Every finding on record at Desert Blossom Health & Rehab Center

Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#103)'s medication was not left at bedside and resident was assessed for self-administration of medication. The deficient practice could place resident's safety at risk.Findings include:Resident #103 was admitted to the facility on [DATE] with diagnoses that included dementia, Obstructive Sleep Apnea (OSA), depression, heart failure, and chronic kidney disease.A review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14.0, indicating cognitively intact.The care plan dated November 13, 2025, revealed resident was at risk for impaired cognitive function/dementia or impaired thought processes related to new admission. The interventions included keep routine consistent to decrease confusion, monitor/document/report to provider and to the nurse any changes in cognitive function specifically changes in decision making ability, memory, recall and general awareness, sleepiness/lethargy, and confusion.Another care plan initiated on November 26, 2025 revealed that resident had the potential for psychosocial well-being problem related to disease process, and takes psychotropic medication. The interventions included observe for side effects of anti-depressant medication such as confusion, mood change, hallucinations/delusions, drowsiness, sedation, social isolation, suicidal ideations, withdrawal, decline in ability to help with/do activities of daily living, dizziness/vertigo, and fatigue.However, the comprehensive care plan did not include a self- administration of medication care plan.A review of physician order revealed an order for Diphenhydramine Hydrochloride (HCl) oral tablet 25 milligram (MG), give one tablet by mouth every 24 hours as needed for itching for 14 Days at bedtime with a start date of December 14, 2025 and a start time of 10:00 AM.There was no order for self-administration of medication found in the resident's clinical record.According to [NAME] Nursing Drug Handbook, Diphenhydramine is used for short-term management for insomnia (difficulty falling asleep or staying asleep) in adults. The brand name is Benadryl, and it is available over-the-counter. The tablet comes in different dosages, 25 MG and 50 MG.On December 14, 2025, approximately 8:00 AM, Resident #103 was observed in her room lying in bed and next to her bed was her bedside table. On top of her bedside table there was a medication cup, and inside of the medication cup was a small rectangular pink pill.An interview was conducted on December 14, 2025, at 8:07 AM with a Licensed Practical Nurse (LPN/Staff #12) in Resident #103's room. Staff #12 described the pill found at the resident's bedside table as half a tablet that looks like Benadryl. Staff #12 asked the resident if she had asked for a Benadryl and the resident responded by saying do not to take my Benadryl. Staff #12 took away the medication cup with the pill inside the cup from the resident's bedside table. At 8:11 AM, Staff #12 opened her work laptop computer parked outside the room in the hallway to look at resident #103's electronic clinical record. Staff #12 said that she does not see an order for the Benadryl in the resident's electronic clinical record. Staff #12 walked towards a Registered Nurse (RN/Staff #89) who was the nurse for Resident #103. Staff #12 informed Staff #89 that Resident #103 said that the Benadryl was left at her bedside last night. Staff #89 stated that it was not him that left it and that he was not made aware about any Benadryl for the resident. Staff #89 wasted the pill by throwing it in the sharp container located at the side of the medication cart. Staff #89 stated that he will notify the resident's provider about the Benadryl.A review of the Medication Administration Record (MAR) for December 2025 revealed a transcribe order for Diphenhydramine HCl oral Tablet 25 MG give 1 tablet by mouth every 24 hours as needed for itching for 14 Days at bedtime dated December 14, 2025, at 9:48 AM with a discontinue date of December 14, 2025, at 1:21 PM. And, another transcribed order for Diphenhydramine HCl oral Tablet 25 MG give 0.5 tablet by mouth every 24 hours as needed for itching for 14 Days at bedtime dated December 14, 2025, at 1:21 PM.An interview was conducted on December 15, 2025 at 9:50 AM with another LPN (Staff #108). The LPN stated that the process for medication administration included verifying the resident's name, right resident, right time, and right medication. She stated that before administration of medication to a resident, she would make sure that an order or a prescription for the medication was received from the doctor. She said that after receiving an order, she would place the order in the resident's electronic clinical record, and then she can administer the medication to the resident. Further, she stated that she would not give a medication without an order because a resident's medication needs an order from the resident's provider. She said that if one of her residents asked for a Benadryl, she will first get an order from the provider, transcribed the order in the MAR, then give the medication to the resident, and then document in the MAR that the medication was administered. She said that she would not administer Benadryl without an order, and it is not within her nursing scope of practice to give a medication without an order. She also stated that she will not leave a medication at bedside because anybody who wanders can walk in the resident's room and take the resident's medication, the resident could get double dose, and leaving a medication at bedside is against the facility's policy.Another interview was conducted with an LPN on December 15, 2025 at 12:39 PM. The LPN (Staff #1) stated that during medication administration, he will make sure that the medication matches the medication order to keep the resident safe and prevent medication error. He said that a medication order from the provider was needed before he can administer a medication. He said that he cannot administer Benadryl without an order even if his residents tell him that they take Benadryl at home. Further, he will reach out to the provider using a secured work cellphone to communicate the resident's medication request. He stated that once he had received an order for Benadryl, he will verify the medication to the order, prepare the medication for the resident, administer the medication to the resident, and stay with the resident to make sure the resident can swallow the pill without any issue. He will not leave a medication at bedside for resident's safety, because his resident might not take the medication. Further, he said that there is a process called self-administer when medications are left at bedside. He said that self-administration of medication requires a provider order, and the assessment of the mental capacity of the resident because he would not leave a medication at bedside to a resident who is confuse or with dementia due to lack of judgement and cognitive impairment. He reinstated that everything he provides to his residents for their needs requires an order from the provider.On December 15, 2025, at 1:00 PM, the Director of Nursing (DON/Staff #46) was interviewed. The DON stated that the process and expectation for medication administration was to have orders and administer the medications according to the orders given by the provider, and she expects her staff to stay and observe the resident taking the medication during administration. The DON stated that she would not give a medication without an order. She said that there should be an order from the provider, and if the staff gave a medication without an order, she would initiate an investigation. The DON stated that she was made aware of the Benadryl medication issue for Resident #103. She stated that a self- administration of medication process would include an assessment to check a resident's competency. She said that for a resident to self-administer medication, the resident needs to be alert and oriented; understands the medication and how to administer it; what the effects of the medication; and requires an order from the provider to self-administer the medication. Regarding the Benadryl for Resident #103, the DON stated that there was an order obtained from the provider to give Benadryl. She said that the order was in the staff/provider work cellphone text message. She said that the Benadryl order was received on Saturday evening, the nurse administered the medication, the night nurse watched the resident take her Benadryl, the nurse left the resident's room after the resident placed the medication in her mouth, the resident bite the medication in half and the resident requested to save the other half of the Benadryl. The DON stated that the Benadryl medication was not self-administered and not given without an order. The DON stated that she will provide the documentation of Benadryl order received on Saturday from the staff work cellphone text message.Review of the facility document from a staff work cellphone text message regarding Benadryl order revealed on top of the message was Saturday 8:49 PM, and the text messages were Resident #103 would like a Benadryl to sleep. Can I have an order for that, and Yeah prn.Upon further review of the Benadryl text message, the Benadryl order did not have a date stamped on the message, the Benadryl text did not include the dose and frequency of administration, time of administration, and route of administration. Regarding the text messages of Benadryl, the resident's electronic clinical record did not reveal a documentation that an order for Benadryl to sleep prn was received on Saturday at 8:49 PM, the December 2025 MAR did not reveal a transcribed order for Benadryl to sleep prn received on Saturday at 8:49 PM, and there was no documentation on the December 2025 MAR that the resident was administered a Benadryl to sleep prn after an order was received on Saturday at 8:49 PM.A follow up interview was conducted with the DON on December 16, 2025 at 12:58 PM. The DON stated that regarding physician orders, she expects the staff to get an order from a physician, and place the order in the electronic clinical record in a timely manner. She said that a timely manner was dependent on the situation. She said she expects the staff to place the order in the electronic clinical record by the time the dose is due. Regarding the Benadryl order, the DON said that when her staff received an order, the expectation was to give the medication. The DON read the order of Benadryl from the staff/provider cellphone text message. From the staff/provider cellphone text message, the DON said, order Benadryl as needed, and did not provide a dose. Further, the DON stated that her expectation of the Benadryl order was that if the order was different from a normal over-the-counter dose, then she expects a specific order. The DON stated that the provider was notified of the order clarification on the morning of December 14, 2025, and the half-dose order clarification was entered at 1:30 PM on December 14, 2025.However, according to [NAME] Nursing Drug Handbook, Benadryl is available over-the-counter, and the tablet form comes in different dosages, 25 MG and 50 MG. Since Benadryl, an over-the-counter medication comes in different dosage, the Benadryl text message order received on Saturday at 8:49 PM did not include a specific order for dosage for the nurse to administer to the resident.Review of facility policy titled Medication Administration-Oral revised on September 2025, revealed that it is the facility policy to accurately prepare, administer and document oral medications. The procedure included to identify resident eMAR (electronic Medication Administration Record) orders, administer the drug to resident, document administration of medication. The policy's Essential Points revealed no medication is to be administered without a physician's written order, the nurse preparing the drug administers it, the person administering medication must remain with the resident until all medication has been swallowed, fractional dosage: whole tablets not marked in one-half by means of well-defined line may not begiven by breaking the dry tablet in what seems to be half, and if there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage.Review of another facility policy titled Physician Orders revised on September 2025, revealed that drugs shall be administered, and the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to prescribe such drugs. The procedures included that all drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such as order; verbal orders will be recorded timely in the resident's chart by the person receiving the order and must include the date and the time of the order; drug orders must be recorded in the resident's medical record under orders; medication, treatment or related procedure orders are transcribed in the eMAR, accordingly; and orders of the medication must include:A. Name and strength of the drug;B. Quantity or specific duration of therapy;C. Dosage and frequency of administration;D. Route of administration if other than oral; andE. Reason or problem for which given.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure that 1 out of 10 sampled residents (# 41) received pain medication as ordered by the physician. The deficient practice could result in the potential for the resident to be in unnecessary pain.Findings include: Resident #41 was admitted on [DATE], with diagnoses that included fracture of the pelvis without disruption of the pelvic ring, fall from a roof, pain in the right shoulder, and muscle weakness.Review of the Resident's care plan revealed that Resident # 41 is currently prescribed an opioid for pain, effective September 11, 2023, with an intervention task that included to administer opioid medication as prescribed. Review of Resident's # 41 Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS revealed that Resident # 41 was on Opioids for pain, which he received occasionally, and rated his pain level an 8 out of 10 over the last 5 days. Review of the Resident's orders revealed the following orders,Dated September 12, 2023, at 1:25 p.m. Oxycodone HCL Oral Tablet 5 MG 1 tablet by mouth every 4 hours as needed for pain 1-3. Discontinued September 19, 2023, at 2:58 p.m.Dated September 12, 2023, at 1:25 p.m. Oxycodone HCL Oral Tablet 5 MG 2 tablets by mouth every 4 hours as needed for pain 4-10. Discontinued September 19, 2023, at 2:58 p.m.Dated September 19, 2023, at 2:59 p.m. Oxycodone HCL Oral Tablet 5 MG 1 tablet by mouth every 4 hours as needed for pain 1-3. Discontinued September 22, 2023, at 7:56 a.m.Dated September 19, 2023, at 2:59 p.m. Oxycodone HCL Oral Tablet 5 MG 2 tablets by mouth every 4 hours as needed for pain 4-10. Discontinued September 22, 2023, at 7:56 a.m. Review of September 2023 Medical Administration Record (MAR) revealed on September 15, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 8:47 a.m., one tablet was administered for a pain level of 6 out of 10.Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 15, 2023, only one tablet was pulled from the cart at 8:00 a.m.Review of September 2023 MAR revealed on September 17, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 2:05 p.m., one tablet was administered for pain level 5 out of 10, and at 11:35 p.m., only one tablet was administered for a pain level of 8 out of 10.Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 17, 2023, only one tablet was pulled from the cart at 2:10 p.m., and one tablet was pulled from the cart at 11:40 p.m.Review of September 2023 MAR revealed on September 18, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 4:40 a.m., one tablet administered for pain level 8 out of 10. At 12:50 p.m., one tablet was administered for a pain level of 6 out of 10, and at 4:55 p.m. and one tablet was administered for a pain level of 7 out of 10. Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 18, 2023, only one tablet was pulled from the cart at 4:00 a.m., and 12:51 p.m. Two tablets were pulled at 5:00 p.m., even though only one tablet was marked administered at that time. Review of September 2023 MAR revealed on September 19, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 4:15 a.m. one tablet administered for a pain level of 5 out of 10, and at 12:37 p.m., one tablet was administered for a pain level of 7 out of 10.Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 19, 2023, only one tablet was pulled from the cart at 4:15 a.m. and 12:40 p.m.Review of September 2023 MAR revealed on September 20, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 5:21 a.m., one tablet for a pain level of 6 out of 10, and at 1:37 p.m., one tablet was administered for a pain level of 7 out of 10.Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 20, 2023, only one tablet was pulled from the cart at 5:23 a.m. and 1:35 p.m.Review of September 2023 MAR revealed on September 21, 2023, administration of Oxycodone HCL Oral 5 MG Tablets at 1:30 a.m., one tablet for a pain level of 6 out of 10, and at 7:19 p.m., one tablet was administered for a pain level of 7 out of 10.Further review of the Controlled Drug Receipt/Record/Disposition Form revealed that on September 21,2023 only one tablet was pulled from the cart at 1:31 a.m. and 6:48 a.m.An interview was conducted on July 18, 2025, at 10:12 a.m. with Registered Nurse (RN/Staff # 108), who stated that if a narcotic needed to be administered, we would look at the orders and usually we need to try a non-pharmaceutical intervention first but if that does not work then we would dispense the narcotic based on the parameters of the orders. Once the medication is pulled from the cart, she would document the date, time. and the amount of the narcotic on the narcotic count sheets. Once it is recorded, we then administer the narcotic to the resident, and then we document the administration into the MAR. RN #108 revealed that after some time, she would then follow up with the resident to see if the medication was effective. An interview with the Director of Nursing (DON/Staff # 125) was conducted on July 18, 2025, at 11:46 a.m. revealed that when a patient requests medications, the nurses are to look at the order on the MAR, dispense the medications per the order, and administer the medication. In reviewing the September 2023 MAR, DON # 125 acknowledged that nurses must have misread the orders and possibly got confused with the multiple changes in orders. DON # 125 reveled that she expects that doctors' orders are followed in the MAR. Review of the facility policy titled, Medication Administration, reviewed September 2024, revealed that it is the policy of the facility to accurately prepare, administer and document oral medications. The policy also revealed that if there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies the drug dosage.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 out of 10 sampled residents (# 41). The deficient practice could result in the potential for the resident to not being properly medicated. Findings include: Resident # 41 was admitted on [DATE] with diagnoses that included fracture of the pelvis without disruption of the pelvic ring, fall from a roof, pain in the right shoulder, and muscle weakness.Review of the Resident's care plan revealed that Resident # 41 is currently prescribed an opioid for pain, effective September 11, 2023, with an intervention task that included to administer opioid as prescribed. Review of Resident's # 41 Minimum Data Set (MDS) dated [DATE] revealed a BIMS of 15, which indicates the resident is cognitively intact. The MDS revealed that Resident # 41 was on opioids for pain, which he received occasionally and rated the pain an 8 out of 10 over the last 5 days. Review of the Resident's orders revealed the following orders,Dated September 12, 2023, at 1:25 p.m. Oxycodone HCL Oral Tablet 5 MG 1 tablet by mouth every 4 hours as needed for pain 1-3. Discontinued September 19, 2023, at 2:58 p.m.Dated September 12, 2023, at 1:25 p.m. Oxycodone HCL Oral Tablet 5 MG 2 tablets by mouth every 4 hours as needed for pain 4-10. Discontinued September 19, 2023, at 2:58 p.m.Dated September 16, 2023, at 3:12 p.m. Oxycodone HCL Tablet 5 MG 2 tablets by mouth two times a day for pain. Discontinued September 19, 2023, at 2:44 p.m. Dated September 19, 2023, at 2:59 p.m. Oxycodone HCL Oral Tablet 5 MG 1 tablet by mouth every 4 hours as needed for pain 1-3. Discontinued September 22, 2023, at 7:56 a.m.Dated September 19, 2023, at 2:59 p.m. Oxycodone HCL Oral Tablet 5 MG 2 tablets by mouth every 4 hours as needed for pain 4-10. Discontinued September 22, 2023, at 7:56 a.m.Dated September 19, 2023 at 2:44 p.m. Oxycodone HCL Tablet 5 MG 2 tablets by mouth two times a day for pain management. Discontinued September 22, 2023, at 7:56 a.m. Review of the Controlled Drug Receipt/Record/Disposition forms for September 13, 2023, revealed that Oxycodone HCL 5 MG tablets were taken from the cart at, 8:20 a.m. 2 tablets marked. This entry was crossed out with a note of dropped/wasted along with two staff initials.8:45 a.m. 2 tablets marked12:55 p.m. 2 tablets marked4:50 p.m. 1 tablet marked8:40 p.m. 2 tablets marked Review of September 2023, Medical Administration Record (MAR) revealed on September 13, 2023, administration of Oxycodone HCL Oral 5 MG Tablets was at the following times,8:45 a.m. 2 tablets as needed for pain of 8.12:55 p.m. 2 tablets as needed for a pain of 7.4:40 p.m. 1 tablet as needed for a pain of 3. Review of the Controlled Drug Receipt/Record/Disposition forms for September 16, 2023, revealed that Oxycodone HCL 5 MG tablets were taken from the cart at, 8:00 a.m. 2 tablets marked.5:24 p.m. 2 tablets marked.8:00 p.m. 2 tablets marked.Review of September 2023, Medical Administration Record (MAR) revealed on September 16, 2023, administration of Oxycodone HCL Oral 5 MG Tablets was at the following times,8:00 p.m. 2 tablets scheduled for a pain of 5.Review of the Controlled Drug Receipt/Record/Disposition forms for September 21, 2023, revealed that Oxycodone HCL 5 MG tablets were taken from the cart at, 1:31 a.m. 1 tablet marked6:59 a.m. 1 tablet marked No Time marked, there is a note indicating the rest of the medication was sent home with the patient on September 21, 2023, with two staff initials.Review of September 2023, Medical Administration Record (MAR) revealed on September 21, 2023, administration of Oxycodone HCL Oral 5 MG Tablets was at the following times,1:30 a.m. 1 tablet as needed for pain of 6.7:19 a.m. 1 tablet as needed for pain of 7. 8:00 a.m. 2 tablets scheduled for pain of 6.An interview was conducted on July 18, 2025, at 10:12 a.m. with Registered Nurse (RN/Staff # 108), who stated that if a narcotic needed to be administered, once the medication is pulled from the cart, she would document the date, time, and the amount of the narcotic on the narcotic count sheets. Once it is recorded, we then administer the narcotic to the resident, and then we document the administration into the MAR. If the resident refuses or the narcotic gets dropped, we then waste the medication and document on the narcotic sheet that the medication was wasted, and have two nurses sign off on the narcotic sheet. RN # 108 also stated that at the end of the shift, the narcotic cards and each individual pill are counted with the oncoming nurse. If count is off, then they would try and recount it. If it continued to be off, we would contact the Director of Nursing for further instructions. An interview with the Director of Nursing (DON/Staff # 125) was conducted on July 18, 2025, at 11:46 a.m. revealed that at the end of every shift, the outgoing and incoming nurses will reconcile the count of the narcotic cards to the actual count of narcotics on hand. The facility has an independent pharmacy that conducts reconciliation between narcotic count sheets and the MAR. DON # 125 acknowledged that the count is off between September 13, 16, and 21 narcotic counts and MAR. DON # 125 explained that her expectation is that whatever narcotic is pulled from the cart is accounted for on the MAR. Review of the facility policy titled, Controlled Medications- Storage and Reconciliation, reviewed April of 2025, revealed that when a controlled medication is administered, the licensed nurse administering the medication immediately enters the date and time of administration amount administered and signature of the nurse administering the dose, completed after the medication is actually administered.

Based on clinical record review, facility records, staff interviews, and facility policy, the facility failed to ensure that that an allegation of abuse was reported as required. Findings include:-Resident #100 was admitted on [DATE] with diagnoses of Major Depressive Disorder, difficulty walking, and type 2 Diabetes Mellitus.An annual Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact. This document included that this resident required supervision for all activities of daily living.-Resident #12 was admitted on [DATE] with diagnoses of Major Depressive Disorder, hemiparesis and hemiplegia.A quarterly Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively severely impaired with fluctuating inattention and required extensive assistance for bed mobility, dressing, toilet use and personal hygiene.An intake for a facility reported incident received September 16, 2022 included that resident #12 was the resident involved and that previous complaints states male resident touched resident in the vagina. This intake included that a call was received from the Administrator and when APS worker notified him of the allegation on Friday, all parties were notified. The alleged perpetrator (Resident #100) who is alert and oriented, was immediately placed with a 1:1 sitter around the clock and will remained so until the resident is transferred out to another facility which may happen today.A 5-day report with a fax date of September 23, 2022 included that the date of this incident was on September 16, 2022.However, a nursing progress note dated September 9, 2022 included that around 1830 a Certified Nursing Assistant (CNA) informed the nurse that a resident complained that resident #100 touched her inappropriately. This note included that the charge nurse was notified and that she informed the Director of Nursing (DON).An interview was conducted on July 18, 2025 at 9:08 AM with a CNA (staff #14) who said that it is my job is to prevent abuse, and to protect the residents. This staff said that first she would come to see what is the scenario and make sure the residents are safe, and if it is a resident to resident abuse, she would remove one of the residents and inform her nurse. This CNA said the nurse would take over because it is abuse.An interview was conducted on July 17, 2025 at 10:16 AM with a Licensed Practical Nurse (LPN/staff #110) who said that abuse can be financial, emotional or physical. She said that if she witnessed abuse, that she would try to deescalate the situation then she would try to separate the residents and immediately call her administrator, notify the provider, and the supervisor or administrator usually reach out to the resident's family.An interview was conducted on July 18, 2025 at 10:40 AM with a LPN (staff #107) who said that she was provided abuse training and that she would report it to the Nurse Manager or the DON and that they report it to the Department of Health and other authorities.An interview was conducted on July 18, 2025 at 10:50 AM with an Assistant Director of Nursing (ADON/staff #82) who said that staff should immediately call the Abuse Coordinator/Executive Director or the DON.An interview was conducted on July 18, 2025 at 11:06 AM with the DON (staff #82) included that her expectation for her staff would be to immediately report it. This DON included that the Abuse Coordinator/Executive Director is involved and that usually he calls her and they investigate. This DON included that they report sexual abuse within 2 hours and that they try to get an initial investigation so they know a little better what to report. This DON reviewed the clinical record and said that the progress note dated September 9, 2022 looked like the incident reported on September 16, 2022. A follow up interview was conducted on July 18, 2025 at 11:45 AM with the DON (staff #82) who verified that the incident reported on September 16, 2022 was the incident that was recorded on September 9, 2022 progress note. This DON said that it was probably because that nurse was agency and did not report it correctly and that she was not working in the facility during that time. A policy titled Abuse: Prevention of and Prohibition Against reviewed September 2024 included that allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one of three residents (#62) received services that met professional standards in regards to his medications being administered per provider order. This deficient practice could lead to medical complications.Findings include:Resident #62 was admitted on [DATE], with diagnoses that included bacteremia, urinary tract infection, sepsis and sacral decubitus.A provider order was written on April 7, 2025, for Ceftaroline Fosamil (an antibiotic), 400 milligrams intravenously (IV) every 8 hours for sepsis for 29 days. The first dose of the medication was scheduled to be administered the night of the resident's admission on [DATE].Review of Resident #62's Medication Administration Record (MAR), dated April 2025, revealed a code of 7 for the following scheduled IV doses: April 7, 2025 at 8:00 PM, April 8, 2025 at 8:00 AM and 2:00 PM, April 9, 2025 at 2:00 PM and April 10, 2025 at 8:00 AM. A code of 7 was defined in the MAR as meaning the medication was not administered, and to see the progress notes.Progress notes for Resident #62 were reviewed. A note on April 7, 2025, at 11:52 PM, stated, waiting on pharmacy. On April 8, 2025, at 6:59 PM, it stated, on order. On April 9, 2025, at 1:40 PM, the note stated, pending arrival. On April 10, 2025, at 10:54 AM, it stated night shift charting. Unknown if hanged.There was no indication in the progress notes that the provider was notified that the IV antibiotics were not administered per order.Two infectious disease doctor visit summaries, dated April 8, 2025 and April 10, 2025, revealed the reason for the consultation was for antibiotic management. The provider indicated that the plan was for the resident to take Ceftaroline until May 7, 2025. The note indicated that the provider discussed with nursing on duty. There was no indication in the note that the provider was aware that the resident had missed some scheduled doses of the IV antibiotic.An interview was conducted with a Licensed Practical Nurse (LPN/staff #41) on July 16, 2025, at 9:35 AM. The LPN stated that if she were missing a medication from the medication cart, she would check the facility for the medication, re-order it through the system, call the pharmacy and notify the director of nursing or the manager on duty.An interview was conducted with a Registered Nurse (RN/staff #45) on July 17, 2025, at 11:25 AM. The RN stated if he were missing an IV medication, he would notify the IV company. If it was unavailable, he would notify the provider and the director of nursing and document in the progress notes.An interview was conducted with the Director of Nursing (DON/staff #125) on July 17, 2025, at 12:45 PM, who stated that if an IV antibiotic was missing, she would expect staff to look for it, call the pharmacy and notify the provider. She stated those actions should be documented in a progress note.The DON then reviewed Resident #62's medical record. She located several progress notes stating that the medication was not administered per the provider's order. She stated she was unsure as to the reason the antibiotics were not administered according to the order. She could not locate any progress notes stating a provider had been notified.A follow-up interview was conducted with the DON on July 18, 2025, at 11:10 AM. The DON acknowledged that the IV antibiotics should have been administered per the provider's order and that the documentation showed that the resident missed several doses, without proper documentation of the provider being notified. The risk of the deficient practice was that the resident's infection could be prolonged and could possibly worsen.A review of the facility's medication policy revealed that staff are to notify the provider if there are irregularities in the administration of medications.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to follow resident's advanced directives by not providing Cardiopulmonary Resuscitation (CPR) on 1 of 3 sampled residents (#21). The deficient practice could result in death of the resident. Findings include: Resident #21 was admitted on [DATE], with diagnoses of acute and chronic respiratory failure with hypoxia. Review of the Preferred Intensity of Care document signed [DATE] revealed Resident # 21's advanced directive was to receive resuscitation and transfer to an acute Hospital. A physician's order dated [DATE] included CPR Full Code, Oxygen at 3-4 liters per minute via nasal cannula, continuous, allowing to titrate up 5 liters per minute to keep oxygen saturation above 88, and pulse oximetry testing as needed for signs and symptoms of respiratory distress. According to the comprehensive care plan initiated on [DATE], the resident had oxygen therapy due to lung cancer, in which the Facility was to monitor for signs and symptoms of respiratory distress and report to the medical doctor as needed: respirations, pulse oximetry, and increased heart rate. Review of the overnight shift schedule dated [DATE] revealed the staff assigned to Resident #21 included: Certified Nursing Assistant (CNA/Staff #7) from 6:00 p.m. - 6:00 a.m., Registered Nurse (RN/Staff #4) from 6:00 p.m. - 12:00 a.m., Licensed Practical Nurse (LPN/Staff #13) from 12:00 a.m. - 6:00 a.m. RN (#55) was also scheduled to work the back cart from 6:00 p.m.- 6:00 a.m. According the Medical Administration Record (MAR) dated [DATE] at 6:15 p.m. an administration of ipratropium-albuterol solution was administered via nebulizer due to shortness of breath and wheezing. Review of vital signs dated [DATE] at 7:21 p.m., performed by CNA (#7), revealed a blood pressure of 82/48 and pulse oxygenation at 90% via nasal cannula. The MAR dated [DATE] indicated that midodrine oral tablet was administered at 9:29 pm for low blood pressure. According to the MAR, the medication was administered by RN (#4). It was further documented by this RN (#4) at 9:49 p.m. the nebulizer treatment was effective. Review of the clinical record revealed no evidence of follow up of the effectiveness of the midodrine on the critically low blood pressure nor documentation of physician being contacted. A Nursing progress note dated [DATE] at 3:03 a.m., written by LPN (#13) revealed that Resident (# 21) was found by a CNA (not identified) at approximately 2:00 a.m. cold and unresponsive. According to the progress note, CPR was initiated. Review of the record revealed no evidence on who initiated CPR and what time CPR was initiated. The Director of Nursing (DON/ Staff #6) was notified at 2:30 a.m. by LPN (#13). LPN (#13) was given instruction to call 911, at that time. Emergency Medical Technicians (EMTs) arrived at approximately 2:35 a.m. and resident was pronounced deceased at 2:40 a.m. An EMT report dated [DATE], revealed that EMTs were called at 2:34 a.m. and were on the scene at 2:37 a.m. When they arrived to the Facility, CPR was not being conducted, instead Resident (#21) had her sheets pulled over her entire body and staff said that Resident (#21) was deceased . When staff was asked when Resident (#21) was last seen normal, the staff stated they did not know. On assessment performed by the EMTs, Resident (#21) was apneic, pulseless, and unresponsive. Resident (#21) was cold to the touch, stiff, with dependent lividity present. No signs of trauma were present. LPN (#13) signed Transfer of Patient Care for Resident (#21) and stated they would contact family. A phone interview was attempted with LPN (#13) on [DATE] at 3:10 p.m. and on [DATE] at 9:28 a.m. No contact was made. An interview with a CNA (#7) was conducted on [DATE] at 3:14 p.m., CNA (#7) stated that she was assigned to Resident's (#21) room on the overnight shift on [DATE]. She stated that Resident (#21) was wheezing and not feeling well. She further stated that Resident's (#21) roommate, Resident (#36), had pressed her call light concerned for resident, telling staff that Resident (#21) was asking to go to hospital. CNA (#7) informed RN (#4) about Resident (#21) condition and her wanting to go to the hospital. RN (#4) informed CNA (#7) that Resident's (#21) physician was aware. Review of the clinical record reveled no evidence that Nurse (#4) assessed the resident at this time. According to CNA (#7) she went into Resident's (#21) room at approximately 1:40 a.m., and the resident was struggling to breath so she put her nasal cannula on. Review of the clinical record revealed no evidence that the provider was notified during this time. She returned around 2:00 a.m. to check on resident and discovered she was not breathing. She stated that she was unaware of the resident's code status so she called LPN (#13) and asked her. CNA reported that LPN (#13) came into the room assessed the resident and told her that CPR was not necessary because Resident (#21) had clearly passed. CNA (#7) stated that LPN (#13) and RN (#55) discussed what to do and decided to call DON (#6) and EMS. CNA (#7) stated that during this time a Code was never called and CPR was not performed. An interview with RN (#4) was conducted on [DATE] at 3:29 p.m. RN (#4) reported not remembering Resident (#21). She could not recall any incident with Resident (#21). Attempted phone interview with RN (#55) on [DATE] at 3:27 p.m. and then again on [DATE] at 9:25 a.m. A voicemail message was left both times with no return calls. Facility tried to reach out to RN (#55) and reported they were unable to get ahold of her but confirmed she was still employed with facility. An interview with CNA (#43) was conducted on [DATE] at 8:56 a.m. She stated the Facility's process during a code would be to call for help and start getting everything ready, once help arrives, compressions are started and someone else will do the bag. Whoever is not doing compressions usually makes the phone call to EMS. We do this until EMS arrives and takes over. EMS does not take long because they are right next door to us. CNA replied the nurses can get CPR status in the electronic medical record (EMR), a CNA would not have access to that so they would have to look in the books at the nurses' station. CNA (#43) stated that LPN (#13) was let go and had not seen her in the last two weeks. An interview with LPN (#29) was conducted on [DATE] at 9:10 a.m. who stated that the procedure for a code included checking the code status on the computer then check vitals and start CPR, LPN (#29) stated that she would assign someone to call 911. If a CNA discovered a resident, they would call the code through the walkies and check with nurses on code status or look at nurses' station for the paper copies. We train codes here at the facility we just had a mock code a couple weeks ago. She stated that once CPR has been initiated, it isn't stopped until EMS takes over. LPN (#29) stated that EMS will pronounce the patient, the only time nurses can pronounce is if they have a Do Not Resuscitate (DNR) order or are on Hospice. Attempted phone interview with Resident (#36), the roommate to Resident (#21) at the time of the incident, on [DATE] at 10:00 a.m. Phone number was not in operation. An interview with Human Resources Director (HR/Staff #16) on [DATE] at 11:16 a.m. stated that LPN (#13) was terminated on [DATE]. She stated that when a staff member is terminated the manager fills out a termination form and HR (#16) enters into the computer. Usually, corrective actions are conducted by the manager and administrator. She stated that she does not sit in on corrective actions. She reported that there was an investigation conducted by DON (#6) regarding LPN (#13). She recalled that the investigation was about a death and not following procedures but she did not have details. When HR (#16) reviewed her computer, she stated the official reason for LPN's (#13) termination was misconduct. An interview with DON (#6) on [DATE] at 12:05 p.m. stated that during a code, if a resident is found pulseless and not breathing staff will check status, call 911 and call a code blue on the walkies or over the speaker. She stated that staff know the code status because it is in the resident's orders in the Electronic Medical Record (EMR), or there is a binder for the CNAs at the nurses' desk. DON (#6) stated CNAs typically ask the floor nurse as they have immediate access to the chart. CPR is initiated by whomever discovers resident as long as they are certified to perform CPR. She stated that 911 is usually called immediately and they are next door. The faster they get here the sooner we can stop doing CPR because they will take over. DON (#6) responded that EMS or provider would pronounce death if in building. The only time nurses can pronounce death is if the resident status is a DNR or the resident is a Hospice patient, then two nurses can pronounce death. The DON then reviewed Resident's (#21) chart regarding her code. DON stated that Resident (#21) was a full code. DON identified resident change of condition and pointed out last blood pressure was low taken at 7:21 p.m., and facility provided fluids and midodrine. DON reviewed chart for documentation on midodrine follow up. She said staff typically write in MAR the effectiveness but was unable to locate another note in the chart. She went on to state that Resident (#21) was found unresponsive about 2:00 a.m. per the progress note, and CPR started. The DON also stated that she was contacted about 30 minutes later by LPN (#13) about the incident. DON instructed LPN (#13) to call EMS. DON said that there was some confusion by LPN (#13), who thought she could pronounce death with another nurse. DON had to inform LPN (#13) not on a full code resident and EMS needed to be dispatched immediately. DON reiterated that during the 30 minutes from when Resident (#21) was identified until EMS arrived, CPR never stopped, and was performed by CNA #7. DON stated that EMS arrived around 2:35 p.m., and took over. EMS pronounced her dead at 2:40 a.m. The DON said later there was a debrief of the code and CNA (#7) told me she started CPR and we discussed who gets contacted and when. Per DON a mock code for staff was conducted a couple weeks later. DON stated that LPN (#13) was investigated for being disrespectful to coworkers and pushing back on her duties that she felt were not part of her job. DON (#6) stated she believed the staff followed protocol during this incident. Review of Change of Condition Reporting Policy dated [DATE], included for life threatening changes a licensed nurse will initiate appropriate first aid measures until emergency response personnel arrive on scene. Licensed nurse will inform primary physician (alternate physician, or Medical Director) of resident status as soon as possible once resident needs have been met and immediacy of nursing care is completed. It goes on to include, all nursing actions, physician contacts, resident representative, and resident assessment information will be documented in the nursing progress note. Review of CPR and First Aid policy dated [DATE], once CPR is initiated, it will be discontinued only by a physician's order and or the arrival of rescue personnel who take over CPR efforts and/or transport the resident.

Based on observations, interviews, facility document reviews, and facility policy, the facility failed to ensure a comfortable and safe temperatures were maintained in one resident room (Resident #274). The deficient practice could place the resident's at risk for safety and illness. Findings included: Resident #274 was admitted on [DATE] with diagnoses of osteomyelitis, urinary tract infection, chronic systolic heart failure. The resident's Brief Interview for Mental Status (BIMS) dated May 1, 2024 revealed a score of 15 that indicated resident was cognitively intact. During an initial screening on May 6, 2024 at 9:34 AM, Resident #68 stated that the room was hot, she had been in that same room for a month, and staff were aware of her concerns. Resident #68 added that the second week she got there that she almost passed out. She stated she was not used to hot temperatures since she was living in a different state. She further added that the staff brought her lots of ice and cool rags because she was very hot and she felt like she was going to pass out. Resident #274, who shared the same room with Resident #68, stated that the air conditioner did not work and the maintenance staff were aware that the air conditioning was not working. An interview was conducted with Maintenance Director/Staff #115 on May 8, 2024 at 12:14 PM. Staff #115 stated that the certified nursing assistants (CNAs) and all staff can submit work order. He used an app that gave weekly and monthly task and work orders. Staff #115 stated that he viewed and checked the work orders in his phone. After viewing and checking the work orders he had received, he communicated with the nursing team. For example, he communicated a work order for a low air mattress and issues with lighting for a resident. Another interview was conducted with Resident #274 on May 9, 2024 at 9:37 AM. Resident #274 stated that it was still hot in her room. The portable fan was turned on in her room. She added that her roommate was discharged yesterday and she left her the portable fan to use. In addition, Resident #274 stated that her room felt hot since she arrived on May 1st. During the interview, the resident's room had a sliding door and she stated that she felt the sun heat was coming in from the door all day. The sliding door had a shade and the shade was rolled up from the bottom and closed about two thirds from the top. Resident stated that she did not messed with the shade because it was not in her side of the room. On May 9, 2024 at 9:58 AM, a temperature check was performed using a laser temperature gun. The temperature by the window hallway outside the Resident #274 's room was 74.5-75 degrees Fahrenheit. The temperature in the resident's room just outside the resident's bathroom door was 75 degrees Fahrenheit with a portable fan turned on. An interview was conducted with a certified nursing assistant (CNA)/Staff #108 on May 9, 2024 at 2:01 PM. Staff #108 stated that the temperature in the rooms are pretty much even. And, if residents say that their rooms were warm, she will have the maintenance staff check the room. She further stated that the thermostats were controlled in the hallways. An interview was conducted with the Maintenance Director/Staff #115 on May 9, 2024 at 2:06 PM. Staff #115 stated that the facility had 16 units total and each unit controls 7 to 8 rooms with the common area or office per unit. He stated that the back end where the Director of Nursing (DON) and rooms 5 through 18 use unit 12 or 13 to control the temperature. He further added that the thermostat was set between 71 through 74 degrees Fahrenheit. He stated that he checked the temperature every morning. He also felt the vents to make sure that cool temperature was coming out and this is done every weekly. He further added that when he checked the thermostat in the room, he carried his temperature check gun. If the temperature is hot, he will offer a fan to the resident and then communicate the issue with the DON and admission so the resident can be moved to another room. Furthermore, he stated that there was a thermostat issue a week ago or so and a technician was called. On May 9, 2024 at 3:45 PM, Resident #274 stated that it was cooler today but it had been hot. With laser temperature gun, the temperature at vent was 91 degrees Fahrenheit, and the floor fan was on high setting. On May 9, 2024 at 3:52 PM, another interview was conducted with the Director of Maintenance. Staff #115 took temperatures in room [ROOM NUMBER]. Staff #115 used two temperature guns and the first one read 88.2 degrees Fahrenheit. The second reading was 87 degrees Fahrenheit. The temperature in room [ROOM NUMBER] was 61 degrees Fahrenheit, in room [ROOM NUMBER] was 49 - 52 degrees Fahrenheit depending on the thermometer. He further stated that maybe the vents need to be adjusted. He also added that the resident had originally said that it was hot on May 2nd when he was in Resident #274's room fixing a television. He agreed that it was very warm. He added that the thermostat was installed on that unit in May, but did not include the vents, ducts, or actual air conditioning. He added a floor fan in her room. One thermostat will control 7 rooms approximately and it cannot be adjusted for her. On May 9, 2024 at 4:15 PM, an interview with the Director of maintenance was conducted. The administrator/Staff #72 was present during the interview. The Director of maintenance stated that a comfortable environment temperature is between 72 thru 73 degrees Fahrenheit. The administrator added that the temperature range is 71 thru 82 degrees is the safe temperature range but certain resident had a preference for warmer and cooler temperatures. A review of the facility policy titled, Temperature, Rise in Environment and in the Facility, with a reviewed date of May 2022 revealed an acceptable environmental temperature ranges from 71-81 degrees to ensure a home like environment the resident has the right to request adjustment to room temperature for comfort.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure medication services are provided according to accepted standards of clinical practice for one resident (#177). The deficient practice could place residents at risk for developing illness. Findings included: Resident #177 was admitted at the facility on April 18, 2024 with diagnoses of acute on chronic systolic congestive heart failure, generalized edema, and acute kidney failure. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 which meant the resident was cognitively intact. Review of Resident #177 care plan initiated on April 18, 2024 revealed a focus for potential fluid deficit related to diuretic use. The goals included that the resident will be free of symptoms of dehydration and will maintain moist mucous membranes, good skin turgor. The interventions included to administer medications as ordered. On May 7, 2024 at 7:23 AM the medication administration observation pass was conducted with licensed practical nurse (LPN)/Staff #200, she stated that the process of administering medication included the right person and right dose. Resident #177 was amongst the residents observed for medication administration observation pass. During Resident #177's medication preparation on May 7, 2024 at 7:55 AM, Staff #200 stated that the staff noticed two orders for potassium medication and stated that she was holding the potassium 10 mEq (Milliequivalent). Review of Resident #177 record revealed following two physician orders for Potassium Chloride ER medication: -Potassium Chloride ER (Extended Release) Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement -Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis A review of Resident #177's Medication Administration Record (MAR) revealed on May 7, 2024 for 0800 Hours, Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis, was administered by Staff #200 and Potassium Chloride ER Oral Tablet 10 MEQ, give 1 tablet by mouth three times a day for supplement, was marked held/see nurse notes by Staff #200. A follow up interview was conducted with Staff #200 on May 7, 2024 at 3:40 PM. Staff #200 stated that she informed her charge nurse and she stated that the potassium medication was a duplicate order. She stated that if she did not understand something about the medication then she will go to the charge nurse or the director of nursing (DON) or the physician if readily available. A review of Resident #177 clinical record on May 7, 2024 at 3:57 PM revealed a documentation under electronic medication administration record (eMAR)-medication administration note dated May 7, 2024 at 8:04. The note stated that the Potassium Chloride ER Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement, was held for duplicate order. In addition, a review of Resident #177 laboratory results dated [DATE] at 17:16 revealed a potassium of 3.9 millimoles per liter (mmol/L). An interview was conducted with registered nurse RN/Staff #11 on May 8, 2024 at 10:32 AM regarding physician orders. He stated that for an order that he had a question with, he stated that he double checked with the provider. He contacted the provider by using the provider numbers located in the station phone. The station phone included the provider's number and their office numbers. Furthermore, he stated that for medications that needed clarification such as sometimes orders are transcribed in a wrong way for instance the nurses transcribed by mouth instead of enteral feeding. He called the doctor to confirm route. Another example, for same medication with two orders that looked like maybe a mistake, he reads the actual order. An example was a vitamin C order 500 mg everyday but certain days of the week there was an order for vitamin C 1000 mg. He stated that he wondered why he was signing the medication vitamin C twice. He stated He did not hold the order and only gave the medications after the order was confirmed by talking to the provider. An interview was conducted with the director of nursing (DON)/Staff #14 on May 9, 2024 at 2:44 PM and she stated that when preparing medication, she anticipated the nurse to call the provider for clarification and her expectation for her staff was to clarify and notify. The nurse is using her judgement that she will review order and then notify provider. Review of Medication Administration Policy revised 05/2017; last Reviewed 10/2023 revealed the facility to accurately prepare, administer and document oral medications. In addition, Essential Points: 13. Any irregularity in pouring or administering must be reported to the doctor. 14. If there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure staff provided meals according to regulations to one resident (#76). The deficient practice could result in residents not meeting dietary needs. Findings include: Resident #76 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses that included left tibia fracture, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease. Resident #76 had an order dated 4/15/2023 for regular diet with regular texture and thin liquids. There were also orders for once daily dietary supplements; Glucerna 8 ounces and Prostat 30 milliliters, dated 4/19/202 and 4/22/2023 respectively. Medicare Minimum Data Set (MDS) dated [DATE] shows Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment. The care plan initiated on 4/16/2023 reflected a goal related to resident being malnourished. The goal for resident #76 was to maintain adequate nutritional status as evidenced by consuming more than 75% of meals and supplements. Interventions included diet as ordered by the physician and monitor and report to the physician any decreased appetite, unexpected weight loss, A nutritional screening dated 4/18/24 revealed the resident was malnourished due to being bed bound and experiencing rapid weight loss. Recommendations were to provide dietary supplement Ensure. A review of the facility grievance log for April 2023 showed resident #76 had brought up meal concerns with the kitchen and the Assistant Director of Nursing on 4/17/2023. Review of the Plan of Care (POC) task documentation shows one shift on 4/18/2023 and 4/20/2023 each, show no documentation of meals being provided to resident #76. In an interview on 05/09/2024 at 1:41pm with a Certified Nursing Assistant (CNA/Staff #40), Staff #40 stated that activity of daily living (ADL) care is always documented in the electronic health record (EHR) and CNAs document under POC tasks. They stated that ADL's like meals, baths, brief changes, and dressing is documented each time it is completed. In an interview with CNA (Staff #24), she stated ADL care is always documented in the EHR including refusals of care which are also reported to the nurse. Each time they provide the ADL service it is documented in the system. Some of them are required the one time and then it will be as needed. For bowel movements for example, a new entry can be created for each time a brief change is done. Each meal is also a new entry. She reviewed the print out of POC tasks for resident #76 and when asked what the blanks meant, she stated that meant it was not completed. In an interview with the Director of Nursing (DON/ Staff #14) on 05/09/2024 at 2:10pm, she reviewed a print out of the POC tasks for Resident #76 and stated that the blanks are not indicative of the services not being completed. They just mean that it was not documented. There are areas that show that if a service was completed after midnight, then they will roll over to the next day, but it was still completed. Review of Resident #76's chart shows that eating was not documented for 2 days and she indicated this was not due to the midnight rollover glitch. The DON stated that the facility had intitated the following measures after the April 12, 2023 abbreviated survey: -staff to be in-serviced on accuracy and completion of daily Point of Care/Activities of Daily (POC/ADL) Living with a completion date of 06/21/2023. -staff to be in-serviced on recognizing and reporting changes in ADL activity/ability. The completion date was 06/21/2023. -DNS or designee will conduct a daily review Monday through Friday of POC/ADL documentation completion x 4 weeks to ensure substantial compliance. 06/21/2023. -DNS or designee will ensure that the nutrition report will be discussed and reviewed at the weekly nutrition meeting for the Interdisciplinary Team (IDT) to recognize declines or changes in eating patterns and respond proactively to the changes as indicated x4 weeks. The completion date was 06/21/2023. -DNS or designee will report findings of reviewes to the QAPI committee with additioanl follow-up and recommendation as needed until substantial compliance is achieved and maintained. The completion date was 06/21/2023. In a policy titled Documentation and Charting last reviewed 07/2023, it stated that facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care.

Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure nursing documentation reflect care and medical services provided for Resident # 36 according to professional standards. The deficient practice may result in incomplete and/or inaccurate clinical records, and suboptimal care due to the absence of pertinent clinical information. Findings include: Resident # 36 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism, depression, and generalized anxiety disorder. The comprehensive minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, which indicated the resident was cognitively intact. On May 06, 2024 at 10:02 AM, an observation of Resident # 36 revealed discoloration surrounding her left eye darkened at an unknown stage of bruising. An interview conducted with Resident # 36 stated that this was due to a recent fall injury inside the facility which resulted in a left sided-orbital fracture. On May 07, 2024 at 3:39 PM, electronic medical record (EMR) nursing progress notes reviewed from the day of fall dated April 29, 2024 at 3:03 PM, revealed no information detailing how the fall had occurred: Nurse was notified that resident was found on the floor, resident was bleeding from her eyebrow, pressure was applied to site followed by steri strips, and provider notified and advised staff to send resident to emergency department via 911. On May 07, 2024 at 04:45 PM, an interview was conducted with Director of Nursing (DON/Staff # 14) regarding completing and accurately documenting the fall incident. Staff # 14 stated Resident # 36 was found on the floor, alert and oriented, and the fall was not suspected to be a result of neglect or abuse. Staff # 14 stated that the call light was not used by the resident and believed she had tripped over her oxygen tubing. Staff # 14 stated that although these details were not found on the nursing progress notes, this was documented on the facility's risk assessment notes. Staff # 14 attempted to locate the documentation on the facility risk assessment, however realized the documentation was never created and that this information about the incident was just being recalled. Staff # 14 requested that Assistant Director of Nursing (ADON/Staff # 64) join in the interview because she had discussed the incident with her. Staff # 64 joined the interview, but could not recall the incident details or explain accurately when a fall should be reported to the Department of Health Services (DHS). Staff # 64 stated that since she was hired as ADON she was unaware if falls were reported and confirmed she had not reported any falls to DHS. Staff # 14 stated she would like to educate Staff # 64 at this time, and proceeded to explain which falls must be reported to DHS. On May 08, 2024 at 08:45 AM, a list of residents who had previous falls with major injury in the last 6 months was requested. The list revealed a single individual or Resident # 36. On May 08, 2024 at 09:24 AM, Staff # 14 stated that the facility had made an error by failing to document how the fall had occurred, however that the notes were created last night as a late entry through risk management documentation. Staff # 14 stated she was there when it happened, and should have documented or made sure that staff documented. Staff # 14 stated not only was she there and failed to document, but she failed to make sure that her staff documented what happened. She stated that did not meet professional standards. Review of the facility's policy titled, Fall Management System revision date of July 2023 revealed, -review of the fall incident will include investigation to determine probably causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. -the investigation will be reviewed by the interdisciplinary team (IDT). Results of the investigation will be documented in the resident's clinical record. Review of the facility's policy titled, Documentation and Charting revision date of July 2022 revealed, it is the policy of this facility to provide: -a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. -the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident. -nursing service personnel with a record of the physical and mental status of the resident. -the elements of quality medical nursing care -legal record that protects the resident, physician, nurse and the facility.

Based on clinical record review, staff interviews and review of policies and procedures, the facility failed to ensure identify and address the risk factors for the nutritional status for one resident (#1). The deficient practice could result in residents not meeting dietary needs. Findings include: Resident #1 was admitted on [DATE] with diagnoses of transient ischemic attack (TIA), cerebral infarction without residual deficits, gastro-esophageal reflux disease (GERD) without esophagitis and type 2 diabetes mellitus. A care plan initiated on January 14, 2023 revealed the resident had ADL (activities of daily living) self-care performance deficit. Goal was that the resident would maintain current level of function in eating. Interventions included to discuss feelings about self-care deficit, participate to the fullest extent possible, and use mobility bars. The nutrition care plan dated January 14, 2023 included resident had malnutrition. Goal was that the resident will maintain adequate nutritional status as evidence by consuming more than 65% of meals and supplements. Interventions included to monitor and report to physician as needed for any signs or symptoms of decreased appetite, RD (registered dietician) to evaluate and make diet change recommendations, and provide supplements as ordered. A nursing note dated January 14, 2023 revealed the resident was alert and oriented times 1-2, was able to answer yes or no questions only and continued to refuse medications; and that, the nurse educated the resident on the importance of the medications. The weight on January 14, 2023 was 135 lbs. (pounds). The speech therapy note dated January 16, 2023 included the resident was at baseline for cognition and had a history of TBI (traumatic brain injury) with a decline over the past several months. Review of the admission minimum data set (MDS) assessment dated [DATE] included the resident had a brief interview for mental status (BIMS) score of indicating the resident had severe cognitive impairment. A nursing note dated February 8, 2023 included the resident refused medications during the first medication pass and 45 minutes later; and that, the staff attempted another time right before lunch and the resident stated that he was not taking them today. The weights record for February and March 2023 were recorded as follows: -February 1 was 126.4 lbs. which was significant weight loss 6.37% from January 14, 2023; -March 6 was 128.6 lbs. Review of the Documentation Survey report from February 1 through March 31, 2023 revealed that there were multiple dates that the meal intake percentages boxes were blank and not marked. The report also revealed multiple dates that documented resident had meal intake of less than 50%. The clinical record revealed no evidence that the resident was provided with meals on the dates that were not marked in the report. Further, the clinical record revealed no evidence that the provider was notified for the missed meals or intake of less than 50% for February and March 2023. During an interview with a certified nursing assistant (CNA/staff #22) conducted on April 12, 2023 at 10:19 a.m., the CNA stated that resident #1 required adaptive silverware because his grips had gotten weak. Staff #22 stated resident #1 was not on a feeding program and no one was assisting the resident with feeding. Staff #22 stated she would go to the kitchen to get big silverware so the resident could feed himself. An interview was conducted on April 12, 2023 at 10:53 a.m. with a registered dietitian (RD/staff #45) who stated the resident does not use an adaptive equipment; and that, if the resident had a consistent decline in intake and required assistive devices, she would want to be notified to complete a nutritional assessment and work with therapy to meet the resident's need. Regarding resident #1, the RD stated that based on their assessment, resident #1 had an average oral meal intake of 38% and was placed on supplements. The RD said she was never notified of missed meals, lack of intake, or any use of adaptive equipment. An interview with a registered nurse (RN) conducted on April 12, 2023 at 11:52 a.m. The RN stated that if a resident has supplements then there was a required intake percentage of the supplement. The RN said that if the resident's food intake was consistently low, she would inform the Director of Nursing (DON) or the RD. Regarding resident #1, the RN stated that the resident was receptive to care, could follow enough to understand, was thin but not emancipated. The RN further stated that she could not recall the resident having an adaptive utensil/assistive device for eating. In an interview with the DON (staff #70) conducted on April 12, 2023 at 12:55 p.m., the DON stated that the expectation was that staff would set up meal trays when they are delivered to the room. The DON stated that meal percentages are documented in to the electronic chart and some residents eat less than 50% of their meals. The DON stated that the expectation was that if a staff see a regular pattern of eating less than 50%, the nurse should be notified; and, the nurse should notify the dietary manager. The DON stated that a regular pattern was defined as what was normal for that resident and if the intake was less and was a deviation from the regular pattern it should be reported. The DON also stated that if a resident needs adaptive equipment, occupational therapy should screen the resident prior to use of the adaptive equipment. A facility policy titled Change of Condition Reporting (revised 7/2022) included that all changes in resident conditions will be communicated to the physician and documented. The change of condition and response will be documented in the nursing progress notes and the resident's care plan will be updated.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure that medications were available as ordered for one resident (#261). The deficient practice could result in residents not receiving needed medications. Findings include: Resident #261 was admitted to the facility on [DATE] with diagnoses that included dementia, heart disease, encephalopathy, hypotension, breast cancer, and lung cancer. The resident's pain care plan, dated 1/29/22, revealed a goal to manage pain related to cancer and risk of impaired cognition related to dementia. Review of the physician's orders dated 1/30/22 revealed an order for anastrozole (used to treat breast cancer) 1 milligram (mg) per day. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating cognitive impairment. Review of the Medication Administration Record (MAR) for January and February 1 through 8, 2022 revealed that the resident did not receive the anastrozole 1 mg on any occasion. Review of the nursing notes indicated that the anastrozole was not administered because the prescription was not filled and was on order with the pharmacy. The nursing notes did not indicate that the physician had been notified that the medication was not available. The resident discharged from the facility on 2/8/22. During an interview with a Registered Nurse (RN/staff #2) on 1/4/23 at 2:03 PM, she stated that if a medication is not available when a resident is admitted to the facility, the next steps would be to contact the physician, contact the pharmacy, and inform the Director of Nursing (DON) and the resident. She said that depending on the medication, pharmacy may be able to give them a code to get it from the medication dispenser. She said she would document all of these things in the clinical record. She stated that for anastrozole specifically, it would not be available in the medication dispenser or the emergency kit, so they would need to continue to follow-up with the pharmacy. In an interview with the facility's pharmacist (consultant staff #129) on 1/5/22 at 9:57 AM, she stated she could not say what risks or side effects there would be for going so many days without anastrozole, due to it being a maintenance medication for the suppression of cancer. She said that she could see that other medications were dispensed and administered for the resident during the same timeframe. She stated the initial prescription was received for anastrozole on 1/29/22 but it was not filled. She said there may have been some confusion because the resident received a 14-day supply on 1/24/22 when she was at another facility. She said that she could see that the medication was not given and that this was confusing because this would have been an easy fix with one call or message. She stated that the pharmacy keeps records of all communications, and for this resident there weren't any records of the facility contacting them for follow-up. During an interview with the DON (staff #7) on 1/6/23 at 12:33 PM, she stated her expectation when medications are not available for a resident on admission is that the nurses notify the provider who may put the medication on hold while they figure out what is going on. She said that if the medications continues to not be available for multiple days, they should follow up with the provider as often as necessary and the provider will usually give guidance on the next steps. Her expectations for documentation of these actions is that it always is put in a nursing note in the resident's clinical record. She said she did not see any notes to show that the process was followed. Review of the facility's physician orders policy, dated 8/22, revealed that drugs must be ordered before administering the last dose. The policy included that any irregularity in administering must be reported to the doctor.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure continence care was adequately documented for one resident (#266). The deficient practice could result in residents' clinical records not being accurate and complete. Findings include: Resident #266 was admitted to the facility on [DATE] with diagnoses that included fracture of right leg, dislocation of a joint in right foot, epilepsy, dementia, and major depressive disorder. The resident's incontinence care plan, dated 1/19/22, revealed the resident had bowel and bladder incontinence with the goal to remain free from skin breakdown. Interventions included washing and drying perineum and changing clothing as needed after incontinence episodes. A bowel and bladder evaluation dated 1/22/22 showed that the was always incontinent of bowel and bladder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment included that the resident was not on a toileting program and was frequently incontinent. Review of the bowel and bladder continence documentation from 1/20 through 2/18/22 revealed more than 10 occasions where incontinence care was not documented for an entire shift. This included four day shifts in a row where continence care was not documented. The resident was discharged from the facility on 2/18/22. The clinical record did not include any further information regarding continence care during the times that the continence documention was not documented. Review of facility documentation revealed that the problem of documenting Activity of Daily Living (ADL) care had been identified in the March 2022 Quality Assurance (QA) committee and the facility began working on the problem as part of their Quality Assurance and Performance Improvement (QAPI) process. The goal was to improve CNA documentation, specifically with ADL documentation. The information provided included evidence of staff education and monitoring with improvement noted from 57% in January 2022 to 88-90% in November and December 2022. Review of current practice revealed no evidence of deficient practice. An interview was conducted with a Certified Nursing Assistant (CNA/staff #34) on 1/5/23 at 12:10 PM. She stated that residents are changed every two hours and as needed unless they are care planned for something different. She said that the CNAs document the continence care in the record. She said that it is typical to document throughout the shift as it can be a lot to try to catch up on at the end of a shift. The Director of Nursing (DON/staff #57) was interviewed on 1/5/23 at 12:20 PM. She reviewed the continence documentation for the resident and stated that the facility does not track brief changes. She stated she could not locate any further documentation for the resident's continence care. She said that documentation for incontinence care was done once for a whole shift, but that each brief change was not documented. She stated that the issue of missed documentation was identified and addressed in the QA process. Review of the facility's incontinent care policy, revised on 5/2022, revealed that the policy of the facility was to check for incontinent episodes routinely and as needed.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure a physician was notified of an accident resulting in serious injury for one resident (#1), and that one resident's representative (#3) was notified of a significant change in condition. The deficient practice could result in residents not receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: -Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing note dated April 12, 2022 at 7:49 pm included that resident had arrived and was unable to answer questions, so the family was called to complete the admission. A Nursing note dated April 13, 2022 at 1:44 am by a Registered Nurse (staff #50) included that resident #1 was observed on the floor and that resident #1 stated she had pain in her left leg, and could not move her leg. The note included that the POA (Power of Attorney) and the MD (Medical Doctor) were notified. A Nursing note dated April 13, 2022 entered at 6:53 am by staff #50 again included that resident #1 was observed on the floor and that resident #1 stated that the resident had pain in her left leg, and could not move her leg. The note included that the POA (power of attorney) and the MD (medical doctor) were notified. An Order Audit report revealed that on April 13, 2022 at 8:04 am an order had been obtained for an x-ray of hip for new hip pain from fall one time only for hip pain. A Medical Doctor (staff #122) was listed on the order as the primary physician. A BIMS (Brief Interview for Mental Status) assessment dated [DATE] at 9:01 am included that resident #1 had a score of 6 indicating that resident #1 had severe cognitive impairment. An Order Audit dated April 13, 2022 at 9:19 am included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the daily skilled note dated April 13, 2022 at 10:23 am included that the resident complained of pain in left hip. an X-ray was provided and the results of the X-Ray were sent to the DR (doctor). A History and Physical Note dated April 13, 2022 at 2:18 pm by a Medical Doctor (staff #122) included that resident #1 had fallen on the previous night and is now having L (left) hip pain. The note included that x-ray results were still pending and that the family discussed with the doctor that if there was a fracture the resident would be sent to the hospital for evaluation. The note included that pain control would be PRN (as needed) and to avoid opiates. A Radiology report dated April 13, 2022 included results of a Left Hip 2-3 view X-ray. The report included that resident #1 had an acute left hip fracture of the left proximal femoral neck, that there was Varus deformity and with overriding present. The reading of this report was electronically signed on April 13, 2022 at 2:32 pm. A Nursing note dated April 13, 2022 at 4:44 pm included that resident #1 was taken to the hospital per family request. During an interview conducted on May 18, 2022 at 2:29 pm with a Registered Nurse (RN/staff #67), staff #67 stated that if a resident complains of pain she would start them on Tylenol orally based on the standing order in the facility. On May 19, 2022 at approximately 10:00 am the facility provided a physician's standing order for Acetaminophen that included to give two 325 milligram (mg.) tabs every 6 hours as needed for pain. However, the clinical record did not include any documented evidence that the physician's standing order to provide acetaminophen had been initiated. During an interview conducted on May 20, 2022 at 9:03 am with an RN (staff #50), staff #50 stated she called the doctor (staff #122) 3 or 4 times on April 13, 2022 but only left a message one time. Staff #50 stated from the time the resident was found on the ground complaining of pain around 1:40 am through 7:00 am she never spoke directly with the doctor. Staff #50 stated that resident #1 was just resting in bed so she felt there were no issues or pain concerns. During an interview conducted on May 20, 2022 at 11:15 am with a Medical Doctor (MD/staff #122). The MD stated that Tylenol is routine and the first line for pain management, and that he never spoke with anyone on the morning of April 13, 2022 about resident #1. The MD stated he learned of the fall and that pain that resident #1 was having from the resident's family at the resident's bedside between 8:00 am and 9:00 am on April 13, 2022. The MD stated that if he had been notified at 1:40 am he would have ordered pain medication and a STAT x-ray. The MD stated that the resident has severe dementia which meant she could not express pain the way someone with a cognitive deficit could. The MD stated that when he touched the left hip the resident did not say she was in pain but her facial expresses revealed that she was having pain. During an interview conducted on May 20, 2022 at 2:15 pm with the Director of Nursing (DON/staff #13), the DON stated that the staff are to initiate the standing order for pain control if the non-pharmaceutical interventions are ineffective. The DON stated the resident was sleeping and only had discomfort when moved so the non-pharmaceutical interventions were working. The DON stated the expectation is that the staff would use an oral pain medication for acute pain instead of a topical medication, and that it is the expectation that when a resident has an accident, or is complaining of a new onset of pain, the provider will be notified. The DON stated that the expectation is that staff speak directly with the doctor, and not just leave a phone message without some sort of follow up. -Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed that resident #3 had one family member included as a contact on the admission record. An MDS (Medicare Minimum Data Set) assessment dated [DATE], included that resident had severe cognitive impairment. Review of the Admission Care Plan dated January 27, 2022 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes, with interventions including needs supervision/assistance with all decision making. During an interview conducted on May 19, 2022 at 2:42 pm with a Registered Nurse (RN/staff #28), she stated that a change of condition would be documented in the medical record, and the family would be notified for a positive COVID-19 test result. During an interview conducted on May 19, 2022 at 3:13 pm with a Licensed Practical Nurse/Assistant Director of Nursing (LPN/Staff #8), who stated that if a change of condition occurs the physician would be notified, a change of condition would be documented in the progress notes. He also stated that family would be notified. He further stated at that a positive COVID test result would meet the requirements as a change of condition status. During an interview conducted on May 20, 2022 at 9:20 am with the Director of Nursing (DON/staff #13), who stated that if a resident tested positive the family should be notified and documented in the medical record. She also stated that positive COVID-19 test results would constitute a change of condition. The DON further stated that resident #3 did test COVID-19 positive after her admission, and that there was no documentation in the medical record that the resident's family contact was notified. The DON stated that this did not meet the facility expectation, and the risk could result in exposure of COVID-19 to the family if they would come to visit and not know to use PPE (personal protective equipment) while they visit the resident. A facility policy titled Change of Condition Reporting and Documentation included that all changes in resident condition will be communicated to the nurse, the physician, and the resident's family, and will be documented accordingly in the residents' electronic health record (EHR). The purpose of the policy was to clearly define guidelines for timely notification of a change in resident condition. Under Acute Medical Change, the policy included that any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for a physician visit promptly and/or an acute care evaluation. The licensed nurse in charge will notify the physician, and if unable to contact attending physician or alternate physician timely, will notify the Medical Director for follow-up to the change in resident's condition. The policy included that all nursing actions will be documented in the progress notes as soon as possible and after resident's needs have been met. The policy included to document in the HER, nursing progress notes, complete an e-Interact Transfer form, and to update the resident's Care Plan as indicated.

Based on clinical record reviews, staff interviews, review of the Resident Assessment Instrument (RAI) manual and policy and procedures, the facility failed to ensure that comprehensive care plans were developed for two residents regarding oxygen therapy (#2 and #3). Findings include: -Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission note dated February 3, 2022 at 1:38 pm included that the resident arrived and was placed on 3.5 L (liters) of oxygen as ordered. A review of the clinical record did not reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A Quarterly Minimum Data Set (MDS) assessment dated [DATE] included that resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment, and that resident #2 was receiving Oxygen therapy. A review of the resident's care plan did not reveal a care plan for oxygen therapy. During an interview conducted on May 19, 2022 at 1:21 pm with a Licensed Practical Nurse (LPN/staff #43), the LPN stated that if a resident is on oxygen it is part of the care plan and that oxygen assessments should be done every shift. During an interview conducted on May 20, 2022 at 9:18 am with an MDS Coordinator/Registered Nurse (MDS/RN/staff #39), she stated that she does the initial, quarterly, annually, and change of condition assessments. Staff #39 stated that she reviews the orders, notes, and interviews the staff and to determine the resident's needs. Staff #39 stated she develops and updates the care plan based on the assessment. Staff #39 stated she completed the quarterly assessment for resident #2 and that he does use oxygen in the facility. Staff #39 stated she did not care plan the oxygen for resident #2. During an interview conducted on May 20, 2022 at 2:15 pm with the Director of Nursing (DON/staff #13), the DON stated that the expectation is that nursing and the CNAs (Certified Nursing Assistance) provide care based on the resident's care plan. The DON stated that care plans are developed and updated by the MDS Coordinator, the DON, social services, dietary, and nurse managers. The DON stated that the MDS assessments are how care plans are generated. A facility policy titled Comprehensive Person-Centered Care Planning included it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The policy included that comprehensive care plans will be developed by the IDT within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASRR recommendations, and resident's goals and desired outcomes, preferences for future discharge and discharge plans.

Based on clinical record reviews, staff interviews, observations, and review of facility policies and procedures, the facility failed to ensure that two residents (#2 and #3) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: -Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission note dated February 3, 2022 at 1:38 pm included that the resident arrived and was placed on 3.5 L (liters) of oxygen as ordered. A Daily Skilled note dated February 5, 2022 at 6:58 pm included that resident #2 was on Oxygen via Nasal Cannula set at 4 L (liters). A Quarterly Minimum Data Set (MDS) assessment dated [DATE] included that resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment, and that resident #2 received Oxygen therapy while a resident. A review of the care plan for resident #2 did not reveal a care plan for oxygen therapy. On May 20, 2022 at 7:30 am an observation was conducted of resident #2 in his room. During the observation, resident #2 was receiving oxygen from an oxygen concentrator at 4 L per minute via a nasal cannula. Review of the clinical record for resident #2 did not reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview conducted with resident #2 on May 20, 2022, at 7:30 am the resident stated he has been on oxygen the entire time he has been a resident at the facility. The resident stated there is a humidity bottle attached to the concentrator but he does not use it because it causes him to cough. During an interview conducted on May 19, 2022 at 12:28 pm with a Nursing Assistant (NA/staff #116). The NA stated that resident #2 uses an oxygen concentrator with a nasal cannula. During an interview conducted on May 19, 2022 at 12:47 pm with a Certified Nursing Assistant (CNA/staff #24), the CNA stated that resident #2 uses an oxygen concentrator with a nasal cannula, and that to his knowledge resident #2 has used it during the entire admission. During an interview conducted on May 19, 2022 at 1:21 pm with a Licensed Practical Nurse (LPN/staff #43), the LPN stated that if a resident is on Oxygen it is on the report sheet, and that administering oxygen requires a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on May 20, 2022 at 9:18 am with an MDS Coordinator/Registered Nurse (MDS/RN/staff #39), staff #39 stated she does the initial, quarterly, annually, and change of condition assessments, and that she reviews the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #39 stated she develops and updates the resident's care plan based on the assessment. Staff #39 stated she completed the quarterly assessment for resident #2 and that he does use oxygen in the facility. Staff #39 stated she did not develop a care plan the oxygen for resident #2. During an interview conducted on May 20, 2022 at 2:15 pm with the Director of Nursing (DON/staff #13), the DON stated that the expectation is that nursing and the CNAs (Certified Nursing Assistance) provide care based on the resident's care plan, and that care plans are developed and updated by the MDS Coordinator, the DON, social services, dietary, and nurse managers. The DON stated that the MDS assessments are how care plans are generated. -Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an MDS assessment dated [DATE], revealed that resident #3 had severely impaired cognitive impairment, and that resident #3 received oxygen therapy. A physician's note dated January 28, 2022 which mentioned PRN (as needed) oxygen to keep SPO2 (oxygen concentration) greater than 92%. A nurse's note dated February 2, 2022 included that resident #3 was started on O2 (oxygen) 3L (liters), NC (nasal cannula) up to 93%. A nurse's note dated February 2, 2022 included that when resident #3 woke up yelling it was usually it was usually because the resident removed her oxygen and her O2 sat (saturation) level returned to 90. The note included that the nurse monitored the resident during the night each hour and that the resident refused the (oxygen) mask. A daily skilled nursing note dated February 3, 2022 included that resident #3 was receiving Oxygen via Nasal Cannula, continuously, and that it was set at 2 liters via NC. A discharge note dated February 4, 2022, included that resident #3 received O2 via NC at 2 liters. The note included that the resident continued to taking off that oxygen and that when the resident removed it, the O2 Sat's dropped to 87%. The note included that when oxygen was re-applied, the Sat's went back up to 91-92%. A nursing discharge summary dated February 4, 2022, included that resident #3 used oxygen, 2 liters per minute which was delivered through a nasal cannula. Review of the clinical record for resident #3 did not reveal a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on May 19, 2022 at 3:13 pm with a Licensed Practical Nurse (LPN/Staff #8), staff #8 stated that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview conducted on May 19, 2022 at 2:42 pm with a registered nurse (RN/staff #28), staff #28 stated that the facility process is to have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on May 20, 2022 at 9:20 am with the Director of Nursing (DON/#13), the DON stated that the facility policy is to receive a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the risk of receiving oxygen without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy titled Oxygen Administration included it is the policy of the facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of the oxygen therapy is to provide sufficient oxygen to the blood stream and tissues via pressurized oxygen cylinder and stand or an oxygen concentrator. The procedure for the policy included to obtain an appropriate physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -That the oxygen is to be administered -When and how often oxygen is to be administered, -The type of oxygen device to use (i.e. mask, nasal), -Any special procedures or treatment to be administered. -Charting and documentation related to oxygen use.

Based on review of facility records, staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#3) and the resident's family/representative were notified that the resident had tested positive for COVID-19, by 5:00 pm the following day after the occurrence. The deficient practice could result in resident's and their representatives not being aware of new COVID-19 cases in the facility and the actions implemented to reduce the risk of transmission. Findings include: Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for resident #3 revealed a positive COVID-19 test result dated February 2, 2022. Review of Case Manager progress notes dated February 3, 2022, included that the Case Manager had met with the son of resident #3. However, the note did not include that the son of resident #3 had been notified of the positive COVID-19 test results during a meeting. Review of a Discharge Summary dated February 4, 2022, did not include documentation of the resident's positive COVID-19 status. Review of the clinical record for resident #3 did not reveal documentation that resident #3, or the resident's family/representative had been notified that the resident's COVID-19 test was positive. During an interview conducted on May 19, 2022 at 2:00 pm with a Certified Nursing Assistant (CNA/staff #24), she stated that residents are notified of positive COVID-19 test results by the DON (Director of Nursing) or the ADON (Assistant Director of Nursing). During an interview conducted on May 19, 2022 at 2:42 pm with a Registered Nurse (RN/staff #28), the nurse stated that the facility policy is to call the family and notify them of a positive COVID-19 test result and to document that in the clinical record. During an interview conducted on May 20, 2022 at 9:05 am with a Minimum Data Set nurse (MDS/staff #39), staff #39 stated that social services is responsible for notifying family regarding positive COVID-19 test results. During an interview conducted on May 20, 2022 at 9:20 AM with the Director of Nursing (DON/staff #13), the DON stated that the resident's family would be notified of a positive COVID-19 test result, and that would be documented in the clinical record. She also stated that she reviewed the resident's medical record and that the resident did test positive for COVID-19, and that there was no documentation that the resident's family had been notified. The DON stated that this did not meet her expectations, and the could result in the family visiting the resident and not knowing that they need to wear personal protective equipment (PPE), which would place them at risk for exposure to COVID-19. The DON stated that the resident was discharged home and the family was not informed of the risk. Review of the facility policy titled, Change of Condition Reporting and Documentation, revealed it is the policy of the facility that all changes in resident condition will be communicated to the nurse physician, and family and documented accordingly in the electronic health record (EHR). All attempts to reach the physician and responsible party will be documented in the nursing progress notes. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken.

Based on clinical record review, resident and staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#1) was provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The deficient practice could result in residents' pain not being managed. Findings include: Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Initial Care Plan dated April 12, 2022 at 5:36 pm for pain included a goal that resident #1 would voice a level of comfort. The interventions for this goal included to administer analgesia medication per orders, follow a pain scale to medicate as ordered, and to assess pain every shift. An Initial Admission Record dated April 12, 2022 at 5:36 pm included that resident #1 was alert to person only, confused, and able to follow simple commands. A Pain Management Review dated April 12, 2022 at 5:36 pm included that resident #1 was not able to be interviewed for pain and that no possible indicators for pain were observed. Another Pain Management Evaluation dated April 12, 2022 at 5:36 pm included that resident #1 had a pain level of 2. The evaluation included that the resident would occasionally moan or grown and had low-level speech with a negative or disapproving quality. The evaluation included that the resident was consolable with distraction or a reassured voice or touch. A facility standing order for Acetaminophen included to give two 325 milligram (mg.) tabs every 6 hours as needed for pain. Review of the standing order revealed it was per a Medical Doctor (staff #122). A clinical record review revealed a provider order dated April 12, 2022 at 6:44 pm for a [MEDICATION(S)] 4%, apply to affected area topically one time a day for pain and to remove per schedule. A review of the clinical record revealed that no documentation of any medications or non-pharmaceutical interventions provided for a pain level of 2 were documented for April 12, 2022 at 5:36 pm. A Pain Management Review dated April 13, 2022 at 1:40 am included that resident #1 had pain (in) her left hip leg and that the resident was able to be interviewed. The evaluation included that the resident stated she was in pain at a level 3 and that she had not had any pain or hurting in the last 5 days. The evaluation included that the pain was located in her back, bone pain, and hip pain. The evaluation included that the pain felt like aching and crushing and that the pain affected interactions with people and ability to bathe, groom, and dress self. The evaluation included that rising from a chair/bed, feeling fatigued, and feeling anxious made the pain worse. The evaluation included that repositioning, exercise, and rest were non-drug approaches that made the pain better. The evaluation included that over the last 3 months or since the admission the resident's pain had been managed moderately. Further review of the Pain Management Review dated April 13, 2022 at 1:40 am included that staff observations of possible indicators for pain included behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities, loss of function or inability to perform Activities of Daily Living (ADLs) (e.g., rubbing a specific location of the body, or guarding a limb or other body parts), difficulty eating or loss of appetite, and difficulty sleeping ([CONDITION(S)]). The review included that the general overview of the pain and pain management included medications, monitoring side effects of interventions, and effectiveness of interventions. A Nursing note dated April 13, 2022 at 1:44 am by a Registered Nurse (staff #50) included that resident #1 was observed on the floor and that resident #1 stated she had pain in the left leg, and could not move her leg. The note included that the POA (power of attorney) and the MD (medical doctor) were notified. A review of the clinical record did not reveal any orders for oral pain management had been obtained or that non-pharmaceutical interventions had been provided. A review of the clinical record did not reveal that any additional pain management evaluations had been completed. A 72-Hour Neuro-Check sheet revealed that resident #1 was assessed for pain and level of consciousness on April 13, 2022 from 1:45 am through 5:45 am. The check sheet revealed that all of the pain assessments had an 0 under pain nine times. Further review of the sheet revealed that under pain, the sheet uses a 0-10 pain rating scale or non-verbal scale as appropriate. A Nursing note dated April 13, 2022 at 6:53 am by staff #50 again included that resident #1 was observed on the floor and that resident #1 stated she had pain in the left leg, and could not move her leg. The note included that the POA (power of attorney) and the MD (medical doctor) were notified. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the clinical record revealed no documentation that the pain level was assessed after the [MEDICATION(S)] was applied from 7:17 am to 10:23 am. During an interview conducted on May 18, 2022 at 2:29 pm with a Registered Nurse (RN/staff #67), staff #67 stated that if a resident complains of pain she would start them on Tylenol based on the standing order in the facility. Staff #67 stated that if a resident had a new onset of acute pain she would call the doctor to get an order if the non-pharmaceutical interventions did not work. Staff #67 stated that oral medications are reassessed in an hour after administration. Staff #67 stated they would check the effectiveness of a pain patch within an hour as well. Staff #67 stated that if a resident had a pain patch but was still having pain she would contact the provider. During an interview conducted on May 19, 2022 at 1:21 pm with a Licensed Practical Nurse (LPN/staff #43). Staff #43 stated that the facility uses a pain tool with a pain scale of 0-10, with 10 being the worst pain. Staff #43 stated the facility also uses a face scale for dementia residents with a frown being the worst pain. Staff #43 stated that if a new resident did not have anything ordered for pain she would add the standing order for Tylenol as soon as they stated they have pain. Staff #43 stated she would also contact the provider right away to report the new onset of pain, and that when an oral pain medication is given she reassesses the pain in an hour. Staff #43 stated that reassessment of pain with a [MEDICATION(S)] is difficult because it is topical, but she stated she would still reassess in an hour. Staff #43 stated that oral medication would be the first intervention for acute pain, and that there is also an in-house e-Kit (emergency kit) with pain medication if the Tylenol did not work. During an interview conducted on May 20, 2022 at 8:37 am with a Pharmacist (staff #56), staff #56 stated that a [MEDICATION(S)] 4% patch is an over the counter topical not usually used for acute pain. Staff #56 stated that review of resident #1's chart did not reveal any reasons why the resident could not have Tylenol for a minor acute pain. During an interview conducted on May 20, 2022 at 11:15 am with a Medical Doctor (MD/staff #122). The MD stated that Tylenol is routine and the first line for pain management. The MD stated that he never spoke with anyone on the morning of April 13, 2022 about resident #, and that he learned of the fall and pain the resident was having from a family at the resident's bedside on April 13, 2022. The MD stated that if he had been notified at 1:40 am he would have ordered pain medication and a STAT x-ray. The MD stated that the resident has severe dementia which meant she could not express pain the way without someone with a deficit could. The MD stated that when he touched the left hip the resident did not say she was in pain but her facial expresses revealed she was having pain, and that a [MEDICATION(S)] is not the first choice for acute pain and is usually used for chronic pain issues. During an interview conducted on May 20, 2022 at 2:15 pm with the Director of Nursing (DON/staff #13), the DON stated that the staff are to initiate the standing order for pain control if the non-pharmaceutical interventions are ineffective. The DON stated that the resident was sleeping and only had discomfort when moved so, the non-pharmaceutical interventions were working. The DON stated that the expectation is that staff would use an oral pain medication for acute pain instead of a topical. The DON stated there are two Pain Assessments in the electronic record staff can use, and that there is a separate pain assessment for dementia residents. The DON stated this assessment is used for those with a cognitive deficient. A facility policy titled Recognition and Management of Pain included it is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility assists each resident with pain management to maintain or achieve the highest practicable level of well-being and functioning by interviewing or observing the resident to determine if pain is present, evaluate pain, develop and implement a plan using non-pharmacologic and/or pharmacologic interventions to manage and/or prevent pain. For the resident who is unable to communicate verbally or understand abstract concepts, the PAINAD scale for the cognitively impaired will be used and documented in the resident's EHR. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The monitoring of pain status will be done every shift using either the numerical pain rating or PAINAD scale (Pain Advanced Dementia Scoring guide). The facility was unable to provide a policy and procedure for implementing standing orders.Review of the facility's policies revealed there is no policy or procedure for implementing standing orders.

Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident's (#3) responsible party was provided written notice prior to a room change. Findings include: Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medicare Minimum Data Set assessment dated [DATE], included that resident #3 had severe cognitive impairment. Review of the medical record census list revealed that resident #3 received a change of room dated February 2, 2022. Further review of the medical record revealed no documentation that the resident or responsible party was provided a written notice prior to the room change. During an interview conducted on May 19, 2022 at 2:00 pm with a certified nursing Assistant (CNA/staff #24), staff #24 stated that resident's are told the day before they are being moved to another room, and nurses notify the family members. During an interview conducted on May 19, 2022 at 2:42 pm with a registered nurse (RN/staff #28), staff #28 stated that the facility process is to always notify the resident's family of a room change, and that the admissions staff makes the determination regarding the room that resident will be moving to, documents the room change in the clinical record. During an interview conducted on May 19, 2022 at 3:21 pm with the Director of Admissions (staff #103), she stated that when a resident test's positive with COVID-19, they move the resident to a private room for isolation precautions. Staff #103 stated that a room change form is completed for all room changes, and uploaded into the EMR (electronic medical record), and that if admissions staff was not available, nursing would be expected to complete the room change form and notify the resident's family. Staff #103 stated that resident's families are expected to always be informed of room changes. Staff #103 reviewed the resident's clinical record and stated that there was no room change form documented for the room change on February 2, 2022 for resident #3, and that there was no documentation in the progress notes that the resident's family had been notified. Staff #103 stated that this did not follow the facility policy. During an interview conducted on May 20, 2022 at 9:20 am with the Director of Nursing (DON/staff #13), she stated that the facility policy regarding room changes includes notification of family/representative and document on the room change form. The DON stated that she reviewed the resident's record and did not see any documentation that the resident's family had been notified of the room change, and did not see documentation of a room change form. The DON stated that the risk of not being informed of a room change could result in the resident's family or legal representative not being aware of the resident's room status. Review of a facility policy titled, Notification of Room or Roommate Change, revealed that notification of room changes will be documented according to the facility's established practices, and to include completion of a Notification of Room or Roommate Changes form signed by the resident and/or resident's legal representative. The policy included that the resident has the right to notification of room or roommate changes and to agree prior to the change taking place.

Based on observation, clinical record review, resident and staff interviews, and policies and procedures, the facility failed to ensure that one resident (#38,) received consistent showers/bathing, and that one resident (#23) received assistance with oral care. The deficient practice could result in the resident's grooming and hygiene needs not being met. The facility census was 82 residents, and the sample was 6. Findings Include: -Resident #38 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the shower schedule revealed the resident was scheduled for showers every Sunday and Thursday. A care plan dated October 29, 2021 included the resident had an ADL (Activities of Daily Living) self-care performance and would safely perform grooming, and personal hygiene. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction. Review of the skilled nursing notes from October 29 through November 20, 2021, revealed no documentation that the resident was offered, refused or was provided any showers or bed baths. An admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident's cognition was intact. The MDS included the resident required extensive assistance with personal hygiene. Review of bathing task documentation for the past 30 days revealed no documentation that the resident had received a shower or bed bath, except for November 21, 2021. Observations were conducted on November 29 and 30, 2021, which revealed that the resident's fingernails had a dark substance underneath all of the nails on both hands, and the nails were approximately 0.4 centimeters long. An interview was conducted with the resident on November 29, 2021 at 09:16 AM, and she stated that she had asked a CNA (Certified Nursing Assistant) to cut her fingernails but was told that he could not cut them because she is diabetic. Further interview with the resident was conducted on November 30, 2021 at 9:54 AM, and she stated that she has not yet had a shower or her nails cut. An interview was conducted on November 30, 2021 at 11:49 AM with a Registered Nurse (RN/staff #4) who stated that showers and bed baths should be performed twice a week. She further stated that CNAs clean the resident's nails during showers or bed baths. An interview was conducted on November 30, 2021 at 11:55 AM with a Licensed Practical Nurse (LPN/staff #74) who stated that the shower schedule shows that resident #38 should receive showers on Sunday and Thursday. She also stated that CNAs document showers on a skin observation shower sheet, including if the shower was provided or refused. She reviewed the skin observation shower sheets for October 2021 and did not see a shower sheet for this resident. She also stated that she did not see any shower sheets for the resident in November. The LPN stated that the facility policy is to complete showers twice weekly and document if the shower was provided or refused. She further stated that this did not follow the facility policy. The LPN reviewed the bath task form in the EMR (electronic medical record) for November and stated that there was no documentation that a shower or bed bath had been provided or refused except on November 21, 2021. An interview was conducted on November 30, 2021 at 12:40 PM with a CNA (staff #27), who stated that they follow a shower schedule that is divided by shift and room number. She also stated that they document on a skin and shower form if the shower was provided or refused. She reviewed the shower schedule and stated that the resident should be offered showers on Thursday and Sunday. The CNA further stated that someone picks up the shower sheets when they are completed, and that CNAs also document in the EMR on the bathing task, if a shower was given or refused. An interview was conducted on November 30, 2021 at 12:56 PM with the Director of Nursing (DON/staff #107), who stated that the facility policy is to provide showers to residents twice weekly. She further stated that bath/shower documentation is not consistent, but CNAs can document on a skin shower form or in the EMR bathing task. She also stated that there should be documentation that the shower was provided or refused in the EMR or on the skin shower form. Further interview was conducted on November 30, 2021 at 01:29 PM with the DON (staff #107) who reviewed the shower sheets and stated that the only shower sheet she saw was for November 21, 2021. She also stated that she did not find any other completed skin shower forms. She reviewed the EMR bathing task documentation in the EMR and stated she did not see and documentation that any baths or showers had been provided or refused except on November 21, 2021. The DON stated that this did not meet the facility policy regarding showers and stated the risk would be poor hygiene and possible skin issues. Review of a facility policy titled, ADL services to carry out, revealed it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. If a resident is unable to carry out activities of daily living, the necessary services to maintain good grooming will be provided by qualified staff. Bathing will be offered at least twice weekly, and PRN per resident request. ADL care provided will be documented in the medical record accordingly. Review of a facility policy titled, Shower and bed bath, services to carry out, revealed that showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided. Shower and bed baths will be documented in the medical record/POC. -Resident #23 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan initiated on April 24, 2021 included an Activities of Daily Living (ADL's) self care performance deficit related to muscle weakness and difficulty walking. The goal was that the resident will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene. The Minimum Data Set (MDS) completed November 19, 2021 included a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS also included the resident required extensive assistance and the physical assistance of one person to perform personal hygiene activities, and that the resident had impairment in his range of motion for both upper extremities. The Point Click Care (PCC) Certified Nursing Assistant (CNA) Personal Hygiene documentation included one section for all of the following: combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) Review of the PCC personal hygiene documentation for resident #23 revealed there was no specific area to document teeth brushing. During an interview with resident #23 on November 29, 2021 at 01:06 PM the resident said he had not had his teeth brushed in about 2 weeks. An interview was conducted on December 1, 2021 at 10:08 AM with a Temporary Nursing Assistant (TNA/staff # 32). She said her process for ADL's when she comes on shift in the morning is to start taking vitals, provide personal care, and pass out the trays. After the residents are done eating she starts from one end of the hall to the other getting her residents ready for the day. She said at times she does miss tasks because it is very busy. Resident #23's record was reviewed and she was unable to locate specifics in the medical record for teeth brushing. When informed that the resident had reported he had not had his teeth brushed in 2 weeks, and asked if this was is was accurate, she said yes, but she could only speak for the last week as she was out with an injury. She confirmed his teeth did not get brushed on her shift on 11/30/21. An interview was conducted with Temporary Nursing Assistant (TNA/staff #27) on December 1, 2021 at 11:42 AM regarding oral care and teeth brushing. She said the residents on her shift do not get missed. She stated her residents are alert and orientated and she waits until they ask to brush their teeth. She does not do it unless they ask. An interview was conducted on December 1, 2021 with Licensed Practical Nurse (LPN/ staff #83) regarding tasks for residents being missed. She said tasks do often get missed due to the fact that there are a lot of residents who are total care only so many CNAs. She said the staff report to her at end of shift to inform her of what tasks have been missed and it is reported to the next shift. Review of the task area in resident #23's medical record revealed there was no specific area for oral care to be documented. Another interview with resident #23 was conducted on December 1, 2021 at 10:57 AM and he stated he did not get his teeth brushed the previous day and has not had his teeth brushed as of the time of the interview. He stated that the Director of Nursing (DON/staff #107) came by prior to this interview, looked in his mouth and stated it looked fine to her. An interview was conducted with the Director of Nursing (DON/staff #107) on December 1, 2021. She stated the expectation for the CNA providing oral care for residents is that it is the resident's personal preference. It is individualized to each resident. If the resident is alert and orientated, the resident has to ask for oral care. If the resident is not able to make needs known, they check with the family to find out what their oral care routine is. Resident #23 was discussed and the DON stated the resident self directs his own care and he has to ask staff to get his teeth brushed. The facility's policy titled ADL's, services carried out was most recently revised in July of 2015 includes that the residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychological well- being of each resident in accordance with a written care plan. The policy also indicated that if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff.

Based on closed clinical record review, staff interviews, hospital documents, and policy review, the facility failed to ensure pain management was provided for one sampled resident (#57) consistent with professional standards of practice. The deficient practice could result in unnecessary pain for residents. Findings include: Resident #57 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a nurse note dated June 28, 2019 that the resident was admitted to the facility at 9:00 p.m. Review of the Initial Admission Record dated June 28, 2019, revealed the resident was alert and oriented times 4 and able to make self-understood and understand others. Review of the clinical record revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated June 28, 2019 revealed the orders were verified and faxed to the pharmacy. The Initial Care Plan with an effective date June 28, 2019, revealed the resident had acute and chronic pain. The goal was that the resident would voice a level of comfort. Interventions included following the pain scale to medicate as ordered and conducting a pain assessment every shift. Review of the admission Pain Management Review assessment dated [DATE] revealed the resident stated that she was having pain in her right above the knee amputation incision and rated the pain level at an 8. The assessment included the level of pain the resident would be satisfied with was a 2 and that [MEDICATION(S)] had relieved her pain in the past. The assessment also included the indicators of pain the nurse observed was negative verbalization and vocalization (e.g., groaning, crying/whimpering, or screaming) and facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw). However, review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MAR for June 2019, revealed Acetaminophen 325 mg 2 tablets were administered on June 29, 2019 at 7:45 a.m. for a pain level of 3 and that the Acetaminophen was ineffective. Review of the electronic MAR progress note dated June 29, 2019 at 11:00 a.m., revealed the resident's pain level was a 10. Review of the nurse progress note dated June 29, 2019 at 11:44 a.m. revealed the resident's medications had not been delivered. The note included the resident complained of pain that morning and was given Acetaminophen for pain. The note also included that at 11:15 a.m., the resident told staff she was calling 911. The nurse then called the pharmacy regarding pulling the pain medication from the emergency kit (e-kit) and to follow up with the resident's other medications. The note included emergency services were in the facility at 11:30 a.m., and that the resident left against medical advice with emergency services before the pain medication could be requested from the pharmacy. A review of the receiving hospital emergency room documents revealed the resident presented with severe right leg/stump pain and that the right anterior leg incision/staples were draining a purulent and cloudy yellowish substance. An interview was conducted with the Licensed Practical Nurse (LPN/staff #122) on August 6, 2019 at 3:06 p.m., who worked the day shift on June 29, 2019. The LPN stated that when a resident is admitted with a prescription for pain medication and the medication does not arrive from the pharmacy in time for a resident complaining of pain, they can call the pharmacy to request a dose from the e-kit. He stated that if the medication is not in the e-kit, he would call the provider for a one time order for a pain medication that is in the e-kit. The LPN stated that when he reported to work on June 28 at 6:00 a.m., he was notified of the resident's pain. He stated that he assessed the resident and she appeared to be in pain. The LPN stated that he administered Acetaminophen to the resident because removing the [MEDICATION(S)] from the e-kit is a lengthy process. He stated the [MEDICATION(S)] is in the e-kit, but authorization is required from the pharmacy to remove it from the e-kit and he did not call the pharmacy for the authorization. He said he was busy passing medications that morning, and wanted to try the Acetaminophen first. The LPN stated that he administered Acetaminophen that morning around 7:30 a.m. He stated that he did not reassess the resident's pain after administering Acetaminophen because he did not have time, he was passing morning medication. The LPN stated the night shift could have pulled the [MEDICATION(S)] from the e-kit and administered it to the resident and that the resident's pain should have been addressed in a better way. He stated that he was notified by staff around 11:00 a.m. that the resident was in a lot of pain and not willing to wait any longer for pain medication. He further stated that since he had not heard anything from the resident, he assumed her pain was under control. The LPN stated that he was on the phone when emergency services arrived and that the resident did not give him a chance to speak to pharmacy or the physician. An interview was conducted on August 7, 2019 at 1:31 p.m. with a LPN (staff #125). The LPN stated that when a resident is admitted from the hospital with a prescription for pain medication and their pain medications have not been delivered and the resident is in pain, they call the pharmacy for a code that allows them to remove the medication from the e-kit. The LPN stated that if the resident is admitted without a prescription, they notify the provider who will call the medication to the pharmacy, so that the pharmacy can provide them the code to remove the medication from the e-kit. An interview with the Director of Nursing (DON/staff #124) was conducted on August 7, 2019 at 2:28 p.m. She stated that when a resident is admitted , the nurse or the assistant DON will input the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that if a resident is asking for pain medications, the nurses are able to obtain a code from the pharmacy to remove the medication from the e-kit. She stated that when a pain medication is administered, she expects the nurses to reassess the resident's pain in 30 minutes and document whether the pain medication was effective or ineffective. During an interview conducted on August 8, 2019 at 8:10 a.m. with the Registered Nurse (RN/staff #109) who worked the night shift on June 28, 2019, the RN stated that when the resident was admitted , an initial pain assessment was conducted and that the resident rated her pain level at an 8. The RN stated that she is supposed to follow through when a resident rates their pain at an 8 but that she did not follow through with this resident. She stated that if anything was done to relieve the resident's pain, it would have been documented and a reassessment after 30 minutes would have been documented. The RN then stated that she does not remember the resident complaining of pain and that she thinks the resident slept all night. Review of facility's policy Pain management stated, It is the policy of this facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: comprehensively assisting pain, developing and implementing a plan, using pharmacological and /or non-pharmacological interventions to manage the pain and/or try to prevent the pain consistent with the resident's goal.