label was filled out appropriately. EI #3 said to show the resident was getting the right tube feeding, at the right rate, and to ensure the resident was not getting expired tube feeding over a 24-hour time period. (2) RI #31 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #31's Quarterly MDS assessment, with an ARD of [DATE], coded RI #31 as receiving tube feedings during this assessment period. RI #31's [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [DATE] at 9:41 AM, the surveyor observed RI #31's tube feeding of Glucerna infusing by way of a feeding pump at 45 ml per hour. RI #31's tube feeding container was not labeled with anything except the date of [DATE], and EI #4's initials at the bottom of the container. On [DATE] at 5:35 PM, in a continued interview with EI #3 the surveyor asked EI #3 what information was missing from RI #31's continuous tube feeding container. EI #3 said everything. On [DATE] at 6:00 PM, an unsuccessful attempt was made to contact EI #4.

Based on interviews, record review, and review of a pharmacy policy titled Ordering and Receiving Medications, the facility failed to ensure Resident Identifier (RI) #57's as needed Oxycodone-Acetaminophen 7.5-325 milligram ([MEDICATION(S)]) supply was not depleted from 11/11/2021 until 11/17/2021. This affected RI #57, one of two residents sampled for pain. Findings Include: A review of undated facility policy titled Ordering and Receiving Medications revealed: . Policy: . The facility will only be responsible for ordering new medications, PRN (as needed) medications, . Procedure: . C. Refills/Reorders Policy: The facility will reorder medications when there is a 5 (five) day supply remaining in order to keep continuity in the medication supply. Nurses should not allow any medication to be depleted before ordering from the pharmacy. D. Controlled Substances Policy: Medications classified as controlled substances are subject to special ordering, receipt, and record keeping in accordance with state/federal laws and regulations. Procedure: . The facility must provide reordering information timely to allow ample time to obtain a valid prescription. RI #57 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses that included Pain, Unspecified; Fibromyalgia; and [CONDITION(S)] of Vertebra, Lumbar Region. A review of RI #57's PHYSICIAN'S ORDERS revealed an order dated 10/15/2021 for OXYCODON(E)-ACETAMINOPHEN [MEDICATION(S)] 7.5-325 MG (milligram) TAKE ONE TABLET BY MOUTH EVERY 6 (six) HOURS AS NEEDED (PAIN). A review of RI #57's CONTROLLED SUBSTANCE RECORD for OXYCODON(E)-ACETEMINOPHEN . Sub for: [MEDICATION(S)] 7.5-325 . revealed RI #57 received at least two doses of the medication daily from 10/22/2021 until 11/10/2021. The final dose of RI #57's supply was administered on 11/10/2021. The seven days prior to the resident's supply of the medication being depleted, 11/4/2021 through 11/10/2021, RI # 57 received 21 doses of the medication. A review of the EMERGENCY DRUG KIT SLIPS revealed facility staff pulled a [MEDICATION(S)] tablet from the emergency supply for RI #57 as follows: on 11/12/2021 at 1315 (1:15 PM), 11/13/2021 at 11:23, 11/14/2021 (no time), 11/14/2021 (no time), 11/15/2021 at 11:30, 11/16/2021 at 12:10, and 11/17/2021 at 0930 (9:30 AM). A total of seven doses was administered over six days and no doses were administered on 11/11/2021. A review of RI #57's Refills Report revealed the OXYCODON(E)-ACETEMINOPHEN ([MEDICATION(S)]) 7.5-325 was electronically requested for refill on 11/12/2021 at 12:55 PM by Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN). A review of a pharmacy document dated November 12, 2021 revealed a prescription request for RI #57's [MEDICATION(S)] 7.5 mg was sent to RI # 57's physician, on 11/12/2021. Further review of the prescription request revealed the physician signed the request on 11/15/2021 (three days later). On 11/16/2021 at 10:52 AM, an interview was conducted with RI #57. RI #57 reported he/she had pain and normally got pain medicine, oxycodone, every six to eight hours. RI #57 reported in the last week or so he/she had an issue with the facility not having the prescription signed, and then a problem with the pharmacy. On 11/17/2021 at 9:57 AM, an interview was conducted with EI #13, an LPN. EI #13 was asked how many [MEDICATION(S)] did RI #57 have available in his/her personal supply at the time. EI #13 answered, none. EI #13 reported that she had to pull a [MEDICATION(S)] from the emergency kit earlier that morning for RI #57. EI #13 reported she did not know how long RI #57's [MEDICATION(S)] supply had been depleted. On 11/17/2021 at 10:07 AM, an interview was conducted with EI #14, the Registered Nurse (RN)/Unit Manager. EI #14 was asked, when was RI #57's last dose of [MEDICATION(S)] administered from his/her supply. EI #14 replied, on 11/10/2021. EI #14 was asked, what was facility's policy or process to re-order a supply of narcotic medications. EI #14 replied, the staff re-ordered from the computer's software Electronic Medication Administration Record (EMAR) and then called the pharmacy and asked if a refill prescription was needed. EI #14 replied RI #57 did need a refill prescription. EI #14 reported she spoke with RI #57's physician on 11/16/2021 around 2:00 PM, and he said he would send the prescription. EI #14 added, she followed up that morning and pharmacy did not have the prescription and the physician said he sent it. On 11/17/21 at 10:22 AM, a follow-up interview was conducted with RI #57. RI #57 reported he/she thought his/her supply of [MEDICATION(S)] was depleted about five to six days ago. RI #57 reported that he/she asked for pain medication and he/she was provided Tylenol that helped but did not alleviate his/her pain as well as the [MEDICATION(S)] that he/she was prescribed. RI #57 reported that a nurse did tell him/her that he/she was out of [MEDICATION(S)] and provided Tylenol due to the prescription not being re-ordered. RI #57 did not know when or who the nurse was. A review of RI #57's printed Medication Administration Record (MAR) revealed no [MEDICATION(S)] was administered to RI #57 on 11/11/2021. On 11/17/2021 at 3:32 PM the surveyor observed RI #57's supply of [MEDICATION(S)] delivered from back-up pharmacy. On 11/17/2021 at 5:36 PM EI #14 reported RI #57's [MEDICATION(S)] was initially requested on 11/12/2021 and should have been requested when the supply had no less than eight doses. When asked why she did not request RI #57's [MEDICATION(S)] to be sent when she administered one of the last doses, EI #14 said normally she did but just did not at that time. On 11/18/2021 at 7:34 AM, another resident's card of 60 [MEDICATION(S)] was observed with EI #10, an LPN and it was noted that the last 10 tablets on the card had a blue coloring around them. EI #10 was asked, what did the blue on the card indicated and she replied, that the supply was low, and it needed to be re-ordered. A printed MAR for RI #57 was reviewed with EI #10 and she was asked, was that her administration initials on 11/06/2021, 11/12/2021, 11/13/2021, and 11/14/2021. EI #10 replied, yes. EI #10 was asked, on 11/06/2021, did she select the refill option for [MEDICATION(S)] for RI #57. EI #10 answered she did not recall, but if it was low, she normally did. EI #10 was asked, when should RI #57's refill request have been submitted. EI #10 replied, it should have been submitted when RI #57 had about 10 doses remaining in the pack. EI #10 was asked, when she submitted to refill RI #57's [MEDICATION(S)] on 11/12/2021, how did she follow up. EI #10 replied, she thought that was the day that she called the pharmacy to be sure it was not discontinued. EI #10 said the pharmacy said it had not been discontinued and they were going to send another request for a refill to the physician. On 11/18/2021 at 9:28 AM, an interview was conducted with EI #15, an LPN. EI #15 was asked, on 11/7/2021 at 9:00 PM and 11/8/2021 at 3:30 AM, did she recall administering [MEDICATION(S)] to RI #57. EI #15 replied, RI #57 requested it every six hours so that sounded right, but she did not recall specifically. EI #15 was asked, when should as needed narcotic pain medication be re-ordered when the supply was low. EI #15 replied, it would depend on how frequently the resident took it. EI #15 said for RI #57, they normally re-ordered when he/she had 10 to 15 left. EI #15 was asked, on 11/07/2021 at 9:00 PM and 11/8/2021 at 3:30 AM, when she signed the narcotic book for RI #57's [MEDICATION(S)] with the amount remaining nine and eight, did she re-order the medication. EI #15 replied, she did not remember. EI #15 was asked, did she re-order the medication at all. EI #15 replied, sometime the first week of November, she tried to re-order and it had already been re-ordered. EI #15 said the computer would not let it be re-ordered within three days of someone re-ordering. EI #15 added, when the medication was re-ordered the refill sticker was removed from the blister pack. EI #15 said she did not remember the exact date, but she remembered the sticker not being on there. EI #15 continued to say she did select the re-order button one of the days and it was within three days of it being re-ordered. EI #15 said another medication, [MEDICATION(S)] had also been re-ordered and on the next shift the [MEDICATION(S)] was delivered, but not [MEDICATION(S)]. EI #15 was asked, on 11/16/2021 when the EMAR indicated she administered [MEDICATION(S)] to RI #57, where was it pulled and what steps were taken to re-order the medication. EI #15 reported that it was pulled from the Emergency Supply Kit (E-Kit) and she was told in report by EI #14 that someone picked up the prescription from the physician and had taken it to the pharmacy and to pull needed doses of the [MEDICATION(S)] from the E-Kit. On 11/18/2021 at 6:00 PM, a follow-up interview was conducted with EI #15. EI #15 was asked, when did she tell RI #57 that his/her [MEDICATION(S)] supply was out. EI #15 replied, EI #16, an LPN gave RI #57 one on day shift and reported to her that there was only one left in the E-Kit. EI #16 said, when RI #57 asked her for Tylenol that night and she told him/her that EI #16 told her that there was another [MEDICATION(S)] available, and RI #57 did not ask for the [MEDICATION(S)], just the Tylenol. EI #15 said she never told RI #57 that the [MEDICATION(S)] was unavailable. On 11/18/2021 at 10:14 AM, an interview was conducted with EI #16, an LPN. EI #16 was asked, on 11/11/2021 when the MAR indicated she administered two doses of Tylenol to RI #57, and no Tylenol had been administered in November to RI #57 before 11/11/2021, why did she administer Tylenol and not the [MEDICATION(S)] that RI #57 had been taking more regularly. EI #16 replied, RI #57 usually asked for Tylenol in between [MEDICATION(S)]. EI #16 said she had told RI #57 that his/her supply of [MEDICATION(S)] ran out. EI #16 said RI #57 might have asked for the Tylenol thinking that he/she did not have [MEDICATION(S)], but she had told RI #57 the staff could pull [MEDICATION(S)] from the E-Kit. EI #16 was asked, how often did RI #57 ask for the [MEDICATION(S)]. EI #16 replied, usually RI #57 asked before it had been six hours or at six hours unless he/she was sleeping. EI #16 was asked, what was the process for re-ordering as needed narcotic pain medication. EI #16 replied, usually, nurses selected refill in the computer software, and it indicated the last time the medication was re-ordered, and then a sticker was removed from the medication card to let other staff know that it has been re-ordered. EI #16 continued by saying, RI #57's [MEDICATION(S)] card indicated it did not have refills remaining, but staff had ordered the refills and it looked like it went through. EI #16 said she told EI #14 before the supply ran out that the card said RI #57 did not have refills left but did not recall what day. EI #16 was asked, on 11/07/2021 when RI #57's [MEDICATION(S)] count sheet indicated she administered a dose of [MEDICATION(S)] leaving ten tablets remaining, what steps were taken to re-order the medication. EI #16 replied, usually she would have re-ordered in the software unless someone had taken the sticker off of the card. EI #16 was asked, on 11/10/2021 RI #57's [MEDICATION(S)] count sheet indicated that she administered two doses of [MEDICATION(S)] leaving one and then zero tablets remaining, what steps were taken to re-order the medication. EI #16 replied, she would have selected refill, but it would have not gone through if someone had re-ordered within three days. On 11/18/2021 at 2:26 PM, an interview was conducted with EI #17, an LPN who reported she was an agency nurse and had been at this facility since mid-October and worked on night shift. EI #17 was asked, what could she report about RI #57's pain or the resident's [MEDICATION(S)]. EI #17 replied, RI #57 always said he/she hurt all over and always asked for a [MEDICATION(S)] around 8:00 PM and then usually slept the remainder of her shift, but occasionally would wake around 3:00 to 4:00 AM and ask for a pain pill. EI #17 was asked, what was the process to re-order as needed narcotic pain medication. EI #17 replied, she did not know, other staff usually did that in the morning. EI #17 said she was taught when a resident was down to seven tablets that the medication needed to be re-ordered because it did not need to run out if the resident was having constant pain. EI #17 was asked, on 11/9/2021, when RI #57's [MEDICATION(S)] count sheet indicated she administered a dose of [MEDICATION(S)] leaving two tablets remaining, what steps were taken to re-order the medication. EI #17 replied, it was already re-ordered, and they were waiting on the doctor. EI #17 said she did not remember who told her that it was re-ordered. EI #17 said when she left on 11/09/2021, RI #57 had two doses of his/her medication left. EI #17 said when she came back on 11/12/2021 RI #57 did not have any [MEDICATION(S)] and she was told if RI #57 needed that medication to pull it from the E-Kit. EI #17 said she did not pull any [MEDICATION(S)] from the E-Kit. EI #17 reported that she told RI #57 that his/her supply of [MEDICATION(S)] was depleted but she could pull the medication from the E-Kit and RI #57 asked for headache medication. EI #17 reported that when she returned to work on 11/13/2021 and 11/14/2021, she was told the medication had been approved by the doctor, but it was not delivered. On 11/18/2021 at 11:24 AM, a final interview was conducted with EI #14. EI #14 was asked, what could she report about RI #57's [MEDICATION(S)]. EI #14 replied, on 11/9/2021, she was working on the medication cart and called RI #57's physician to let him know RI #57 needed a prescription. The physician told her that he had sent it to the pharmacy and would send it again. EI #14 was asked, what was the process for re-ordering as needed narcotic pain medication. EI #14 replied, staff selected the refill button in the Computer Software but also called the physician. EI #14 replied when pharmacy needed a prescription, they sent it to the facility by fax, and the facility sent it by fax to the physician's office or walked it over to his office and had him fill it out and fax it from the facility. EI #14 said when she called pharmacy sometimes, they told her that the phones were down; and several months ago, they were having issues and she was having to walk prescriptions over to the physician's office nearly all the time. EI #14 said the problem was resolved until the past month and they began having to walk and get prescriptions and fax from the facility. EI #14 was asked, what was the problem. EI #14 replied, the problem was the physician's office sending faxes to pharmacy, but the facility could fax pharmacy. EI #14 was asked, what did she recall about EI #16 reporting concerns with RI #57's [MEDICATION(S)] being refilled. EI #14 replied, on 11/11/2021 EI #16 told her the supply was low and the refill was not delivered despite being ordered. EI #14 said she again told the physician in person about RI #57's [MEDICATION(S)]. EI #14 was asked, what could she report about RI #57's pain. EI #14 replied, sometimes RI #57 asked for pain medication and then when staff went to administer the medication, they found RI #57 asleep. EI #14 said RI #57 also had an alarm on the phone for every six hours to ask for pain medication. On 11/18/2021 at 12:03 PM, an interview was conducted with RI #57's physician. The physician reported that generally, when prescriptions needed to be refilled, pharmacy sent a request to his office and he completed the request within a couple of days at the most and faxed it back to pharmacy. The physician added, the office would get a report that the fax was successful, but there seemed to be an issue with pharmacy receiving. The physician reported that he thought last week his office sent the prescription to pharmacy and he knew earlier that week his office sent the prescription for [MEDICATION(S)] for RI #57's refill to pharmacy. The physician reported that on 11/09/2021, EI #14 called and told him RI #57 needed [MEDICATION(S)] refilled and generally, he waited until pharmacy sent the prescription form for the refill to address it. The physician was asked, what would potential harm be for RI #57 not getting [MEDICATION(S)] for a day or decreased frequency of dosage over several days. The physician replied, more pain. The physician said RI #57 would not have withdrawals at the dose he/she was taking. On 11/18/2021 at 5:08 PM, an interview was conducted with EI #1, the RN, Director of Nursing. EI #1 was asked, what could she report about RI #57's pain and pain medication. EI #1 replied, RI #57 had complaints of pain in his/her neck and back and received pain medications of [MEDICATION(S)] and Tylenol along with other medications. EI #1 was asked, what was the process for nursing staff to re-order as needed narcotic pain medication. EI #1 replied, nursing staff should have selected the refill option in the computer software for the medication within five days of being out of the medication. EI #1 was asked, when should a resident's supply of as needed pain medication be depleted for six days without re-supply. EI #1 replied, it should not happen. EI #1 said the facility did have an E-Kit and the [MEDICATION(S)] was available in the E-Kit. EI #1 was asked, what evidence did the facility have that RI #57's as needed [MEDICATION(S)] was re-ordered before 11/12/2021. EI #1 said EI #14 informed her that she asked EI #18 for a prescription around 11/9/2021, but it was not documented. EI #1 was asked, why was the [MEDICATION(S)] not requested from pharmacy before the supply was depleted. EI #1 replied, possibly a computer glitch but she thought it was an oversight. EI #1 was asked who was responsible to ensure resident's as needed pain medication supply was not depleted. EI #1 replied, the nurses' assigned to the resident's care. EI #1 was asked what responsibility did the pharmacy have. EI #1 replied, after nursing sent a refill request to pharmacy, their responsibility was to be sure the refill request was sent to the physician timely, and that they received a response from the physician. EI #1 was asked, what was the potential harm to a resident when their supply of as needed pain medication was depleted, and the resident did not receive that medication for a day when he/she usually took it every day. EI #1 replied, he/she could have had increased pain. On 11/18/2021 at 4:40 PM, an interview was conducted with EI #19, the Pharmacist. EI #19 was asked, when did the facility initially request RI #57's [MEDICATION(S)] be re-supplied. EI #19 replied, the pharmacy sent a request to EI #18 on 11/12/2021 after request was received from the facility. EI #19 was asked, how long did it generally take to re-supply a resident's [MEDICATION(S)] medication. EI #19 replied, pharmacy sends it the same day if the physician provided the prescription. EI #19 said when the physician had not provided the prescription, the pharmacy continued to fax three times and then fax the nursing home if they had not gotten a response. EI #19 reported the pharmacy faxed the physician, EI #18, on 11/12/2021, 11/15/2021, and 11/16/2021 and then also faxed the facility on 11/16/2021. EI #19 was asked, when should the facility re-order a supply for as needed narcotic pain medications like [MEDICATION(S)]. EI #19 replied the request should be submitted when there was at least five days left of the supply. EI #19 was asked, why was the [MEDICATION(S)] not in the resident's supply from 11/11/2021 until 11/17/2021. EI #19 replied, because EI #18 did not provide the prescription and she thought they pulled it from the narcotic box. EI #19 was asked, when did the physician provide the prescription. EI #19 replied, on 11/17/2021, and the pharmacy could have sent the medication that night, but the facility sent it to a backup pharmacy, and they delivered it on 11/17/2021.

Based on interviews, record review, and review of a facility policy titled Medication Administration the facility failed to ensure licensed staff documented pain medication on the Electronic Medication Administration Record as administered when administering pain medication to Resident Identifier (RI) #57. This affected one of two residents sampled for pain. Findings Include: A review of a facility policy titled Medication Administration with an implemented date of 3/2018 and revised date of 3/2021 revealed: Policy: Medications are administered by licensed nurses, . as ordered by the physician and in accordance with professional standards of practice, . Policy Explanation and Compliance Guidelines: . 17. Sign MAR after administered. 18. If medication is a controlled substance, sign narcotic book. A review of RI #57's CONTROLLED SUBSTANCE RECORD (narcotic log/book/record) and Medication Administration Record (MAR or eMAR) revealed on 11/1/2021 29 doses of [MEDICATION(S)] remained in RI #57's supply and were recorded as administered on the CONTROLLED SUBSTANCE RECORD between 11/1/2021 and 11/10/2021; and 18 doses were documented on the MAR from 11/01/2021 through 11/10/2021. The following doses were signed out of the CONTROLLED SUBSTANCE RECORD and not documented on the MAR: 11/1/2021 at 19:36 by Employee Identifier (EI) #15; 11/2/2021 at 01:30 by EI #15; 11/2/2021 at 14:35 by EI #16; 11/2/2021 at 21:00 by EI #15; 11/3/2021 at 19:34 by EI #17; 11/5/2021 at 00:00 by EI #20; 11/6/2021 at 00:00 by EI #20; 11/6/2021 at 22:30 by EI #15; 11/7/2021 at 21:00 by EI #15; 11/8/2021 at 03:30 by EI #15; and 11/9/2021 at 03:00 by EI #17. On 11/18/2021 at 9:28 AM an interview was conducted with EI #15, Licensed Practical Nurse (LPN). EI #15 was asked, on 11/7/2021 at 9:00 PM and 11/8/2021 at 3:30 AM did she recall administering [MEDICATION(S)] to RI #57. EI #15 replied, RI #57 requested it every six hours so that sounded right, but she did not recall specifically. EI #15 was asked, on 11/7/2021 at 9:00 PM and 11/8/2021 at 3:30 AM, she signed narcotic book for RI #57's [MEDICATION(S)] and there was not administration documented on the MAR, why. EI #15 replied, occasionally RI #57 would request pain medication and not take them or fall asleep, so she waited until the resident took the dose to document on Electronic Medication Administration Record (EMAR) and just forgot to document on the EMAR, but if she signed them out of the book, RI #57 took them. EI #15 was asked, what was potential harm to a resident when a narcotic pain medication was signed on narcotic sheet as administered and not signed on EMAR as administered. EI #15 replied, it could be given early if staff did not check the narcotic sheet and it was poor documentation. On 11/18/2021 at 2:26 PM an interview was conducted with EI #17, LPN who reported she was an agency nurse and had been at this facility since mid-October and worked on night shift. EI #17 was asked, on 11/3/2021 at about 7:30 PM and 11/9/2021 at 3:00 AM the [MEDICATION(S)]'s narcotic count sheet for RI #57 had a dose being removed from supply by her but no dose documented on the EMAR, why. EI #17 replied, on the EMAR software, sometimes it would give a message that previous results had not been documented and would not allow documentation, EI #17 added, after the second time it happened, she told one of the nurses and they showed her how to correct it. EI #17 was asked, was her documentation on the EMAR accurate. EI #17 replied yes, since she could not document it; it had been corrected now. EI #17 was asked, when administering medications, when should the EMAR reflect that medications administered were administered. EI #17 replied, it should reflect similar to the record in the narcotic book. On 11/18/2021 at 5:08 PM an interview was conducted with EI #1, Registered Nurse, Director of Nursing. EI #1 was asked, when should a nurse remove a narcotic and sign it out of the narcotic book and not document the medication as administered in the EMAR. EI #1 replied, the only time it should not be documented is if it was refused and wasted, if wasted it would be documented in the narcotic book as wasted. EI #1 was asked, what was potential harm when staff do not document a narcotic pain medication as administered. EI #1 replied, if staff did not document the medication as administered the next nurse could not know the resident had a dose and administer a dose too soon.

Based on observation, interview and review of a facility policy titled, Leftover Food Storage and Use the facility failed to ensure unlabeled, undated and expired food items were not found stored in a kitchen cooler used to serve residents. This had the potential to effect all 62 residents served meals from the kitchen. Findings Include: Review of a facility policy titled Leftover Food Storage and Use effective date [DATE], revealed: Process: b. Leftovers foods should be covered, labeled and dated . i. Labels should have the following information . Food Item, Open Date and Discard Date. On [DATE] at 7:49 AM a brief initial tour of the kitchen was conducted. During this observation a canister with a red lid holding sliced cheese was observed to have no open use by date or name of the food; ,[DATE] boneless ham in a storage bag, no open, use by date or name of the food item; shredded cheese label ITEM: cheese DATE [DATE] . USE BY: [DATE] . On [DATE] 02:00 PM, in an interview with Employee Identifier (EI) #5, Dietary Team Leader/Manager. She was asked what did she observe on [DATE] regarding the canister containing sliced cheese, EI #5 replied no label. EI #5 was asked what did she observe on the clear storage bag with a partially used boneless ham. EI #5 replied no label. EI #5 was asked how did staff know when food items were opened or when their use by date was if there was no label. EI #5 replied they do not know so it would have to be thrown away. EI #5 was asked what did she observe on the container of shredded cheese. EI #5 replied, an out-of-date label. EI #5 was asked how should opened multi-use food items be stored. EI #5 replied it needs to be in an approved sized storage container, sealed and labeled with an open by date and used within three days. EI #5 was asked why. EI #5 replied to prevent potential harm for their residents. EI #5 was asked how many residents were served meals from the kitchen, including recreational trays. EI #5 replied 62 residents.

Based on review of Pharmacist recommendations, interviews and review of the facility policy titled, Use of [MEDICAL CONDITION] Drugs, the facility failed to ensure Gradual Dose Reductions were attempted for Resident Identifier (RI) #14 for the continued use of a [MEDICAL CONDITION] medications. This affected RI #14, one of five residents who were sampled for unnecessary medications use. Findings Include: A review of the facility policy titled, Use of [MEDICAL CONDITION] Drugs with an implementation date of (MONTH) (YEAR) revealed, . Policy: Residents are not given [MEDICAL CONDITION] drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: . 6. Residents who use [MEDICAL CONDITION] drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. A review of the medical record revealed RI #14 was admitted to the facility on [DATE] with diagnoses to include [MEDICAL CONDITION] without Behavioral Disturbance, Depressive Episodes and Anxiety Disorder. A review of the Physician's orders dated 10/1/18 through 10/31/18, for RI #14 revealed, . [MEDICATION NAME] (Klonopin) 0.5 MG (MILLIGRAMS) TABLET . GIVE ONE TABLET BY MOUTH 3 TIMES A DAY DX (DIAGNOSIS): ANXIETY 9/23/2016 . DULOXETINE . Generic for: [MEDICATION NAME] 60 MG CAPSULE GIVE ONE CAPSULE BY MOUTH ONCE DAILY (no diagnosis) 5/1/2017 . TRAZADONE 50MG TABLET . GIVE ONE TABLET BY MOUTH ONCE DAILY AT BEDTIME FOR [MEDICAL CONDITION] 7/5/2016 . A review of a Pharmacist recommendations form for request of dose reductions for RI #14 revealed, . REVIEW DATE: 09/07/2018 Resident is receiving 3 [MEDICAL CONDITION] medications: [MEDICATION NAME] 60 mg (milligrams) daily since 6/2017 (or before) [MEDICATION NAME] 0.5 mg tid (three times a day) since 9/2016 Trazadone 50 mg qhs (every bedtime) for [MEDICAL CONDITION] No recent psych (psychiatric) eval (evaluation) in chart (last (YEAR)?) Please evaluate medication for continued need and effectiveness, ensuring that resident is on an optimal minimum effective dose. Consider gradual dose reduction on one or more of medications if appropriate. If continued at current doses, please document rationale below. Physician Response Section: Disagree (box for checked with an X) Please offer clinical rationale below . (He/She) is currently doing well on these medications. signed by Employee Identifier (EI) #4, Medical Doctor and dated 10/5/18. A review of a faxed request from EI #2, the Director of Nursing (DON), to EI #4 revealed, . DATE: 10-4-18 . REGARDING: ( residents name, RI #14) . Please discontinue or reduce listed meds to be in compliance with state regs (regulations). Please document on form clinical rationale for continued use. signed by EI #2. An interview was conducted on 04/04/19 at 10:30 AM, with EI (Employee Identifier) #1, (Registered Nurse) RN/Staff Development/QA (Quality Assurance) Nurse. EI #1 was asked what non-pharmacological approaches were used for RI #14. EI #1 replied RI #14 (Resident's Name) was highly involved in activities and socialization activities. EI #1 was asked what was the clinical indication for the medications in question for RI #14. EI #1 answered Klonopin was for anxiety, Trazadone was for [MEDICAL CONDITION] and [MEDICATION NAME] was for [MEDICAL CONDITION]. EI #1 was asked how the facility monitored the medication. EI #1 answered staff review MAR (Medication Administration Record), progress notes, and pharmacy reviews. EI #1 was asked for [MEDICAL CONDITION] medications, how they determined what behavior to monitor. EI #1 answered they chose what behavior was indicated at the time the medication was started or if new behaviors develop. EI #1 was asked how the facility ensured a review of medications for dose reductions. EI #1 answered the pharmacist reviewed the [MEDICAL CONDITION] medications and gave recommendations to EI #2, the DON. An interview was conducted on 4/04/19 at 10:55 AM, with EI #2. EI #2 was asked if the pharmacy recommendation on 9/7/18 for RI #14 was implemented. EI #2 answered no. EI #2 was asked why not. EI #2 answered he (physician) refused. EI #2 was asked what was his rationale. EI #2 answered the resident was currently doing well on those medications. EI #2 was asked when was RI #14's last dose reduction attempted. EI #2 answered one had not been attempted. EI #2 was asked when should a dose reduction have been attempted. EI #2 answered after six months (of initiation of the medication). EI #2 was asked how did she know a reduction would have a negative affect if a reduction is not attempted. EI #2 answered, you really do not know. EI #2 was asked what was the facility policy regarding attempting a GDR for [MEDICAL CONDITION] drugs. EI #2 answered they try to follow the Federal guidelines and ask the physician to attempt a reduction when they are indicated. EI #2 was asked was that policy followed for RI #14. EI #2 answered they tried and the physician refused. EI #2 was asked what was the concern of not attempting a dose reduction when it was indicated. EI #2 answered the resident may experience side effects. EI #2 was asked if the inaction of the physician to attempt any GDR, that had been recommended (by the Pharmacist), comply with their facility policy. She answered, no. An interview was conducted on 4/04/19 at 11:37 AM, with EI #3, the facility Consultant Pharmacist. EI #3 was asked if a monthly medication review was conducted for residents. EI #3 answered yes. EI #3 was asked if each resident's medical record was included in this monthly review and she answered yes. EI #3 was asked how she evaluated PRN (as needed) medications, specifically PRN [MEDICAL CONDITION] and antipsychotic medications. EI #3 answered she evaluated the resident, the progress notes, the MAR and made recommendations to the MD (Medical Doctor) for compliance with regulations. An interview was conducted on 4/4/19 at 1:03 PM, with EI #4, the Medical Doctor. EI #4 was asked how could he determine a resident was receiving the lowest dose possible of a [MEDICAL CONDITION] drug if no dose reduction was attempted. EI #4 answered that you really could not.

Based on observations, interviews, and a review of the facility policy titled, Care Plans the facility failed to ensure the plan of care was followed for RI (Resident Identifier) #205 regarding unwanted facial hair. This affected RI #205, one of eighteen residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Care Plans with an effective date of (MONTH) (YEAR), revealed: . Regulatory Reference: PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and time tables to meet a resident's medical, nursing and mental/psychosocial needs, that are identified in the comprehensive assessment. A review of the medical record for RI #205 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set) assessment, dated 4/18/18, revealed RI #205 required extensive assistance of one person for performing personal hygiene. A review of a care plan with an initiation date of 4/11/18, revealed a focus area of The resident has an ADL (Activities of Daily Living) self-care performance deficit. Interventions . PERSONAL HYGIENE: The resident requires assistance X1 (times 1 person) with personal hygiene and oral care. An observation was made on 5/09/18 at 9:39 AM, of RI #205 with facial hair. The facial hair was light in color and was across the entire upper lip. The hairs observed on and under the chin were white and thick. Some of the hairs were in a patch near the right side of the lower lip and the others were scattered across the chin. An interview was conducted on 5/09/18 at 9:39 AM, (at the time of the observation) with RI #205. RI #205 was asked about the hair on his/her face. The resident reported an aide had shaved him/her a couple of weeks ago during a shower. RI #205 was asked if he/she wanted the facial hair to be kept trimmed. RI #205 answered, I want them shaved. RI #205 was asked if he/she could shave themselves without assistance. RI #205 responded, No. An interview was conducted on 5/09/18 at 2:43 PM, with EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant). EI #6 was asked if RI #205 shaved their own facial hair. EI #6 answered she would do it for the resident. EI #6 was asked what amount of assistance RI #205 needed for shaving. EI #6 answered One person assist. EI #6 was asked what did the care plan indicate as far as what assistance RI #205 was supposed get with ADLs. EI #6 answered, Get assistance. An interview was conducted on 5/09/18 at 3:31 PM, with EI #5, a CNA. EI #5 was asked when she had given the resident a bath on the previous day what did she observe regarding facial hair. EI #5 answered, I saw whiskers. EI #5 was asked if RI #205 could shave their own facial hair. EI #5 answered, No ma'am. EI #5 was asked what did the care plan indicate as far as what assistance RI #205 was supposed get with ADLs and she answered, Assistance with ADLs. An interview was conducted on 5/09/18 at 3:50 PM, with EI #4, a LPN (Licensed Practical Nurse). EI #4 was asked who was supposed to provide assistance with facial grooming for RI #205. EI #4 answered, The CNAs. EI #4 was asked who was responsible for ensuring ADL assistance was provided in accordance with the plan of care and she answered, Myself. EI #4 was asked what was the facility policy regarding following the plan of care. EI #4 answered, It provides the instructions for how to care for the individual. An interview was conducted on 05/10/18 at 4:31 PM, with EI #2, the DON (Director of Nursing). EI #2 was asked what was the concern of not following the plan of care. EI #2 answered the resident's needs may not be met if staff do not follow the plan of care.

Based on observations, interviews, record reviews, and review of a facility policy titled, Hygiene and Grooming the facility failed to ensure a resident was not observed with unwanted facial hair on one of three survey days. This affected RI (Resident Identifier) #205, one of eighteen sampled residents observed for ADL (Activities of Daily Living) care. Findings Include: A review of the facility policy titled, Hygiene and Grooming with a effective date of (MONTH) 2004, revealed: . PURPOSE: Good hygiene and grooming help (helps) prevent the spread of infection and promote the resident's feelings of self worth and dignity. STANDARD: Guidelines for the provision of hygiene and grooming services are: . Shaving daily or as needed. A review of the medical record for RI #205 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set) assessment dated [DATE], revealed RI #205 required extensive assistance of one person for performing personal hygiene. A review of a care plan with an initiation date of 4/11/18, revealed a focus of The resident has an ADL (Activities of Daily Living) self-care performance deficit. Interventions . PERSONAL HYGIENE: The resident requires assistance X1 (times 1 person) with personal hygiene . An observation was made on 5/09/18 at 9:39 AM, of RI #205 with facial hair. The facial hair was light in color and was across the entire upper lip. The hairs observed on and under the chin were white and thick. Some of the hairs were in a patch near the right side of the lower lip and the others were scattered across and under the chin. An interview conducted on 5/09/18 at 2:43 PM, with EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant). EI #6 was asked when was RI #205 supposed to be showered and she answered, Yesterday. EI #6 was asked who was the CNA yesterday for RI #205. EI #6 answered, I wasn't here, so I don't know. EI #6 was asked when she had given RI #205 a bath on 5/9/18, what she observed regarding facial hair. EI #6 responded she did not notice any because the resident cleans their own face. EI #6 was asked if RI #205 shaved their own facial hair. EI #6 answered she would do it for the resident. EI #6 was asked what about the amount of assistance RI #205 needed for shaving. EI #6 answered One person assist. EI #6 was asked what was the concern of a resident that required assistance for shaving facial hair, being found with highly visible white facial hair on their face. EI #6 answered, It could be embarrassing. At the conclusion of the interview the surveyor and EI #6, the CNA, went to the room of RI #205 and observed the resident lying supine (face up) in bed with daylight shining lightly on the resident's face. EI #6 saw the facial hair and reported she (EI #6) was very embarrassed. An interview was conducted on 5/09/18 at 3:31 PM, with EI #5, a CNA. EI #5 was asked when was RI #205 supposed to be showered and she answered, Yesterday. EI #5 was asked when you gave the resident a bath what did you observe regarding facial hair. EI #5 answered, I saw whiskers. I don't think it was a whole lot. It was under chin and nose. I have to wait for the nurse to give me a razor. EI #5 was asked if she followed through to ensure the facial hair was removed. EI #5 answered, I did ask the nurse again, EI #5 was asked if the facial hair was removed the day before the interview. EI #5 answered As of 9:30 last night, it was not done. EI #5 was asked if RI #205 could shave their own facial hair. EI #5 answered, No ma'am. EI #5 was asked how much assistance did RI #205 require with grooming. EI #5 answered, One person assist. EI #5 was asked what was the concern of a resident that required assistance for shaving of facial hair being found with highly visible white facial hair on their face. EI #5 answered, They could be confused as to why it wasn't done. An interview was conducted on 5/09/18 at 3:50 PM, with EI #4, a LPN (Licensed Practical Nurse). EI #4 was asked who was supposed to provide assistance with facial grooming for RI #205. EI #4 answered, The CNAs. EI #4 was asked who was responsible for ensuring ADL assistance was provided in accordance with the plan of care and she answered, Myself. EI #4 was asked what was the concern of a resident found with highly visible white facial hair that was not desired. EI #4 answered I would think they would want it off.

Based on a review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation and interviews, the facility failed to: 1. Implement their policy requirement to conduct reference checks on newly hired employees prior to or at the time of employment. This affected four of four newly hired employee files reviewed. The facility further failed to ensure: 2. Allegations of abuse were reported to the State Agency within 24 hours. This affected two of three abuse allegation reports reviewed. Findings include: 1. A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, with a supersede date of November 2016, revealed the following: . Process: Employee Screening Background, reference .checks are conducted on employees prior to or at the time of employment . A review of four newly hired employee files were reviewed with no evidence references were checked. The hire dates were 3/13/2017, 3/06/2017, and 11/28/2016. On 03/23/2017 at 9:16 a.m., the surveyor spoke with EI (Employee Identifier) #2, DON (Director of Nursing) and inquired about reference checks regarding newly hired employee files and why the references had not been checked in their personnel files. EI #2 explained their corporation did not check references, only background checks for new hires. EI #2 further explained as of 03/23/2017 the facility had removed the term reference from their policy on abuse prevention. On 03/23/2017 at 2:40 p.m., an interview was conducted with EI #2. EI #2 was asked when she reviewed the Abuse Policy with the supersede date of November 2016, why were references not checked. EI #2 replied the corporation did the background checks and not the facility. EI #2 was asked should the references have been checked per the Abuse policy. EI #2 said it was an error to include the word reference. EI #2 was asked why the references were not checked. EI #2 said it was the corporation's policy. 2. A further review of the facility policy titled, Freedom from Abuse, Neglect and Exploitation with a supersede date of November 2016 revealed the following: .Investigation of Alleged Abuse, Neglect and Exploitation . In response to allegations of abuse . are reported .not later than 24 hours if the events that cause the suspicion do not involve physical abuse or result in serious bodily injury . A review of the facility's online incident report revealed the date of the alleged incident of verbal abuse on 02/24/2017. The actual date the report was submitted to the State Agency was 02/27/2017. A document dated February 25, 2017 further revealed the alleged verbal abuse was reported to a staff member. A review of another facility online incident report revealed the date of 12/15/2016 as the date of the alleged occurrence of physical abuse. The date the report was submitted to the State Agency was 12/21/2016. On 03/23/2017 at 2:20 p.m., an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 was asked what was the timeframe for reporting alleged occurrences of abuse to the State Agency. EI #1 replied two hours for the initial report. EI #1 was informed of an alleged incident of abuse with a date of 12/15/2016 which was submitted online to the State Agency on 12/21/2016. EI #1 was asked why staff did not report the allegation to her and the State Agency before 12/21/2016. EI #1 replied Believe me that was my question and I received a variety of answers. EI #1 was asked when should it have been reported to the Abuse Coordinator and to the State Agency. EI #1 said immediately. EI #1 was also informed of an incident dated 02/24/2017 which was submitted to the State Agency on 02/27/2017. EI #1 was asked why the alleged verbal abuse was not reported to the State Agency within 24 hours. EI #1 said the staff member it was reported to did not feel it rose to the level of being reported. EI #1 was asked who was responsible for ensuring all alleged incidents of abuse are reported within the required time frame to the State Agency. EI# 1 said staff, the DON, and herself. EI #1 was asked what was the staff's responsibility if they witness or were informed of alleged occurrences of abuse. EI #1 said to protect the resident and report it. EI #1 was asked what was the potential harm in not reporting alleged occurrences of abuse and or neglect within the required time frame to the State Agency. EI #1 replied it could jeopardize the resident's safety based on a case by case basis.

Based on medical record reviews, interviews, and review of a facility policy titled, Care Plans, the facility failed to ensure side rails used as enablers were addressed in the care plans for RI (Resident Identifier) #s 2, 3, 5, and 6. This affected 4 of 13 residents whose care plans were reviewed. Findings include: A review of the facility policy titled, Care Plans, with a effective date of January 2017, revealed, . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs, that are identified in the comprehensive assessment. A review of the medical record revealed RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), dated 3/8/17, revealed RI #2 required moderate to extensive assistance of staff for all ADLs (Activities of Daily Living). RI #2 was assessed with [REDACTED]. A review of the Care Plans for RI #2 revealed the side rails used as enablers were not addressed. A review of the medical record revealed RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS assessment dated [DATE] revealed RI #3 was totally dependant on staff for all ADLs. The resident was assessed with [REDACTED]. This score indicated RI #3 was cognitively impaired for daily decision making skills. A review of the Care Plans for RI #3 revealed the side rails used as enablers were not addressed. A review of the medical record revealed RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS assessment dated [DATE] revealed RI #5 required minimal to moderate assistance of staff for ADLs. RI #5 BIMS score was 9 out of 15 indicated the resident was moderately impaired of cognition. A review of the Care Plans for RI #5 revealed the side rails used as enablers were not addressed. A review of the medical record revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS assessment dated [DATE] revealed RI #6 required minimal to moderate assistance of staff for ADLs. A review of the Care Plans for RI #6 revealed the side rails used as enablers were not addressed. An interview was conducted with EI (Employee Identifier) #3, an MDS/Care Plan Coordinator, at 3:57 p.m. on 3/23/17. EI #3 was asked why side rails were being used for RI #s 2, 3, 5, and 6. She answered for mobility. EI #3 was asked what the care plan indicated regarding side rails for RI #s 2, 3, 5, and 6. She answered the side rails were not in the care plans for these four residents. EI #3 was asked who was responsible for developing a plan of care for residents with side rails. She answered, It would probably be an IDT (Interdisciplinary Team) decision. EI #3 was asked why the care plan did not include use of side rails. She answered, I don't know why I didn't do it. EI #3 was asked what was the facility's policy regarding developing a plan of care to match the resident's needs. She answered, It's supposed to match. EI #3 was asked what was the concern of side rails not being care-planned for. She answered, Lack of communication. An interview was conducted with EI #2, the Director of Nursing, at 4:37 p.m. on 3/23/17. EI #2 was asked who was responsible for developing a plan of care for residents with side rails. She named EI #2 and another staff member. EI #2 was asked why the care plan did not include use of side rails and EI #2 answered, I don't know. EI #2 was asked what was the facility's policy regarding developing a plan of care to match the resident's needs. She answered that the needs of the resident will be identified in the care plan. EI #2 was asked what was the concern of side rails not being care-planned for. She answered, If the side rails were being used in a manner that didn't meet the resident needs.

Based on record review, interview, and a review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, the facility failed to provide evidence CNAs (Certified Nursing Assistants) received Dementia Management Training within the required 12 month time frame. This affected six of six CNAs employed within the facility. Findings include: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, with an effective date of March 2017, revealed the following: .Employee Training/Education .is required to complete a performance review of every CNA at least once every 12 months .Training must include Dementia Management . A review of six CNAs' annual continued education forms revealed they did not receive the required Dementia Management training within the 12 month time frame. Date of hire for each CNA consisted of the following: 08/31/2002, 08/31/2002, 02/20/2003, 02/15/2010, 02/29/2012, 08/17/2011, and 02/06/2014. On 03/23/2017 at 2:59 p.m., an interview was conducted with EI (Employee Identifier) #2, DON (Director of Nursing). EI #2 was asked what proof/evidence did she have for the six CNAs training for Dementia Management. EI #2 explained those CNAs had not received the Dementia training for the year but had received training in previous years. EI #2 was asked what evidence she had to prove Dementia Management Training was conducted. EI #2 replied it had not been done yet. EI #2 was asked if training was required every 12 months what did that mean. EI #2 replied annually. EI #2 was asked what time frame was used for CNAs' to receive Dementia Management Training. EI #2 explained their corporation looked at the hire date of each CNA for their training.

Based on interviews and record reviews, the facility failed to provide evidence of a minimum of 12 hours of Continuing Education for Certified Nursing Assistants (CNAs). This affected 3 of 4 files that were reviewed. Findings include: On 3/31/2016, the surveyor reviewed CNA training transcript reports for EI (Employee Identifier) #s 4, 5, and 6. EI #4's transcript record showed a total of 10 hours and 14 minutes of completed training. EI #5's transcript showed a total of 5 hours and 8 minutes of completed training. EI #6's transcript showed a total of 8 hours and 38 minutes of completed training. Additional Continuing Education information was provided by the facility which showed sign in sheets with EI #'s 4, 5, and 6 signatures on them but no verification of how long these in-services/training hours totaled. The facility was not able to provide verification that EI #s 4, 5, and 6 received 12 total hours of Continuing Education training. On 3/31/2016 at 3:53 PM, an interview was conducted with EI #2, the DON (Director of Nursing)/Staff Development. EI #2 was asked what were the training requirements for CNAs. EI #2 stated, Every year, they (CNAs) are required to attend 100% of training and inservices and they are evaluated accordingly. This includes mini inservices and annual facility orientation and completion of health screening. EI # 2 was asked how many training hours should CNAs receive a year. EI #2 stated, 12 hours. EI #2 was asked how the facility ensured a minimum of 12 hours Continuing Education hours were provided to CNAs. EI #2 stated, We monitor it through (named training program used) and we monitor our own attendance at inservices. EI #2 was asked who was responsible for ensuring all CNAs received a minimum of 12 hours Continuing Education. EI #2 stated, That would be me. EI #2 was asked if the facility ensured a minimum 12 hours Continuing Education was provided to EI #s 4, 5, and 6. EI #2 stated, As much as we can. EI #2 was asked the potential concern of employees not receiving a minimum of 12 hours Continuing Education training hours. EI #2 stated, Lack of knowledge. On 3/31/2016 at 4:39 PM, an interview was conducted with EI #3, the Administrator. EI #3 was asked what were the training requirements for CNAs. EI #3 stated, A minimum 12 hours training. EI #3 was asked how many training hours should CNAs receive a year. EI #3 stated, A minimum of 12 hours training. EI #3 was asked how the facility ensured a minimum of 12 hours Continuing Education hours were provided to CNAs. EI #3 stated, We do not have a staff development coordinator, the DON serves in that role so she determines the inservice education provided. EI #3 was asked who was responsible for ensuring all CNA's received a minimum of 12 hours Continuing Education. EI #3 stated, The Director of Nursing. EI #3 was asked if the facility ensured a minimum 12 hours Continuing Education was provided to EI #s 4, 5, and 6. EI #3 stated yes. EI #3 was asked what was the potential concern of employees not receiving a minimum of 12 hours Continuing Education training hours. EI #3 stated, May not understand process or hinder their ability to provide proper care.

Based on record reviews and interviews, the facility failed to ensure medication orders were complete for RI (Resident Identifier) #'s 12, 13, and 16. This affected RI #'s 12 and 13, two of 13 sampled residents and RI #16, one of three closed charts that were reviewed. Findings include: A review of a facility policy with an effective date of 6/12/08 and titled, MEDICATION ORDERS, revealed, . Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Procedures A. Elements of the Medication Order 1) Medication orders specify the following: a. Name of medication b. Strength of medication, where indicated c. Dose and Dosage form d. Time or frequency of administration e. Route of administration f. Quantity or duration (length) of therapy. g. [DIAGNOSES REDACTED]. A review of the medical record for RI #12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the MEDICATION ORDERS FOR [REDACTED]. Sliding scale (Humalog) 100 units/ml (Milliliters) 201-205=(equals)4 units 251-300=6 units 301-350=8 units 351-400=12 units > (greater than) 400=16 units . No route was included in this order. Another hand written order dated 3/10/16 revealed, . 4) [MEDICATION NAME] 40 mg (Milligrams) IM (Intramuscular) . No frequency was included in this order. The transcribed order to the printed physician's orders [REDACTED]. HUMALOG 100 UNITS/ML . SLIDING SCALE; 201-250=4, 251-300=6, 301-350=8, 351-400=12, >400=16, . No dosing measurement or route was noted on the order. A review of the MAR (Medication Administration Record) for RI #12 for the month of March revealed, . HUMALOG 100 UNITS/ML . SLIDING SCALE; 201-250=4, 251-300=6, 301-350=8, 351-400=12, >400=16, . No dosing measurement or route was noted on the MAR. A review of RI #13's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the MEDICATION ORDERS FOR [REDACTED]. (suppository) 1 PRN (as needed) if No BM (Bowel Movement) after 2 day(s) . No route was indicated. The printed physician's orders [REDACTED]. [MEDICATION NAME] R (Regular) 100 UNITS/ML . PER S/S (Sliding Scale): 150-200=4, 201-250=6, 251-300=8, 301-350=12, 351-400=16, >400=16 . No dosing measurement or route was noted on the order. Added to the physician's orders [REDACTED]. No route was indicated on the order. Added to the physician's orders [REDACTED]. No route was indicated on the order. A review of the MAR for RI #13 for the month of March revealed, . SLIDING SCALE; 150-200=4, 201-250=6, 251-300=8, 301-351=12, 351-400=16, >400=16, . No dosing measurement or route was indicated on the MAR. A review of the medical record for RI #16 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a handwritten physician's orders [REDACTED]. 3. Insulin Sliding Scale - Insulin [MEDICATION NAME] ([MEDICATION NAME]) Injection 150 -200 4 units, 201- 250 6 units, 251-300 8 units, 301-350 12 units, 351-400 16 units, >400 Call MD (Medical Doctor) 4. [MEDICATION NAME] 1 packet in 6 oz (Ounces) water BID (twice daily) to aid in wound healing. No route was noted on the order. A review of the physician's orders [REDACTED]. . [MEDICATION NAME] ORANGE MIX ONE PACKET IN 6 OZ. OF WATER 2 TIMES A DAY TO AID IN WOUND HEALING . . [MEDICATION NAME] 100 UNIT/ML VIAL CHECK ACCUCHECK BEFORE MEALS AND AT BEDTIME SQ (Subcutaneous) PER SLIDING SCALE 150 -200 = 4, 201-250 = 6, 251-300 = 8, 301-350 = 12, 351-400 = 16, >400 = CALL MD . No route was indicated on the order. An interview was conducted with EI (Employee Identifier) #1, an RN (Registered Nurse), on 3/31/16 at 4:04 PM. EI #1 was asked what were the 5 rights of a medication order. She answered person, route, medication, dose, and time. EI #1 was asked why were the rights important. She answered to make sure the nurse identified the patient and does not give the wrong medication at the wrong time by the wrong route. EI #1 was shown the orders for RI #16. EI #1 was asked if the orders were complete and she answered no. EI #1 was asked what was missing from the orders. She answered the [MEDICATION NAME] had no route and the sliding scale insulin was missing units. EI #1 was asked why and she answered it was written without a route. EI #1 was asked what she would do if she saw these orders during a medication pass. She answered she would go back and re-write the order to indicate the route of [MEDICATION NAME] and put units on the sliding scale. EI #1 was asked what could be the potential negative outcome of administering a medication/supplement according to an order that was not complete. She answered the patient could get medicine the wrong way or amount. EI #1 was shown the orders for RI #12 and asked what was the frequency of the [MEDICATION NAME] ordered on [DATE]. She answered there was not frequency. EI #1 was asked what route was ordered for the Humalog sliding scale for RI #12. She answered it doesn't say sub-Q (subcutaneous). EI #1 was asked what was the dose measurements of the sliding scale Humalog for RI #12. She answered units was not on there. EI #1 was shown the orders for RI #13 and asked what route was ordered for the [MEDICATION NAME] suppository for RI #13. She answered no route. EI #1 was asked what route was ordered for the [MEDICATION NAME] sliding scale insulin. She answered no route. EI #1 was asked what was the dose measurement for the [MEDICATION NAME] sliding scale insulin. She answered no units listed. EI #1 was asked to review the order for [MEDICATION NAME] for RI #13. She reviewed the [MEDICATION NAME] 0.5-1 ml Q (every) 2 hours. EI #1 was asked what was missing from the order and she answered how it was to be given- the route, pill or liquid. EI #1 was asked why it was missing and she answered apparently whoever wrote it did not indicate it. EI #1 was asked to review the [MEDICATION NAME] order for RI #13. She reviewed the [MEDICATION NAME] 0.25 mg/ml Q 2 hours as needed for anxiety. EI #1 was asked what was the concern with the order. She answered dose information and route were incorrect. EI #1 was asked if the orders she had reviewed were complete. She answered no. EI #1 was asked who signed off the orders were correct for 2/1/16 through 2/29/16. She stated she did. EI #1 was asked what was the purpose of a chart check. She answered to make sure the medications were listed completely and correctly. EI #1 was asked who was responsible for ensuring orders were completed. She answered anyone that is writing them, Pharmacy, the person giving the medicine, and the person doing the chart check. An interview was conducted with EI #2, the Director of Nursing, on 3/31/16 at 4:39 PM. EI #2 was asked what were the 5 rights of a medication order. She answered right patient, medicine, time, route, and dose. EI #2 was asked why were the rights important. She answered to ensure the patient gets the right medication, the right dose, and at the right time. EI #2 was shown the orders for RI #16. EI #2 was asked if the orders were complete and she answered no. EI #2 was asked what was missing from the orders. She answered the [MEDICATION NAME] had no route and the sliding scale insulin did not have units. EI #2 was asked why and she stated she did not know. EI #2 was asked what she would do if she saw these orders during a medication pass. She stated she would have to write a clarifying order and fax it. EI #2 was shown the orders for RI #12 and asked what was the frequency of the [MEDICATION NAME] ordered on [DATE]. She answered there was no frequency. EI #2 was asked what was the route ordered for the Humalog sliding scale for RI #12. She stated it did not indicate the route. EI #2 was asked what was the dose measurements of the sliding scale Humalog for RI #12. She stated it did not specify units. EI #2 was shown the orders for RI #13 and was asked what was the route ordered for the [MEDICATION NAME] suppository for RI #13. She answered none. EI #2 was asked what route was ordered for the [MEDICATION NAME] sliding scale insulin. She stated it was not there. EI #2 was asked what was the dose measurement for the [MEDICATION NAME] sliding scale insulin. She answered it did not specify. EI #2 was asked to review the order for [MEDICATION NAME] for RI #13. She reviewed the [MEDICATION NAME] 0.5-1 ml Q 2 hours prn anxiety. EI #2 was asked what was missing from the order and she answered how to give it, no route. EI #2 was asked why it was missing and she stated she did not know. EI #2 was asked to review the [MEDICATION NAME] order for RI #13. She replied same way, amount and time with no route. EI #2 was asked what was the purpose of a chart check. She answered to double check things like this and ensure accuracy. EI #2 was asked who was responsible for ensuring orders were completed. She answered the person that writes the order, takes off the order, the person that signs off on verbal orders, the pharmacy, and the nurse administering the medicine.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) An oxygen concentrator tubing and humidifier bottles were changed and dated. This was observed on two of four survey days. This affected RI (Resident Identifier) #4, one of four residents sampled for concentrators. 2) Air conditioner vents were not observed with an accumulation of dust. This affected RI #3 and RI #11, two of fifteen sampled residents. Findings include: A review of the document titled, "OXYGEN NURSING PROCEDURES MANUAL ...Policy Title: Oxygen Concentrator Effective Date: January 2012... PURPOSE: ... PROCESS: ... k. Cannulas and masks should be changed weekly. ... II. Care of the Concentrator a) The main body cabinet should be dusted when needed, and can be wiped clean with a damp rag and mild household cleaner if necessary. b) Every Wednesday, the LPN (Licensed Practical Nurse) Charge Nurse is to replace tubing and place in a clear plastic bag. c) Rinse the filters as needed." A review of the medical records revealed RI #4 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/09/2015 revealed RI #4 was cognitively intact for daily decision making skills. This MDS also indicated RI #4 required extensive to total assistance with ADLs (Activities of Daily Living). An observation was made of RI #4 on 03/04/2015 at 8:45 AM. RI #4 was receiving oxygen at 4 liters per minute. The tubing was not labeled and the filter on the concentrator was dirty and light gray in color. An observation was made on 03/05/2015 at 8:45 AM. RI #4's concentrator's external cabinet filter was observed to have a moderate to heavy gray dust like substance covering the filter. The humidifier and oxygen tubing had no date. On 03/05/2015 at 1:50 PM, an interview was conducted with EI (Employee Identifier)#3, the ADON (Assistant Director of Nursing) and Infection Control Nurse. EI #3 was asked when were oxygen concentrator's tubing and humidifier bottles changed. EI #3 stated, "Weekly or Wednesday nights." EI #3 was asked where was that information documented. EI #3 stated, "The nurses have it on their check list. There is a check list to document where it is done." EI #3 was asked what was the concern when oxygen concentrator equipment was not changed or labeled. EI #3 stated, "Infection." EI #3 was asked when were filters on oxygen concentrators cleaned. EI #3 stated, "I will have to get with EI #8, the Administrator on that. She is working with (the name of the company), the oxygen concentrator company." EI #3 was asked where was that information documented. EI #3 stated, "I don't know at this time." On 03/05/2015 at 3:15 PM, an interview was conducted with EI #7, the Maintenance and Facility Manager. EI #7 was asked what was done to maintain oxygen concentrators by nursing staff. EI #7 stated, "The night shift changes the oxygen concentrator tubing and humidifiers weekly or (on) Wednesdays." EI #7 was asked if humidifier bottles and oxygen tubing were dated at the time they were changed. EI #7 stated, "They are supposed to be dated." 2) A review of the medical records revealed RI #11 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 12/09/2014 revealed RI #11 was moderately impaired of cognitive skills for daily decision making. This MDS also indicated RI #11 required total assistance with ADLs. An observation was made of RI #11's air condition vent on 03/05/2015 at 8:55 AM. An accumulation of dust and a brown substance was observed on the vent. A review of RI #3's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS, with an ARD of 01/06/2015, indicated RI #3 had a BIMS (Brief Interview for Mental Status) score of 14. This score indicated RI #3 was cognitively intact. RI #3 required extensive to total assistance with all activities of daily living. An observation of RI #3's air condition's vent was made on 03/05/2015 at 9:55 AM. An accumulation of dust was observed in the vent. An interview was conducted with EI #7 on 03/05/2015 at 3:15 PM. EI #7 was asked how often air condition vents were cleaned. EI #7 stated, "As needed." The surveyor asked EI #7 where was that information documented. EI #7 stated, "It is not documented." The surveyor asked EI #7 what was the concern when air condition vents had an accumulation of dust. EI #7 stated, "I am not a clinical person, but I guess that dust could bother their (the residents) breathing." The surveyor and EI #7 made observations of RI #3 and RI #11's air condition vents. The surveyor asked EI #7 what did he observe during the observations. EI #7 stated, "They needed to be cleaned. It does not take a rocket scientist."

Based on an observation, interview, and record reviews, the facility failed to ensure an RN (Registered Nurse): 1) Did not leave the room without washing her hands after performing wound care. 2) Did not perform wound care and then place her hands in a container that held clean dressing supplies. 3) Did not provide wound care with the same gloved hand used on another wound. 4) Did not measure two wounds with the same measuring tape. 5) Wash hands after removing gloves during wound care. This had the potential to affect RI (Resident Identifier) #6, one of two residents observed for wound care. Findings include: A review of POTTER-PERRY, Fundamentals of Nursing, Page 1535, Skin Integrity and Wound Care revealed, "... The nurse should perform thorough hand hygiene before and after wound care." A review of POTTERY-PERRY, Fundamentals of Nursing, Page 793, Infection Control revealed, "1.Wash hands with plain soap or antimicrobial soap and water when hands are visibly dirty. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands... a. After contact with a client's intact skin... b. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings as long as hands are not visibly soiled. c. When moving from a contaminated body site to a clean body site during client care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the client. ... f. After removing gloves." A review of POTTER-PERRY, Fundamentals of Nursing, Page 799, Infection control revealed, "...Gloves help to prevent the transmission of pathogens by direct and indirect contact. ... Clean, non-sterile gloves should be worn when touching blood, bloody fluid, secretions, excretions, and contaminated items. Clean gloves should be donned just before touching mucous membranes and nonintact skin. Gloves should be changed between tasks and procedures on the same client after contact with material that may contain a high concentration of microorganisms. Gloves should be removed promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another client. Hand hygiene should be performed immediately to avoid transfer of microorganisms to other clients or environments. ..." A review of the medical records revealed RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set) with an ARD (Annual Reference Date) of 01/30/2015, revealed RI #6 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #6 required total assistance with ADLs (Activities of Daily Living). On 03/04/2015 an observation was made of EI #3 performing wound care on RI #6's Pressure Ulcers. EI #3 was observed measuring and touching both the left medial foot wound and right great toe wound with the same measuring tape. EI #3 cut two different wound care dressings. EI #3 removed the gloves, and left the room without washing her hands. EI #3 returned to the room and donned gloves without washing her hands. After placing skin prep around the wounds, she took off her gloves and donned new gloves without washing her hands. EI #3 placed the a wound care dressing on the left foot and covered it with a different wound care dressing. A wound care dressing was placed on the side of the right great toe and covered with a different dressing. EI #3 did not change gloves between wounds. EI #3 removed her gloves and placed her hands inside of the container holding clean dressing supplies, without washing her hands. EI #3 then donned new gloves, turned RI #6 to the right side to check the sacral area, and removed her gloves. Again EI #3 did not wash her hands. She then closed the clean dressing container and placed it in the closet. On 03/04/2015 at 3:20 PM, an interview was conducted with EI #3, the ADON (Assistant Director of Nursing) and Infection Control Nurse. EI #3 was asked if she had performed the dressing change on RI #6 during the observation on 03/04/2015. EI #3 stated, "Yes." EI #3 was asked when should hands be washed during wound care. EI #3 stated, "Before you start and use hand sanitizer in between each time you take your gloves off and wash at the end." EI #3 was asked should hands be washed after changing the dressing on one wound and before moving to do care on another wound. EI #3 stated, "Yes they should be." EI #3 was asked if she used the same gloves to perform care on both wounds. EI #3 stated, "I'm sure I did what you saw." EI #3 was asked if hands should be washed after gloves became soiled and before donning new gloves. EI #3 stated, "Yes because of contamination or infection control. You never know if there's going to be a break in the glove. Your hands are considered contaminated even if they're in the gloves." EI #3 was asked should hands be washed after taking off gloves and before leaving the room. EI #3 stated, "Yes, because they're considered contaminated. I remember doing that." EI #3 was asked should hands be washed after gloves were taken off and before touching clean dressing supplies. EI #3 stated, "Yes, because your hands are contaminated. I do remember doing that." EI #3 was asked when using a measuring tape to measure a wound and it touched the wound, should it then be used to measure another wound. EI #3 stated, "No, to prevent cross contamination. I remember using the same measuring tape."

Based on an observation, interviews, and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant): 1) Changed the position of the wash cloth during incontinence care for RI (Resident Identifier) #3. 2) Cleaned RI #3's perineal area in a manner to prevent the potential for cross contamination during incontinence care. 3) Washed her hands and changed gloves, after opening the chest of drawers during incontinence care for RI #3. This affected RI #3, a resident with a significant history of UTIs (Urinary Tract Infections) and who was recently treated for [REDACTED]. Findings include: A review of "POTTER & PERRY... Fundamentals of Nursing...7th Edition...copyright 2009," revealed: "...page 655...Chapter 34 Infection Prevention and Control... The CDC (Center for Disease Control Prevention) (2002 b) recommends the following: ... 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: ... e. After contact with inanimate objects (including medical equipment) in the immediate area of the client..." A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...copyright 2009," revealed: "...page- 877 to 879...39-2...Perineal Care... 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection ... Discard gloves. Perform hand hygiene ... 10. If fecal material is present, enclose in a fold of underpad or toilet tissue ...Cleanse buttocks and anus, washing front to back ...Cleanse, rinse, and dry area thoroughly. ... 11. If gloves are soiled, perform hand hygiene and then apply new pair of gloves. ... 15. Provide perineal care. ... B. Male perineal care... (3)Gently raise penis, and place bath towel underneath. Gently grasp shaft of penis. If client is uncircumcised, retract foreskin ... (4) Wash tip of penis at urethral meatus first. Using circular motion. Cleanse from meatus outward. ...Discard washcloth, and repeat with clean cloth until penis is clean. Rinse and dry gently. Return foreskin to its natural position. (6) Wash shaft of penis with gentle but firm downward [MEDICAL CONDITION]. ... (7) Gently cleanse scrotum. Lift it carefully, and wash underlining skin folds. Rinse and dry. ... 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene. ..." A review of RI #3's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual, MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 1/06/15, indicated RI #3 a BIMS (Brief Interview for Mental Status) score of 14. This score indicated RI #3 was cognitively intact. RI #3 required extensive to total assistance with all activities of daily living. RI #3 was coded as frequently incontinent of bladder and always incontinent of bowel. A review of RI #3's medical record revealed a urine culture that tested positive for, "Extended Spectrum Beta-Lactamase (ESBL) on 12/27/2014. RI #3 was on Contact Isolation during the survey observations. A review of RI #3's physician's orders [REDACTED]. "12/30/14 (at) 1210 (12:10 AM) Send to ER (emergency room ) for eval(evaluation) + (and) tx (treatment): Mental status changes, UTI..." A review of RI #3's, "Admission History and Physical" dated 12/31/2014 revealed: ...2. Catheter - associated chronic urinary tract infection, resistant organism/ESBL..." On 3/4/15 at 9:25 AM, an observation was made of a bath/incontinence care for RI #3. The bath and incontinence care was performed by EI (Employee Identifier) #6, a CNA. EI #6 performed a bath for RI #3 and changed the water in two basins, washed her hands and applied gloves. EI #6 opened the chest of drawers and obtained deodorant, lotion, and a skin barrier. EI #6 obtained a clean wash cloth and removed the top of the adult brief. EI #6 wiped the top of the perineal area in a back and forth motion, then wiped down the right side in a back and forth motion without changing the position of the wash cloth. EI #6 wiped the left side of the perineal area in a back and forth motion twice without changing the position of the wash cloth. EI #6 obtained a clean wash cloth and retracted the foreskin of the penis and wiped in a circular motion 5 times without changing the position of the washcloth. EI #6 obtained a clean wash cloth and rinsed the head of the penis in a back and forth motion, and then in a circular motion three times without changing the position of the wash cloth. EI # 6 cleaned RI #3's scrotum by wiping in a circular motion four times without changing the position of the wash cloth. EI #6 rinsed the front of RI #3's perineal area in the same manner and dried the area with a towel. RI #3 was turned to the left side. EI #6 obtained a clean soapy wash cloth and cleaned RI #3's bottom by wiping in a back and forth motion three times without changing the position of the wash cloth. EI #6 obtained a bath towel and cleaned the buttock fold in a back and forth motion twice without changing the position of the towel. EI #6 changed the position of the towel after removing a smear of stool. EI #6 used the opposite end of the bath towel to rinse and dry RI #6's bottom. On 3/4/15 at 3:10 PM, an interview was conducted with EI #6. The surveyor asked EI #6 how she was taught to provide incontinence care for a male resident. EI #6 stated, "If they have not been circumcised you pull the skin back and wash around, rinse and dry, and pull the foreskin back over." The surveyor asked EI #6 how she cleaned the front of RI #3's perineal area. EI #6 stated, "I washed the front part, then got another towel and pulled the foreskin back, cleaned and rinsed. I then pulled the foreskin back over after I dried his front area." The surveyor asked EI #6 how she cleaned RI #3's bottom during incontinence care. EI #6 stated, "I did the cheeks first and then went to the dirtiest part and cleaned that area." The surveyor asked EI #6 if she changed the position of the wash cloth during incontinence care for RI #3. EI #6 stated, "I know on the front, I got another wash cloth. I believe I did change the position of the washcloth, because RI #3 had a little stool. I know I did not re-wipe the BM (bowel movement)." The surveyor discussed the above observation with EI #6, and asked what was the concern. EI #6 stated, "Cross Contamination." EI #6 was asked when did the facility provide her with an in-service on incontinence care. EI #6 said they talked about it on last month. The surveyor asked EI #6 if she did a return demonstration. EI #6 stated, "No I didn't." On 3/5/15 at 1:50 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked how staff members were trained to provide incontinence care for a male resident. EI #3 stated, "In-services on perineal care done annually and as needed." The surveyor asked what direction should staff wipe during incontinence care. EI #3 stated, "Clean to dirty. With a male you wipe from the meatus and down the shaft of the penis." The surveyor shared the above observation of the incontinence care for RI #3, and asked what the concern was. EI #3 stated, "The concern would be contaminating the urinary tract with organisms from the other part RI #3's body or the environment."

Based on an observation, interviews, and a record review, the facility failed to ensure eleven vials of expired injectable Ativan were not observed in the refrigerator in the medication room. This was observed on one of four survey days and one of one medication rooms. Findings include: A review of the facility's document with a revision date of [DATE] revealed, "MEDICATIONS STORAGE IN THE FACILITY STORAGE OF MEDICATIONS Policy Procedures... M. Outdated, contaminated or deteriorated medications...are immediately removed from stock, disposed of according to procedures for medication disposal..." On [DATE] at 10:35 AM, an observation was made of one bottle of expired injectable Ativan with the use by date of ,[DATE] and ten bottles of expired injectable Ativan with the use by date of ,[DATE] stored in the locked refrigerator. On [DATE] at 10:35 AM, an interview was conducted with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), who witnessed the expired Ativan during the above medication room observation. EI #1 was asked whose responsibility was it to check the locked refrigerator with narcotics for expired dates. EI #1 stated, "7 PM-7 AM and 7 AM-7 PM Licensed nurses caring on each shift." EI #1 was asked would expired Ativan be effective if administered to a resident. EI #1 stated, "Oh no." EI #1 was asked what potential harm could occur if a resident received expired Ativan. EI #1 stated, "It's no longer considered good or healthy by the manufacturer." On [DATE] at 10:50 AM, an interview was conducted with EI #2, the DON (Director of Nursing). EI #2 was asked whose responsibility was it to check the refrigerator for expired dates on narcotics. EI #2 stated, "All the nurses, the two hundred hall nurse has the key." EI #2 was asked would expired Ativan be effective if administered to a resident. EI #2 stated, "I wouldn't think so." EI #2 was asked what concern would it be if a resident was given expired Ativan. EI #2 stated, "The effectiveness would be a problem I would think."

Based on observations, interviews and record reviews the facility failed to ensure: 1) A licensed nurse did not drop two pills on top of the medication cart and then administer them to RI (Resident Identifier) #9. This had the potential to affect one of five residents observed during medication pass. 2) A licensed nurse documented on a Implanted device dressing the date and time it was accessed. This occurred on two of four survey days and had the potential to affect RI #6. 3)The CNA (Certified Nursing Assistant) washed hands and changed his gloves between residents during an ice pass observation on 3/4/15. This was observed on one of three halls in the facility. Findings include: 1) A review of the medical records revealed RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/12/2014, revealed RI #9 was cognitively intact for decision making skills. This MDS also indicated RI #9 required limited assistance with ADLs (Activities of Daily Living). On 03/04/2015 at 8:45 AM, an observation was made of EI (Employee Identifier)#1 dropping a pill on the medication cart and placing it in RI #9's medication cup. EI #1 was again noted to drop another pill on top of the medication cart and put it in RI #9's medication cup. EI #1 then proceeded in administering the pills to RI #9. On 03/04/2015 at 1:50 PM, an interview was conducted with EI #1, an LPN (Licensed Practical Nurse). EI #1 was asked if she had set up RI #9's medications. EI #1 stated, "Yes ma'am." EI #1 was asked to explain how she had set up RI #9's medications. EI #1 stated, "I matched them with the orders on the screen and RI #9 is unable to swallow so we crush them. RI #9 has trouble swallowing. I didn't crush her [MEDICATION NAME]. I crushed the other pills in a cup and put it in pudding and then administered it." EI #1 was asked what was the concern of giving pills to a resident when they had fallen on the medication cart. EI #1 stated, "The cleanliness of the cart. The germs from the cart could get into (RI #9's) medication and could possibly get (RI #9) sick. EI #1 was asked if she should have administered the pills after they had touched the medication cart. EI #1 stated, "No ma'am." 2) A review of the facility's document titled: "OAKWOOD NURSING PROCEDURES MANUAL Section: Advanced Care Procedures..." with a revision date of May 2013 revealed... "2. a. Document date and time of dressing change." A review of the medical records revealed RI #6 was readmitted to the facility 01/30/2015 with [DIAGNOSES REDACTED]. A review of the Admission MDS with an ARD of 01/30/2015, revealed RI #6 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #6 required total assistance with ADLs. On 03/2/2015 at 5:05 PM, an observation was made during the initial tour of RI #6's implanted port dressing not having a date and time documented on it. It was accessed and infusing an antibiotic. On 3/3/2015 at 10:32 AM, an observation was made of RI #6's implanted port dressing. The dressing continued to not have a date and time documented on it. It was accessed and infusing an antibiotic. On 03/04/2015 at 3:45 PM, an interview was conducted with EI #5, an RN (Registered Nurse). EI #5 was asked if she accessed RI #6's implanted port. EI #5 stated, "I did." EI #5 was asked what should be documented on the implanted port dressing when it was accessed. EI #5 stated, "Date and time and initials.You have to change it out every third day." EI #5 was asked if there was no date or time on the dressing how would staff know when to change it. EI #5 stated, "If there was no date or time I would go ahead and change it or call the facility and find out." EI #5 was asked what potential harm could occur to a resident if the dressing was not dated and timed. EI #5 stated, "It wouldn't get changed and it would get an infection- because it needs to be changed." EI #5 was asked when was the implanted port accessed. EI #5 stated, "When (RI #6) came in." EI #5 was asked what staff took care of the port if she was not at work. EI #5 stated, "Any RN can take care of it." EI #5 was asked if the other RN's could not see a visible date and time how would they know when to change it. EI #5 stated, "They could call me, if they needed to." 3)The facility policy entitled, "...HAND WASHING" with the effective date of May 2013, revealed: "...PURPOSE: To prevent infection. STANDARD: All personnel shall wash their hands to prevent the spread of infection and disease to other residents, personnel, and visitors. ... PROCESS: Hands should be washed: ...2. Before and after each procedure 11. After handling the resident's belongings. ..." An ice pass observation was done on 3/4/2015 at 1:50 PM. EI #4, a CNA, was observed with gloved hands filling ice pitchers. EI #4 knocked on the door of RI #1 picked up the water pitcher, and put the top of the water pitcher with the straw in place, on top of the bed side table. The bedside table did not have a paper towel in place under the water pitcher top to prevent the potential for cross contamination. EI #4 took the water pitcher in the bathroom, emptied the contents and closed the bathroom door with the same gloved hands. EI #4 went to the ice chest in the hallway, removed the ice scoop that was stored in a plastic zip lock bag, and EI #4 filled the water pitcher with ice, and took it back to the resident's room. EI #4 put the top with the straw back on top of the water pitcher. EI #4 knocked on an un-sampled resident's door and entered with same contaminated gloved hands. EI #4 took the water pitcher into the bathroom and empted it. EI #4 put the top with the straw on the top of the bed side table. EI# 4 did not clean the bedside table top. EI #4 took the ice water pitcher to the ice chest and filled it with the scoop stored in the zip lock bag. Droplets of water were observed inside the zip lock bag. The CNA asked the resident if water was desired in the pitcher. The resident said yes. EI #4 opened the bathroom door and put water into the pitcher by turning on the faucet with the same contaminated gloves. EI #4 then put the top with the straw that was placed on the top of the un-cleaned bedside table onto the water pitcher. EI #4 continued to fill ice pitchers in the same manner from room to room with the same contaminated gloves. EI #4 was not observed to wash his hands or use alcohol gel between residents during the ice pass. EI #4 removed the contaminated gloves at the end of the ice pass. EI #4 was not observed to wash his hands. An interview was conducted with EI #4 on 3/4/2014 at 3:45 PM. The surveyor asked EI #4 how he was taught to pass ice out to residents. EI #4 stated, "Get the ice chest put gloves on, make sure the scoop is in the plastic storage bag, and make sure the lid is on the ice chest between filling the ice containers. Once you enter the room you knock on the door and tell the resident that that you are here to refill the ice. I take the lid off with the straw and place it on the bedside table. If there is any water in the container, you pour it in the commode. I exit the room to fill (it) up with ice. (I) ask the resident if they want ice or ice with water. If they want ice and water, we use the sink to fill it up with one half water. I place the ice pitcher back on the (bedside) table and return the lid on with the straw. I then ask if there is anything else I can do for them." The surveyor asked EI #4 when did he wash his hands between filling the ice water pitchers for residents during the above observation. EI #4 stated, "Twice when I dropped the ice on the floor. I have never been told to change gloves between residents while passing ice." EI #4 was asked what the concern was, when hands were not sanitized, washed, or gloves were not changed between residents while passing out ice. EI #4 stated, "Well, passing germs between residents. You could have a resident with the flu or who touched his/her private areas, and then handle their water pitcher." The surveyor asked was the water pitcher top and straw put on a paper towel when placed on the bedside table. EI #4 stated, "No." The surveyor asked why not. EI #4 stated,"Didn't think about it. I get busy trying to take care of all of the patients." An interview was conducted with EI #3, the Infection Control Coordinator of the facility on 3/5/15 at 1:50 PM. The surveyor shared the above ice pass observation with EI #3. EI #3 was asked what the concern was when a staff member did not wash their hands or change gloves between residents. EI #3 stated, "Contamination/Cross Contamination."

Based on observation, interview and record review, the facility failed to ensure the [MEDICATION NAME] ordered for breakthrough pain for Resident Identifier (RI) #5 was given timely to provide pain relief during wound treatment. This affected 1 of 2 sampled residents observed during wound care. Findings include: RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with an Assessment Reference Date of 06/01/12, assessed RI #5 as being cognitively impaired (unable to complete the Brief Interview for Mental Status interview). RI #5 was assessed as being dependent on one person for extensive assist with transfers and with bed mobility. RI #5 was also assessed as having one Stage III pressure ulcer, not identified on the previous assessment. The pain intensity assessment which was rated on a scale of 1 to 10 (with 10 being the worst pain you can imagine), RI # 5 was rated as #7 in the last 5 days. RI #5's care plan, updated 06/1/12, documented, "Potential for Alteration in Comfort related to chronic generalized pain" included: "4/4/12 New Decubitus. Routine [MEDICATION NAME] as well as medicated prior to dressing changes. Also receives PRN (as needed) pain meds as needed for breakthrough pain." The "Physician order [REDACTED]. Give 1 ml po (by mouth) or sl (sublingual) q (every) 2 hr PRN breakthrough pain." On 06/13/12 at 2:45 PM, the wound care to the left heel was observed for RI #5; At 2:45 PM, Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) entered the room and administered [MEDICATION NAME], to RI #5. EI #3 poured the liquid [MEDICATION NAME] into RI #5's mouth from the medication cup. (It was not administered slowly from a dropper under the resident's tongue.) While EI #3 was administering the [MEDICATION NAME] , the wound nurse (EI #2) washed her hands and donned gloves. She then removed the cover from RI #5. Immediately, RI #5 was repositioned onto her side. As RI #5 was being repositioned, the resident called out, "Oh, Lordy!" RI #5's foot was raised to remove the bootie. RI #5 called out, "Don't move my foot. Oh no!" RI # 5 was noted to have her eyes tightly closed. After removing the bootie, EI #2 then removed the dressing. EI # 5's foot was raised higher so EI #2 could measure the wound on the left heel. When the foot/leg was moved, the resident called out again, "Hurt! Oh no!" At this time, RI #5 was attempting to reach her leg. RI #5's eyes were tightly closed and she displayed facial grimaces. EI #2 cleaned the area on the foot with the wound cleanser and 4x4 gauze, RI #5 exclaimed, "Oh no! Who is scratching my foot?" Facial grimacing was observed at this time. When RI #5's leg/foot was lifted so the dressing could be applied, RI #5 cried out, "Oh, oh! Please ease up on it!" RI #5's eyes were tightly closed. As the bootie was placed onto RI #5's foot, RI #5 stated, "Oh Lord, oh Lord! Have mercy on me!" After the treatment was completed at 3:00 PM, EI #2 asked RI #5 what was hurting. RI #5 stated, "My whole foot." EI #2 asked RI #5 if her knee was hurting. RI #5 stated, "It hurts too. Oh Lord Jesus!" A nurse note dated 6/13/12 at 5:01 PM, documented: "Resident was premedicated with [MEDICATION NAME] about 1 hour before and Roxinol just before dressing change. She continued to cry and pray during care, beginning before the boot was removed continuing until after dressing was complete. C/O pain in foot, legs and all over.... Resident calmed quickly when left alone in bed." Information furnished by the facility from "[MEDICAL CONDITION] Center of the University of Pennsylvania" documented: "Roxonol ([MEDICATION NAME]) will begin working to relieve pain in 15 to 30 minutes, and reaches its peak effect in 1 hour." The "Geriatric Dosage Handbook " 12th Edition, page1047 reveals: [MEDICATION NAME] Oral solution peak 1 hour.... Oral absorption is variable. The wound care nurse, EI #2, was interviewed on 06/13/12 at 5:00 PM. When asked how she would have assessed RI #5's pain during the observed wound care, EI #2 responded, "I feel like it was a 9 or 10. I know she was hurting." EI #2 was asked why she had not stopped the treatment when RI #5 continued to call out. EI #2 replied, "She had just had the [MEDICATION NAME]. She settles down real quick when we finish. Moving and repositioning her legs puts her into a tizzy." EI #2 was asked if this was the way RI #5 always responded. EI #2 replied, she does and not just during wound care. She has aches and pain in her legs. She is scared. She is blind and hard of hearing. EI #6, an RN Supervisor was interviewed on 06/14/12 at 10:20 AM. When asked how often a resident is assessed for pain, EI #6 stated it was an ongoing process. When asked about assessing RI #5 for pain, EI #6 stated if the resident had facial grimacing, guarding, non verbal signs, or crying out, she is hurting. On 06/14/12 at 2:00 PM, the medication LPN, EI #3 was interviewed. When asked how long it took for liquid [MEDICATION NAME] to take effect, EI #3 stated, "I would say 20 minutes." EI #3 was asked how far in advance of providing wound care should the PRN be administered? EI #3 replied, 30 to 45 minutes. On 06/14/12 at 2:20 PM, EI #2 was asked if she thought the [MEDICATION NAME] had taken effect before the wound treatment. EI #2 responded, "No, not the full effect. I normally would have waited at least 15 minutes on the [MEDICATION NAME]." On 06/14/12 at 2:35 PM, EI #3 was asked what the [MEDICATION NAME] was supposed to target. EI #3 stated that it was for (to be given) before the wound care. When asked who was responsible for making sure the medication is given at the right time before the treatment, EI #3 stated that she was. EI #3 was asked if the [MEDICATION NAME] was ordered for the wound treatment or for the movement of her legs. EI #3 explained that most of RI #5's pain was during movement of her legs and she has to be moved during wound care. When EI #3 was asked if she had waited to be sure the [MEDICATION NAME] had taken effect, EI #3 stated it would take a few minutes, no longer than 20 minutes. The facility's Licensed Consultant Pharmacist, EI #4 was interviewed on 06/14/12 at 3:15 PM. EI #4 was asked how long does it take for [MEDICATION NAME] to take effect SL (sublingual) and PO. EI #4 stated it would take 15 to 20 minutes SL and 20 to 30 minutes PO. The Director of Nursing, EI #1, was interviewed on 06 14/12 at 4:50 PM. The surveyor asked EI #1 what she would expect the nurse to do if a resident continued to call out in pain during wound treatment. EI #1 stated, "I would expect them to stop and reassess. I would not want to see someone in pain. They need to come back and reapproach to see if we need more time for the medication to be effective."