Every finding on record at Flagstone

Based on interview and document review, the facility failed to ensure complete and comprehensive Minimum Data Set(s) (MDS) were completed for 1 of 5 residents (R4) reviewed for assessment accuracy. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2025, identified the MDS as an assessment tool that facilities are required to use. The manual directed comprehensive assessments, include the completion of both the MDS and the CAA process, as well as care planning. The CMS RAI manual also identified that the RAI process (i.e., MDS) was completed to help evaluate residents' strengths and areas for care planning. R4's annual MDS dated [DATE], included the following information:-Section B- Hearing, Speech, and Vision: indicated B0100 (Persistent vegetative state/no discernible consciousness) was answered as no, so staff were to continue to B0200, Hearing. B0200-B1000, fields regarding R4's hearing, speech, his ability to understand and make himself understood, and vision, were dashed.-Section C- Cognitive Patterns: indicated C0100 (Should Brief Interview for Mental Status (C0200-C0500) be Conducted?) was answered as yes, so staff were to continue to C0200. Sections C0200 through C1310, fields regarding mental status, memory, cognitive skills, and signs of delirium were dashed.-Section D- Mood: indicated D0100 (Should Resident Mood Interview be Conducted?) was answered yes, so staff were to continue to D0150. D0150 questions A-I, an interview assessing the resident's mood, were dashed, and D0160 had a score entered of 99, which indicated that the interview was unable to be completed. D0500-D0600, the section for staff assessment of resident mood was left blank.-Section F-Preferences for Customary Routine and Activities: indicated F0300 (Should Interview for Daily and Activity Preferences be Conducted?) was coded as yes, continue to F0400. Section F0400 A-H, an interview for daily preferences, was all dashed. Section F0800, the staff assessment of daily and activity preferences was left blank. During an interview on 3/19/26 at 10:28 a.m., registered nurse (RN)-C, the MDS coordinator, stated she had received an email from the nursing team that they had missed completing parts of the MDS assessment for R4, such as mood, cognition, and social assessment, before the assessment reference date (ARD). RN-C stated that by the time she looked for the assessments to use to complete the MDS, it was past the ARD. RN-C stated she hadn't noticed until it was too late to complete the assessments, so she had dashed the areas for which she could not find an assessment. During an interview on 3/20/26 at 7:49 a.m., the director of nursing (DON) stated that the floor nurses completed the MDS assessments, and then the unit managers were in charge of ensuring MDS assessments were completed and completed accurately.The facility's Resident Assessment Instrument (RAI) Process: MDS 3.0, Care Area Assessments, Care planning, and Submission policy dated 3/2025, indicated the facility's multidisciplinary team would work together to complete the MDS assessment according to the RAI manual.

Based on observation, interview, and document review, the facility failed to comprehensively assess and, if needed, determine or develop proactive interventions to help address pressure injury risk and prevent skin alteration worsening, after a pressure-induced skin alteration was identified for 1 of 3 residents (R19) reviewed for pressure injuries. Findings include: R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, no rejection of care behaviors, and was diagnosed with heart failure, kidney failure, and diabetes. The MDS indicated R19 had a functional limitation in range of motion to both upper extremities, needed moderate assistance with toileting hygiene, was dependent for bathing, and needed moderate assistance for bed mobility. The MDS indicated R19 was at risk for pressure ulcers and had no current pressure ulcers.R19's order summary dated 6/9/25, included an order dated 6/9/25 to place R19's CPAP or BiPAP on at bedtime, check overnight, remove in the morning, clean the tubing, and fill the chamber with water before use. R19's care plan dated 12/22/25, indicated staff were to inspect R19's skin for redness, open areas, scratches, cuts, or bruises while providing care and report changes. The care plan indicated R19 was at risk for skin impairment, and the nurse was to be notified immediately of any new areas of skin breakdown. The care plan indicated R19 required assistance from staff with repositioning and toileting, and staff were to wash his skin with mild soap, rinse, and dry thoroughly while providing care. The care plan indicated that staff were to assist R19 in applying his CPAP machine per MD/NP orders. R19's medication/treatment administration record dated 3/1/26 to 3/18/26 at 8:00 a.m., indicated R19's CPAP/BiPAP had been applied every night and removed every morning during the period. R19's progress note dated 3/6/26 at 1:51 p.m., indicated that R19's body audit indicated his skin was clean, dry, and intact.R19's progress note dated 3/16/26 at 4:50 p.m., indicated a bowel, bladder, skin risk summary and analysis were completed, and that his skin remained intact. R19's progress notes dated 3/6/26 to 3/16/26 were reviewed with no note of the redness or scabbing under R19's eyes. During an interview and observation on 3/17/26 at 10:52 a.m., R19 was observed in his room in his wheelchair. Under R19's right eye, a skin alteration was observed in the wrinkle that ran from his undereye diagonally down, following the curve of the nose to his mouth. In this wrinkle, R19 had redness that was about 2.5 centimeters (cm) long by one cm wide, with a dark red scab about the length and thinness of the end of the nail of an adult thumb. R19 stated he had some drainage from the scab and thought the drainage started about a week ago. R19 was unable to further describe the drainage. R19 stated he thought the skin alteration was from the CPAP machine he wore at nighttime. R19 stated the redness caused slight pain, but not enough to stop using the machine. On 3/18/26 at 10:44 a.m., he thought he had had the skin redness and scab under his right eye for about three weeks to a month. R19 was observed with the same skin alteration on the right side as described above, although the skin redness was now about one cm by one cm. R19 also had new redness in the mirrored wrinkle on the left side of the face, which extended approximately 4 cm long with a width of approximately one cm. During an interview and observation on 3/18/26 at 10:58 a.m., registered nurse (RN)-A stated he was the nurse in charge of R19's care today, but normally worked on a different unit, so he was not that familiar with R19's care. RN-A was observed to assess R19's skin and confirmed the above measurements from 3/18/26. RN-A was observed to press on the redness, the skin turning white, and then turning red again. RN-A stated he thought R19's CPAP mask might be too tight, causing the facial redness and scabbing. R19 stated he was unsure how long R19 had had the scab and redness on his face, but thought it was caused by pressure from his CPAP mask. RN-A was observed to apply a CPAP mask to R19. The mask was observed to sit on top of the skin alterations. RN-A stated the aides should report when the resident has skin alterations like this one, but it had not been reported to him, and he was unsure if it had been in the past. RN-A stated he was going to notify the provider of the skin alteration to determine what treatments or methods needed to be utilized to prevent the skin alteration from worsening. During an interview on 3/18/26 at 11:06 a.m., nursing assistant (NA)-A stated R19 had a pattern of redness and scabbing under his eyes from his CPAP machine that would heal and then recur, and this the redness and scabbing under his right eye had been there for about a week to a week and a half. NA-A stated she had noticed that the scab under his right eye had been bleeding slightly when she took the machine off him at around 8 a.m. this morning. NA-A stated she thought she had told licensed practical nurse (LPN)-A about the wound previously, but thought he should know about it anyway because anyone going into his room could see it. During an interview on 3/19/26 at 9:42 a.m., LPN-A stated he had worked with R19 in the last week, but did not recall if he had scabbing or redness under his eyes, but did not think that was something he noticed. LPN-A stated he was unsure if any NAs had notified him of any skin alterations for R19 in the last couple of weeks, but thought he would have added a progress note about the skin alteration if he had. During an interview on 3/19/26 at 11:49 a.m., the nurse manager for the unit, RN-B, stated she had not been notified of the redness and scabbing on R19's face prior to the surveyor questioning the staff about the skin alteration, but she would have expected the staff to. RN-B stated that now that she had been made aware of the issue, she had assessed the CPAP mask, and it appeared as if staff had been unvelcroing the straps that adhere the mask to the face instead of using the clips that allow the mask to be detached from the face without altering the strap length. RN-B stated she had refitted the mask to R19, as it was previously too tight, and was completing education with her staff to ensure the clips were used instead of the straps to prevent worsening of R19's skin alterations that were caused by the pressure of R19's CPAP mask. During an interview on 3/20/26 at 7:56 a.m., the director of nursing (DON) stated that if an aide noticed a skin alteration, they should notify the nurse, who should document this occurrence so it can be fully assessed, and a treatment plan can be developed. The facility's Skin Integrity Management policy dated 10/2025, indicated a pressure ulcer/injury referred to a localized damage to the skin or underlying soft tissue usually over a bony prominence or related to a medical or other device. The policy indicated that staff were to inspect the skin for signs or symptoms of breakdown and inspect the skin under medical devices every shift. The policy indicated that body audits were to be performed weekly, and the findings were to be documented.

Based on interview and document review, the facility failed to ensure instructions for use of multiple as-needed (PRN) psychotropic medications were included, to ensure appropriate administration and minimize the risk of unnecessary medication usage for 1 of 5 residents (R43) reviewed for unnecessary medications. Findings include:R43's quarterly MDS dated [DATE], indicated R43 had both long-term and short-term memory impairment and severely impaired cognitive decision-making skills. The MDS indicated R43 had Alzheimer's disease, anxiety, depression, and a psychotic disorder. The MDS indicated R43 did not have hallucinations, delusions, or rejection of care during the look-back period.R43's care plan dated 2/5/26, indicated R43 had an alteration in mood or behavioral expression as well as dementia with psychotic features. The care plan indicated R43's target behaviors were paranoia, beliefs that weren't real, anger at caregivers and family, physical aggression, and wandering/yelling in the hall at others or things that aren't there. The care plan indicated R43 used anticonvulsant medication, including gabapentin and Depakote, with the target behaviors of complaints of pain with completion of activities of daily living (ADLs) and refusal to complete ADLs. The care plan did not give instructions regarding PRN psychotropic medication use, such as the order of administration.R43's Order Summary Report dated 3/4/26 included:- An order dated 3/12/26 for .5 milligrams (mg) of lorazepam (an anti-anxiety medication) twice daily as needed for agitation and psychosis.- An order dated 3/4/26 for 125 mg of delayed-release Depakote sprinkles (an anticonvulsant medication sometimes used for mood stabilization) daily as needed for agitation. - The order summary included no further instructions on which medication should be given first, for what symptoms these symptoms should be given, etc. R43's medication administration record (MAR) dated 3/1/26 to 3/19/26 at 9:17 a.m., indicated R43 had received the PRN Depakote eight times and the PRN lorazepam documented as administered four times and once on 3/15/26 at 8:33 p.m., with an administration code of 9 meaning other/see nursing notes. R43's administration progress note dated 3/15/26 at 8:33 p.m., included a note, agitation. During an interview on 3/19/26 at 9:49 a.m., LPN-A confirmed he was R43's nurse and had worked with her previously. LPN-A stated R43 had a lot of restlessness and agitation, and that is when he would administer the PRN lorazepam or Depakote. LPN-A stated he had used both the PRN lorazepam and Depakote and had found the lorazepam more helpful. LPN-A stated he was unsure what medication he was supposed to try first if the resident had agitation, so he would just pick one of them.During an interview on 3/19/26 at 11:58 a.m., RN-B confirmed she had reviewed the orders and did not see any instructions for administration for the PRN psychotropic medications, such as which medication staff should administer first if agitation was observed. During an interview on 3/20/26 at 7:52 a.m., the director of nursing (DON) stated she would expect the pharmacist to review antipsychotic medications during their monthly reviews to ensure they had an appropriate diagnosis. The DON stated that if a resident had multiple PRN medications written for agitation, the interdisciplinary team (IDT) would need to meet, and they would need to come up with a plan with further instructions for when each medication should be administered. The facility's Psychotropic Medication Use policy dated 3/2025, indicated psychotropic medications were only to be used when the medication was appropriate to treat a resident's specific, diagnosed, and documented condition. The policy did not include instructions for management of multiple (non-antipsychotic) PRN psychotropic medications.

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 3 of 6 residents (R26, R51, R4) and failed to perform hand hygiene to reduce the risk of the spread of infection to others for 1 of 6 residents (R51) reviewed for infection control practices.Findings include: R26 R26's annual Minimum Data Set (MDS) dated [DATE] identified R26 had intact cognition and was dependent on staff for all personal cares including transfers. R26's diagnoses include obstructive uropathy (blockage preventing normal urine flow) and used an indwelling catheter (tube from bladder to a bag outside the body to drain urine). R26's physician orders (PO) dated 1/6/2026 stated Enhanced Barrier Precautions due to catheter. Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting. R26's care plan dated 4/12/24 included, I require enhanced barrier precautions due to an indwelling medical device. During observation on 3/16/26 at 7:32 p.m., R26's door to the hallway had an Enhanced Barrier Precautions sign attached and a personal protective equipment (PPE) cart was outside the room. During observation and interview on 3/17/26 at 7:47 a.m., nursing assistant (NA)-A combed R26's hair, repositioned her in her wheelchair, and then picked up R26's large urine drainage bag and attached it to the underside of her wheelchair. During this time NA-A did not wear a PPE gown. NA-A stated R26 was on EBP due to her coccyx wound and not the presence of a Foley catheter bag. NA-A stated she wore a PPE gown and surgical mask only when performing any type of perineal (genital area) care. During observation and interview on 3/18/26 at 11:03 a.m., NA-D entered R26's room with portable blood pressure monitor and thermometer unit and obtained blood pressure and temperature of R26 and then exited room after removing gloves and sanitizing unit. NA-D verified he did not wear a PPE gown or mask. NA-D stated, we only wear a gown when we change [R26] because of her wounds on her back and catheter. R51 R51's annual MDS dated [DATE] identified intact cognition and dependence on staff for all hygiene and personal cares. R51 had diagnoses of multiple sclerosis, neurogenic bladder and quadriplegia (paralysis of both arms and legs), and used an indwelling catheter (suprapubic catheter). R51's physician orders (PO) dated 1/6/2026 stated Enhanced Barrier Precautions due to catheter. Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting. R51's care plan dated 4/12/24 state, I require enhanced barrier precautions due to an indwelling medical device. During continuous observation and interview on 3/17/26 from 10:51 a.m. to 11:40 a.m., NA-A and NA-B entered R51's room to transfer R51 from bed to wheelchair using a Hoyer lift (medical device that transfers a person from bed to chair and back again). Both were wearing gloves, PPE gown, and mask. NA-A and NA-B turned R51 from his back to his right-side laying hands on him. NA-B applied ointment to R51's buttock and then both NA-A and NA-B turned R51 back onto his back. NA-B then trimmed an abdominal pad to place around the stoma (opening in the abdomen where the urine drains into a bag). NA-B did not perform hand hygiene or change gloves during this process. NA-A applied an alcohol wipe to exit port of the catheter prior to emptying the urine into a graduated cylinder. NA-A emptied urine into the container and then applied a second alcohol wipe to the exit port. During this time, NA-A did not change her gloves or perform hand hygiene. Both aides assisted R51 to wheelchair using a sling and then adjusted his posture, clothes, and catheter bag once he was in the wheelchair. Upon exiting the room NA-B stated expectation to change gloves, every time I go from one body part to another. NA-B stated she could not recall if she changed her gloves from R51's buttock ointment application to the suprapubic catheter site. NA-A also stated they did not recall changing gloves or performing hand hygiene before emptying R51's catheter. During observation on 3/18/26 at 11:26 a.m., an unidentified staff member went into R51's room to answer a call light. R51 stated he wanted a drink of water. The unidentified staff member did not sanitize or wash hands upon entering R51's room. The unidentified staff member provided water and left the room after sanitizing hands. R51 stated there were times when staff failed to wear a PPE gown when emptying his catheter. During interview with director of nursing (DON) on 3/18/26 at 12:52 p.m., DON stated expectation, of all staff to wash or sanitize their hands prior to entering [any] resident room and on exit. DON stated, EBP is a weakness for us, and stated any time a staff member touched a resident who was in EBP they should be wearing a PPE gown, mask and gloves. She stated handling a catheter without wearing a PPE gown is not acceptable, and staff needed to know what direct patient contact means. DON also stated any time a staff member adjusted or assisted with moving a resident in their wheelchair they should be wearing a PPE gown, gloves and mask. In addition, staff must change gloves when providing cares from one area of the body to another. R4 R4's annual Minimum Data Set (MDS) dated [DATE], indicated R4 had an indwelling urinary catheter and was diagnosed with hypertension and diabetes. R4's Order Summary dated 3/19/26, indicated R4 utilized an indwelling urinary catheter, and catheter care was to be completed every shift. The order summary indicated R4 was on enhanced barrier precautions due to a catheter, so staff were to utilize gloves and gowns during high-contact resident care activities, including dressing, transferring, changing linens, providing hygiene, etc. During an interview and observation on 3/19/26 at 8:14 a.m., licensed practical nurse (LPN)-A was observed completing hand hygiene, applying gloves, and entering R4's room. LPN-A was not observed to put on a gown. A sign indicating R4 was on enhanced barrier precautions was observed on her door, and R4 was observed lying in bed. LPN-A approached R4, asked for her name and date of birth , then used a lancet to draw blood from one of R4's fingers. LPN-A then used a glucometer to take R4's blood sugar reading. LPN-A then uncovered R4's stomach, leaning over her bed with his legs leaning against her covers. LPN-A then administered insulin (an injection used to lower blood sugar) into R4's stomach. LPN-A then removed his gloves and completed hand hygiene. R4 asks to be boosted up in bed, so LPN-A (not wearing any gloves or a gown) leaned over R4's bed, legs touching her bed, grabbed a sheet on the bed that was underneath R4, and attempted to boost her up in bed. When asked when a gown and gloves should be worn when a resident was on enhanced barrier precautions, LPN-A stated that it only needed to be worn when changing wounds or working with the catheter. Undated facility policy titled Infection Control Standard Precautions Facility policy titled CC Enhanced Barrier Precautions modified April 2025, identified EBP (targeted gowns and gloves) are used in conjunction with standard precautions and will be implemented during high contact resident care activities which include, When caring for residents with wounds or indwelling medical devices. In addition: 4. When performing high-contact resident care activities staff should: a. Perform hand hygiene b. [NAME] gloves and a gown c. Complete the high-contact activity d. Remove gloves and gown and dispose of in a trash can in the resident's room or if outside of the resident's room (e.g., shower/tub room or therapy gym) in a trash can contained within the area. e. Perform hand hygiene.

Based on observation, interview and record review, the facility failed to ensure medications were administered at the ordered time resulting in worsened pain for 1 of 1 resident (R25) resulting in a significant medication error. Findings include:R25's quarterly minimum data set (MDS), dated [DATE], indicated R25 was admitted to the care facility on 7/26/23, was cognitively intact, and required substantial to maximum assistance with dressing, bathing and toileting. The MDS further indicated R25 received scheduled and as needed pain medication with a pain rating of 7/10 in the past five days. The national library of medicine reports that withdrawal symptoms from baclofen can start within hours of a missed dose to include rebound muscle spasticity and painful spasms. R25' s orders, printed 3/20/26, indicated R25 was receiving the following medications:Baclofen (muscle relaxant used to treat spasticity, specifically spasms, cramping, and tightness) 7.5 milligrams (mg) three times a day at 7:30 a.m., 1:00 p.m., and 6:00 p.m., for muscle spasms and 2.5 mg two times a day as needed for muscle spasms.Give AM meds around 7:30 a.m.R25's medication administration record (MAR), dated 3/1/26 - 3/19/26, indicated R25 rated her pain as 5/10 or higher on 30 shifts (recorded three times a day) and received as needed oxycodone for 9/10 pain on two occasions. R25's care plan, dated 8/14/23, indicated R25 was at risk for pain related to osteoarthritis, neuralgia and neuritis, and lumbar radiculopathy. During interview and observation on 3/17/26 at 10:00 a.m., R25 and family member (FM)-A were sitting in R25's room. FM-A stated R25 had frequent back pain and received Tylenol and baclofen three times a day for pain. FM-A voiced concerns about morning medications repeatedly being administered to R25 late, passed 11 a.m., and stated R25 was scheduled to receive her medications at 7:30 a.m. FM-A stated when medication administration was late, it caused R25 pain. R25 confirmed, stating she was in pain currently. R25 was also displaying visible signs of pain to include restlessness and facial grimacing. By 10:55 a.m., R25 had still not received her morning medications despite them being ordered for 7:30 a.m., administration. During interview on 3/17/26 at 10:58 a.m., trained medication assistant (TMA)-A stated she had not yet administered R25's 7:30 a.m., medications because she was waiting on the nurse to get R25's AREDS 2 (a vitamin for eye health). During an interview on 3/19/26 at 8:10 a.m., TMA-B stated when a specific time is identified for medication administration for a resident, it is expected the medication be given within one hour before and one hour after the specified time. TMA-A confirmed R25's morning medications were ordered to be given at 7:30 a.m. During an interview on 3/19/26 at approximately 11:30 a.m., registered nurse and clinical coordinator (RN)-E stated it would be expected that R25's medications be administered at 7:30 a.m., stating it was concerning that R25's morning medication were being administered past 11:00 a.m. RN-E stated they were aware of the TMA who struggled to administer R25's medication timely. During an interview on 3/20/26 at 8:10 a.m., the director of nursing (DON) stated R25 receiving her morning medication at 11:00 a.m. was an issue and it was expected that medication be administered timely, stating if an exact time for medication was ordered (i.e. 7:30 a.m.) it was expected to be followed. The DON stated R25 was expected to receive her 7:30 a.m. medications at that ordered time to help keep her comfortable. A facility policy, titled Medication Administration Policy, dated 5/2021, indicated the 8 rights of drug administration will be followed when administering all medication, including right time.

Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified and acted upon 1 of 5 residents (R5) reviewed who had psychotropic medications without an adequate medical diagnosis for ongoing use. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had severely impaired cognition and was diagnosed with dementia and depression. The MDS indicated R5 did not have hallucinations, delusions, or rejection of care during the look-back period. R5's Medical Diagnosis summary dated 4/14/25, included a diagnosis of dementia with other behavioral disturbance dated 4/14/25, depression, a cognitive communication deficit, and an additional diagnosis dated 6/25/21 for dementia without behavioral/psychotic/mood disturbance or anxiety. R5's care plan dated 10/31/25, indicated R5 received antipsychotic medication for dementia with behavioral disturbance. The care plan indicated R5's 6.25 mg of Seroquel two times a day had been decreased to once a day at bedtime on 9/19/24. The care plan indicated that the benefits of the medication outweighed the risks of it use. The care plan included target behaviors of crying and talking about needing to get out. The antipsychotic medication use care plan's latest revision was 10/31/25. R5's Provider's Orders form dated 2/12/26, indicated R5 had an order to restart 6.25 milligrams (mg) of Seroquel (an antipsychotic medication) daily at 2 p.m. for a diagnosis of sundowning (a group of symptoms someone with dementia may experience as the sun sets). R5's provider progress note dated 2/12/26 at 12 a.m., indicated R5 had a diagnosis of vascular dementia, had sundowning association, and used Seroquel 6.25 mg every evening. The note indicated that after the provider had previously planned to discontinue the medication, they had talked with nursing staff and learned that the resident's sundowning started at 2 p.m. every day, and the resident became exit-seeking and wanted to call the police. The provider changed the time of the order to 2 p.m.R5's Pharmacy progress note dated 2/26/26 at 12:17 p.m., indicated R5's medication regimen had been reviewed by the pharmacist, and no irregularities had been identified, and no recommendations were being made. R5's Order Summary dated 3/18/26, included an order dated 2/12/26 for 6.25 mg of Seroquel daily at 2 pm for sundowning. During an interview on 3/19/26 at 9:53 a.m., licensed practical nurse (LPN)-A confirmed he was R5's nurse for the day and worked with her frequently. LPN-A stated, when asked what R5's use of Seroquel, that there were times when R5 would get a little agitated, so she received the medication, but was unsure of any further medical diagnosis for the use of Seroquel. During an interview on 3/19/26 at 12:01 p.m., the nurse manager for the unit, registered nurse (RN)-B, stated she had not realized that the Seroquel had been ordered for sundowning and thought it was weird. RN-B stated she would contact the provider and request that the order be changed to include an appropriate diagnosis. During an interview on 3/20/26 at 7:34 a.m., the CP, stated the pharmacist who usually covered this facility was on leave, but he had worked with the facility previously. The CP stated that when he would review a resident's medications and the resident was on an antipsychotic medication, he would ensure the medication had an appropriate diagnosis. The CP stated that if he had noticed that R5 had an order for Seroquel for sundowning, he would have sent a letter to the provider to double-check that the medication had an appropriate diagnosis. During an interview on 3/20/26 at 7:52 a.m., the director of nursing (DON) stated she would expect the pharmacist to review antipsychotic medications during their monthly reviews to ensure they had an appropriate diagnosis.The facility's Psychotropic Medication Use policy dated 11/2024 indicated the consultant pharmacist would review the resident's medical record for any irregularities, and these would be reported to the director of nursing services and the attending physician to be acted upon.

Based on observation, interview and document review the facility failed to ensure residents using a continuous positive airway pressure (CPAP) machine had appropriate orders for use to include equipment settings for 1 of 2 residents (R19) reviewed for respiratory care. Findings include:R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had intact cognition, no rejection of care behaviors, and was diagnosed with heart failure, kidney failure, and diabetes. The MDS indicated R19 had a functional limitation in range of motion to both upper extremities, needed moderate assistance with toileting hygiene, was dependent for bathing, and needed moderate assistance for bed mobility. R19's care plan dated 12/22/25, indicated that staff were to assist R19 in applying his CPAP machine per MD/NP orders. R19's order summary dated 3/17/26, included multiple orders for weekly and daily cleaning and maintenance of R19's CPAP/BiPAP machine. The order summary included an order dated 6/9/25, to place R19's CPAP or BiPAP on at bedtime, check overnight, remove in the morning, clean the tubing, and fill the chamber with water before use. The order summary did not include equipment settings.R19's medication/treatment administration record dated 3/1/26 to 3/18/26 at 8:00 a.m., indicated R19's CPAP/BiPAP had been applied every night and removed every morning during the period. During an interview and observation on 3/17/26 at 10:52 a.m., R19 was observed in his room in his wheelchair with a ResMed Airsense 10 CPAP machine on his bedside table. R19 stated he wore his CPAP machine at night and had since prior to being admitted to the facility. During an interview and observation on 3/18/26 at 10:58 a.m., registered nurse (RN)-A stated he was unsure what R19's CPAP settings were, as the machines came preset and the nursing staff just started the machine every night for the resident. RN-A stated he was unsure where the settings would be documented but thought they should be found somewhere in R19's medical record.During an interview on 3/19/26 at 11:49 a.m., the nurse manager for the unit, RN-B, stated R19 had entered the facility with the CPAP machine and was unsure if they had any record of the settings, but did not think they did. RN-B stated she would review the medical record and provide the order for the settings if she found it. No order for settings was received. During an interview on 3/20/26 at 7:56 a.m., the director of nursing (DON) stated that usually, residents were admitted from the hospital or the community and already had their CPAP machine with preset settings. The DON stated that she would expect these orders to be to be a part of a resident's medical record. The facility's CPAP and BiPAP Management policy dated 1/2023, indicated that staff should review the care plan and the physician's orders if required, but did not give further instructions as to what these orders should include.

Based on interview and document review, the facility failed to ensure safety measure were put in place to prevent accidents for one of two resident (R25) reviewed for accidents who had known fainting episodes, often while on the toilet. Findings include:R25's quarterly minimum data set (MDS), dated [DATE], indicated R25 was admitted to the care facility on 7/26/23 and was cognitively intact. The MDS further indicated R25 required substantial to maximum assistance with dressing, bathing and toileting. During an interview on 3/17 and 10:09 a.m., R25's family member (FM)-A stated she had concerns about R25 being left alone in the bathroom due to her having multiple fainting episodes while on the toilet, stating she believes she had an episode most recently on 3/1/26 while on the toilet. FM-A stated they were not sure what was causing the fainting episodes, but the facility was aware she was having them. R25's care plan, lacked any mention of R25's fainting spells to include interventions for her safety or interventions for staff to take during or after a fainting spell. R25's Orders, dated 7/29/25, contained an order for DNR (do not resuscitate), do not transfer to ER (emergency room) for fainting episode less than 15 minutes. Call family immediately. R25's progress note, dated 12/30/25, indicated R25 had a fainting episode while sitting on the toilet and had a drop of blood coming from her mouth from possibly biting her tongue or cheek. R25's progress note, dated 11/12/25, indicated R25 passed out while being transferred from the toilet to her bed via a stand lift. During an interview on 3/18/26 at 9:36 a.m., nursing assistant (NA)-E stated R25 transferred via an easy stand and staff had to pretty much do everything for her. NA-E stated R25 has had three fainting spells in the past year that she was aware of, stating R25 will be on the toilet and just kind of tip over but that she could be left in the bathroom alone and would use the call light when she was done. During an interview on 3/19/26 at approximately 7:30 a.m., registered nurse (RN)-F stated she did not often work with R25 and she was not aware of any fainting spells but that R25 was able to be left alone in the bathroom. During an interview on 3/19/26 at approximately 11:30 a.m., clinical coordinator and registered nurse (RN)-E stated she was aware of R25's fainting spells and the thought was she maybe having vasovagal episode (a common, usually harmless, faint caused by an overactive nervous system, leading to a sudden drop in heart rate and blood pressure which can be caused when straining to defecate) but the family has also brought up concerns of possible seizures. CC-A stated the episodes seemed to mostly happen when she was on the toilet and that she did not feel R25 was safe to be left alone on the toilet. CC-A confirmed these episodes or safety precautions to not leave R25 alone on the toilet were not care planned or ordered and they should have been. During an interview on 3/20/26 at 8:10 a.m., the director of nursing (DON) stated she was aware of R25 having one or two fainting episodes on the toilet but was under the impression most of the episodes happened at night while R25 was in bed. The DON stated there should be something in place to protect R25 during the fainting episodes.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., facial hair removal) was provided for 1 of 1 resident (R39) reviewed who was dependent of staff for activities of daily living (ADLs).Findings included:R39's quarterly Minimum Data Set (MDS) dated [DATE], indicated R39 had severe cognitive impairment, did not refuse personal cares, and needed setup/cleaning assistance with oral hygiene and personal hygiene. MDS also indicated R39 needed moderate assistance with bathing, dressing, and toileting hygiene.R39's Medical Diagnoses report dated 3/20/26, indicated diagnoses of chronic diastolic heart failure, amnesia, essential hypertension, muscle weakness, and bilateral shoulder pain.R39's care plan dated 3/20/26 indicated R39 was cognitively impaired and was had difficulty in communicating. This care plan indicated the staff will anticipate and meet her needs. R39's care plan also indicated she had self-care performance deficits and needed assistance of one staff member with dressing, grooming and hygiene.During observation on 3/17/26 at 12:33 p.m., R39 had facial hair on her chin. R39 had about 12 beard strands, each measuring approximately 4 to 5 centimeters long. During the interview, R39 raised her shoulders in response to multiple questions including how she felt about the strands on her chin.During interview on 3/18/26 at 9:10 a.m., registered nurse (RN)-D verified R39 facial hair strands. RN-D stated the nursing assistants needed to help her shave.During interview on 3/18/26 at 1:45 p.m., RN-B stated resident needed to be shaved on shower day or during morning cares. RN-B stated, sometimes R39 got agitated during personal cares and wondered if R39 would let the staff shave her. RN-B verified there was nothing documented on R39's care plan about refusing shaving.During interview on 3/19/26 at 11:33 a.m., nursing assistant (NA)-B stated she will shave female residents' facial hair, unless their care plan indicated the female resident didn't want to be shaved. NA-B stated, It's not okay for a woman to have facial hair.During interview on 3/23/26 at 9:54 a.m., resident representative (RR)-B returned call placed on 3/18/26 at 9:45 am. RR-B indicated on 3/22/26, the previous day, he saw a razor in R39's room and the staff shaved R39 and she looked nicer. RR-B stated it would be important for his mother to not have long facial hair.During interview on 3/20/26 at 8:10 a.m., the director of nursing (DON) stated female facial hair needed to be shaved and added It's a dignity issue.Facility policy titled Resident Care Policy dated 7/2024, indicated every resident will have morning and bedtime cares done daily and shave residents per planned individual preferences.

Based on interview and document review, the facility failed to obtain and document informed consent, including an explanation of risks and benefits, for 1 of 5 residents (R43) reviewed for the use of psychotropic medications.Findings include: R43's quarterly Minimum Data Set (MDS) dated [DATE], indicated R43 had both long-term and short-term memory impairment and severely impaired cognitive decision-making skills. The MDS indicated R43 had Alzheimer's disease, anxiety, depression, and a psychotic disorder.R43's order summary dated 3/18/26, indicated R43 had an order for 50 milligrams (mg) of Seroquel (an antipsychotic medication) twice a day for psychosis with a start date of 3/12/26. The order summary also included an order for 25 mg of Seroquel daily for psychosis with a start date of 3/12/26. R43's medical record was reviewed and lacked evidence that consent for the use of the Seroquel at the current dose and frequency was obtained prior to the medication being administered. During an interview on 3/19/26 at 9:39 a.m., licensed practical nurse (LPN)-A stated he worked with R43 frequently and was her nurse today. LPN-A stated he had reviewed R43's medical record and was unable to find documentation that consent had been obtained for R43's Seroquel, but did believe he had talked with resident representative (RR)-A and obtained verbal consent. During an interview on 3/19/26 at 12:05 p.m., RR-A confirmed he was R43's power of attorney. RR-A stated he had been informed of R43's medication changes in the past, but did not believe he had been informed of the most recent March updates to R43's antipsychotic medications, including the Seroquel that was started on 3/12/26. During an interview on 3/19/26 at 11:58 a.m., the nurse manager for the unit, registered nurse (RN)-B, stated that when psychotropic medication updates were made, the floor nurses were in charge of contacting family, discussing the risks and benefits of the medications, and obtaining consent for the medication. RN-B stated they had a form that included the risks of psychotropic medications that RR's would sign and would be uploaded to the medical record.The facility's Psychotropic Medication Use policy dated 3/2025, indicated informed consent was to be obtained for the use of psychotropic medications used for behavior management.

Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:On 7/17/25 at 8:46 a.m., trained medication assistant (TMA)-A was observed administering medications to R4. TMA-A entered the room and touched R4, assisted her to stand up from her bed and then touched the resident's personal fridge to retrieve some apple sauce. TMA-A did not sanitize her hands before administering the medications to R4. TMA-A administered the medications mixed in applesauce by spoon and handed her a cup of water after every spoonful. After administering the medications, TMA-A used hand sanitizer but then touched her face. TMA-A returned to the medication cart and grabbed an already prepared cup of medications for R1. TMA-A did not sanitize her hands prior to entering R1's room at 8:54 a.m. TMA-A gave R1 her medications one at a time, mixed in applesauce and by spoon. TMA-A did not use hand sanitizer after administering the medications.On 7/17/25 at 9:28 a.m., TMA-B was observed preparing medications for R6. At 9:40 a.m., TMA-B entered R6's room without sanitizing his hands. After TMA-B administered R6's medications, hand sanitization was not completed.On 7/17/25 at 10:34 a.m., registered nurse (RN)-B was observed preparing medications for R2. RN-B was not observed completing hand hygiene prior to handling medications at the medication cart. RN-B brought the medications into R2's room for R2 to verify the medications per her preference. RN-B placed the medications into a med cup and handed the medications with a cup of water to R2, R2 finished her medications. RN-B left the room and did not complete hand sanitization.On 7/17/25 at 12:15 p.m., R1 was interviewed and stated she did not usually see staff completing hand hygiene before or after giving her medications.On 7/17/25 at 1:38 p.m., RN-B was interviewed and stated hand sanitizer should be used before and after medication passes.On 7/17/25 at 2:04 p.m., TMA-B was interviewed and stated that staff should sanitize their hands before and after medication administration.On 7/17/25 at 3:25 p.m., the interim director of nursing (DON) was interviewed. She stated hands should be sanitized between medication passes.The facility policy, Infection Control Standard Precautions, no revision date, directed staff that hand hygiene should be performed before and after contact with the resident, after contact with objects in the resident's room and before meals.

Based on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during medication administration for 5 of 5 residents (R1, R2, R4, R5, R6) observed for medication administration.Findings include:R1R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.R1's physician order from the medication administration record, dated 1/6/25, indicated Ativan Oral Tablet 0.5 milligrams (Lorazepam). Give 0.5 milligrams by mouth every 6 hours as needed for panic attack. Camera footage dated 6/21/25 at 12:53 a.m., showed registered nurse (RN)-A entered R1's room with a medication cup and spoon. RN-A stated to R1, I think you are describing a lot of tension. This will help, the lorazepam. R1 said Is it like Ativan? I can't have that. RN-A stated the medication was the same as R1's gabapentin order, administered the medication to R1 and immediately left the room.On 7/17/25 at 9:00 a.m., trained medication aid (TMA)-A went to the medication cart and grabbed an already prepared cup of medications for R1. TMA-A gave R1 her medications one at a time, mixed in applesauce and with a spoon. TMA-A did not explain the purpose of all medications to R1. On 7/17/25 at 12:15 p.m., R1 was interviewed and stated not all staff stayed in the room to make sure she finished her medications.R2R2's quarterly MDS assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.On 7/17/25 at 10:18 a.m., R2 was interviewed and stated that not all staff wait for her to finish her medications before they left her room.R4R4's quarterly MDS assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.On 7/17/25 at 8:46 a.m., TMA-A was observed administering medications to R4. TMA-A administered the pills mixed in applesauce by spoon and handed her a cup of water after every spoonful. TMA-A did not explain what medications she was administering to R4. R5R5's quarterly MDS assessment dated [DATE], indicated she was cognitively intact and required moderate assistance in activities of daily living.On 7/17/25 at 9:05 a.m., TMA-A started to prepare medications for R5, she did not verify the expiration dates for the medications. At 9:11 a.m., TMA-A stated she checked medication expiration dates when new medications arrived from the pharmacy and the nurses came around to check expiration dates.R6R6's quarterly MDS assessment dated [DATE], indicated she was moderately cognitively impaired and required substantial assistance in activities of daily living.R6's physician orders dated 7/17/25, included an order for Polyethylene Glycol 3350 powder (Miralax). Give 17 grams by mouth one time a day for constipation. It also included an order for Potassium Chloride extended-release oral tablet. Give 20 milliequivalent by mouth one time a day for malnutrition. The order lacked instructions to administer with any amount of water. R6's orders lacked a self-administration order allowing R6 to administer her medications independently.On 7/17/25 at 9:28 a.m., TMA-B was observed preparing medications for R6. TMA-B was not verifying medication expiration dates while going through each medication. TMA-B poured 17 grams of Miralax powder into a cup and mixed it with water, he also placed one Potassium Chloride tablet into the medication cup. At 9:40 a.m., TMA-B entered R6's room and R6 was laying at about a 30-degree angle in her bed, TMA-B did not raise the head of the bed prior to giving R6 her medications. R6 swallowed all of her pills at once and drank half of the cup of Miralax. TMA-B walked out of the room before verifying R6 finished the Miralax and the Miralax was left on the bedside table. TMA-B stated there was a staff person who came around and checked expiration dates about once per month.On 7/17/25 at 1:04 p.m., RN-A was interviewed and she stated that staff should inform residents what their medications were and what they were for during medication passes. Medication expiration dates should be checked before medications were administered. Staff should stand with the resident until all of the medications had been taken.On 7/17/25 at 1:38 p.m., RN-B was interviewed and stated staff should inform residents what medications they were receiving and what they were for. Medication expiration dates should be checked everyday. Staff should make sure residents drank everything and took all medications before staff left the room and document. On 7/17/25 at 2:04 p.m., TMA-B was interviewed and stated that it depended on the resident if the medications should be explained to them or not. Some residents did not care. Potassium chloride should be given with a full glass of water and if there was a medication mixed in with a glass of water, staff should ask residents to drink the full glass of water. On 7/17/25 at 2:20 p.m., a pharmacist was interviewed. She stated staff should follow doctors orders to mix the Miralax so if the directions state to mix 17 grams in 8 ounces of water, it would be expected that the patient would drink the full amount.On 7/17/25 at 3:25 p.m., the interim director of nursing (DON) was interviewed. She stated that if a resident asked, staff should explain their medications. Medication expiration dates should be checked with the medication pass during the rights and the three checks. Staff should stay with a resident until they drank the medication fully. The facility policy, Medication Administration Policy, last modified May 2021 directed that residents have the right to know why they were receiving the drug. All medications to be administered according to medication label instructions unless specifically ordered by a doctor. Expiration dates would be reviewed prior to administration of medication. During medication administration, hand washing would be completed when appropriate. Medications would not be left at the bedside unless resident had an order for self-administration and the care plan reflected the resident's ability.

Based on observation, interview and document review, the facility failed to provide assistance with personal hygiene for 4 of 4 residents ( R7, R33, R267) reviewed for activities of daily living (ADL)'s. Findings include: R7 R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had severe cognitive impairment and had diagnoses which included renal insufficiency, dementia, and depression. Identified R7 required one person physical assist from staff with personal hygiene. R7's current care plan revised 2/27/24, indicated R7 had deficits with ADL's related to dementia and muscle weakness. Indicated R7 required staff assistance with personal hygiene and preferred to have staff assistance with removing facial hair. R7's annual comprehensive Care Area Assessment (CAA) dated 6/6/24, identified R7 required assistance with ADL's. Identified R7 had an activity intolerance related to weakness, physical limitations and dementia. R7's care sheet undated, identified it was a standard for staff to shave residents daily. During an observation on 1/27/25 at 1:18 p.m., R7 was sitting in her wheelchair in the day room and had several half inch long white facial hairs on her chin and above her upper lip. During an interview on 1/27/25 at 1:26 p.m., family member (FM)-A stated R7 preferred to be shaved when facial hair was visible. During an observation on 1/28/25 at 8:11 a.m., R7 was sitting in her wheelchair at the dining room table. R7 continued to have several half inch long white facial hairs on her chin and above her upper lip. During a joint interview on 1/28/25 at 8:51 a.m., nursing assistant (NA)-A and licensed practical nurse (LPN)-A verified R7 had several long white facial hairs. NA-A stated R7 required staff assistance to shave facial hair. NA-A stated she had not assisted R7 with shaving recently and was unsure the last time R7 had been shaved. LPN-A stated her expectation was that R7 would have been shaved as soon as facial hair was present. 48740 R33 R33's MDS dated [DATE], identified R33 had no cognitive impairment and diagnoses which included muscle weakness, depression, and diabetes. R33 required moderate assistance with personal hygiene such as combing hair and shaving. R33's care plan dated 12/26/24, revealed R33 had an activities of daily living (ADL) self-care performance deficitsdue to encephalopathy, aspiration, urinary tract infection (UTI) dysphasia, and cognitive impairment. R33 wanted to be clean and well dressed. R33 required one assist for dressing, grooming, and hygiene. Care sheet titled pioneer park west dated 1/28/25, revealed stands of care: call light in reach, encourage use. Shave residents daily. During an interview on 1/27/25 at 12:30 p.m., R33 had approximately 2 cubic centimeters (cm) of facial hair on his chin, upper lip, and cheeks. During an observation on 1/28/25 at 8:47 a.m., R33 had 2 cm of facial hair on his chin, upper lip, and cheeks. During an observation at 1/28/25 p.m. at 3:28 p.m., R33 had 2 cm of facial hair on his chin, upper lip, and cheeks. During an interview on 1/27/25 at 12:30 p.m., R33 reported his shaver did not work and was under the impression the facility requested residents buy their own shavers and did not want to spend money on a shaver. R33 had approximately 2 cubic centimeters (cm) of facial hair. During an interview on 1/28/25 at 3:28 p.m., nursing assistant (NA)-A verified R33 had long facial hair around 2 or 3 cm and needed to be shaved. NA-B verified that the care sheet stated to shave residents daily. NA-A stated shaving tasks did not get completed daily. NA-B indicated residents did not get shaved often. NA-B indicated that the facility had shavers for residents to sue however would have to ask a supervisor to obtain one since they were not kept in the storage room. During an interview on 1/28/25 at 2:28 p.m., registered nurse (RN)-B indicated a resident should have been shaved on their shower day or shaved more often depending on the resident preference. R267 R267 quarterly MDS dated [DATE], identified R267 had no cognitive impairment and had diagnoses of malnutrition, hypertension, and vascular disease. R267 required maximal assistance with personally hygiene, including combing hair and shaving. R267 care plan revised on 11/22/24, revealed R267 had an ADL self-care performance deficit related to weakness, impaired mobility, self-care ability, severe malnutrition, dysphasia, and pain in legs. R267 wanted to be clean and well dressed. R267 needed assist of one for dressing, grooming, and hygiene. Care sheet titled pioneer park west dated 1/27/25, revealed Standards of care: call light in reach, encourage use. Shave residents daily. During an observation on 1/27/25 at 1:18 p.m., R267 had approximately 2 cubic centimeters (cm) of hair growth on his chin, upper lip, and cheeks. During an observation on 1/28/25 at 8:07 a.m., R267 had a razor sitting on his bedside table with 2-3 cm of hair growth on his on his chin, upper lip, and cheeks. During an observation on 1/29/25 at 7:58 a.m., R267 was laying in bed dressed ready to get up, R267 had approximately 3 cm of facial hair. Licensed practical nurse (LPN)-B and nursing assistant (NA)-C entered the room and proceeded to assist R267 with ADLs. LPN-B then shaved R267. During an interview on 1/27/25 at 1:18 p.m., R267 indicated he was supposed to be shaved on Mondays once a week when he has his bath. R267 stated he liked to be shaved often. During an interview on 1/29/25 at 12:19 p.m., R267's daughter indicated R267 liked to be shaved often and did not want facial hair. R267 daughter had bought R267 two different razors. During an interview on 1/28/25 at 1:42 p.m., NA-D did not know how often R267 should have been shaved. NA-D verified that R267 had long facial hair around 3 cm and should have been shaved. R267 stated to NA-D, I like my face shaved, I don't like a mustache. NA-D took out care sheet and verified R267 received a bath on Monday and that R267 would have to request to be shaved. During an interview on 1/28/25 at 2:52 p.m., director of nursing (DON) indicated R7 required staff assistance with shaving. DON stated her expectation was R7 would have been shaved when facial hair was present. During a follow-up interview on 1/28/25 at 4:38 p.m., DON stated the expectation was for staff to shave residents as needed. Staff were expected to do a body audit once a week with the shower and shave at that time if needed. The facility could have provided a razor if the resident did not have their own. A Facility policy titled Activities of Daily Living (ADL's) dated 3/15/21, indicated the facility would have provided care and services for hygiene per the resident's individualized plan of care. Further indicated ADL care would have been provided based on resident preferences.

Based on interview and document review, the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. This deficient practice had the potential to affect all five residents (R29, R39, R45, R35, and R12) who regularly attended the monthly resident council meetings. Findings include: R29's quarterly Minimal Set Data (MDS) dated [DATE], revealed R29 had mild impaired cognition. R39's annual MDS dated [DATE] ,revealed R29 had no cognitive impairment. R45's annual MDS dated [DATE], revealed R45 had no cognitive impairment. R35's quarterly MDS dated [DATE], revealed R25 had mild cognitive impairment. R12's significant change MDS dated [DATE] ,revealed R12 had no cognitive impairment. During an interview on 1/28/25 at 10:01 a.m., with resident council members R29, R39, R45, R35, and R12 revealed none of the residents had been to a resident council meeting. R29, R39, R45, R35, and R12 indicated they had not been invited to attend a resident council meeting. The residents denied staff offering to bring them to a resident council meeting. The review of the resident council meeting minutes on 1/27/25 at 6:39 p.m., revealed a list of residents (R45, R39, R29, R12, and R35) who attend resident council meetings regularly. The resident council meeting minutes revealed the resident council reviewed nursing services, culinary, activities, housekeeping, and maintenance during each resident council meeting and reviewed old concerns. The review of the resident activity calendar for Thursday, 1/21/25, revealed 12:00 p.m., resident council on the first floor, and 12:30 p.m., resident council on the second floor. The resident activity calendar laced identification where the meetings were located. The review of the activity calendar for Friday, 12/27/24 revealed 12:00 p.m., resident council first floor, and 12:30 p.m., resident council on the second floor. The resident activity calendar lacked documentation on where the resident council meeting was located. During review of the activity calendar for Friday, 1/24/25, revealed resident council at 12:00 p.m., for the first floor. Resident council 12:30 p.m., for the second floor. The activity calendar did not identify the location of the resident council meetings. During an interview on 1/28/25 at 10:51 a.m., activity director (AD) revealed the resident council was once a month during lunch. AD indicated her process was to go to the first-floor dining room and have resident council while residents were in the dining room eating lunch. AD then went to the second floor and had a resident council meeting while the residents were eating lunch. AD was unable to answer how people were invited. AD was unable to answer how residents who ate in their rooms or were fed by a feeding tube, attended resident council meetings. During an interview on 1/28/25 at 3:09 p.m., R12 stated she did not know that the dining room meetings were resident council meetings. R12 stated she did not bring up concerns during those meetings however, did listen to the information. R12 felt a private meeting would have been helpful to share things that should have been discussed in a more private setting. During an interview on 1/29/25 at 8:33 a.m., R45 stated she did not know that the resident council meetings were held in the dining room. R45 indicated during meals, staff would bring up topics while residents were eating. R45 indicated no one informed her that talking in the dining room was a resident council meeting. R45 would have rather had a private meeting to bring up topics she had concerns with. During an interview on 1/28/25 at 4:14 p.m., the administrator indicated resident council was on the resident activity calendar and that all residents received a resident calendar. The calendar was also hung in the hallway. The administrator was unable to verify how everyone was invited to participate if the resident did not come to the dining room for lunch. The administrator felt a resident could talk to the AD in private if there was a concern or fill out a grievance form. The administrator did not feel there was a concern with the meetings not being private and was held with dietary and nursing staff in the dining room. The administrator felt residents could have asked a staff member to discuss their concerns one-on-one if needed. A facility policy titled Resident Council Policy dated 8/24, indicated it was the policy of Presbyterian Homes and Services to provide an opportunity for residents to meet in a private space and for the facility to take reasonable attempts with the approval of the group to make residents aware of upcoming meetings in a timely matter. Procedure: 1. Staff, visitors or other guests may only attend resident group meetings only at the respective group's invitation.

Based on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R62) reviewed for activities. Findings include: R62's significant change Minimum Data Set (MDS) dated [DATE], identified R62 had no cognitive impairment and had diagnoses which included depression, failure to thrive and was currently receiving hospice services. R62 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. R62's LTC therapeutic recreation and activities assessment dated [DATE], indicated R62 preferred day/activity room and independent activities in her room. R62's preferences were visits from her daughter, talking with staff, watching television, one to one visits, and activities in a group setting. R62's care plan revised 12/30/24, identified R62 had a long term goal to choose her own activities. R62's careplan further indicated R62 was to be invited to scheduled activities, provided an activities calendar, and provided supplies to pursue her activity interests. During an observation and interview on 1/27/25 at 5:03 p.m., R62 stated she had not been offered any visitors throughout the day and was feeling very sad. R62 further sated she had not been offered any activities since she was admitted . R62 indicated she did not remember seeing an activities calendar in her room. A scan of the room was completed and no activities calendar was noted. During an observation and interview on 1/28/25 at 12:11 p.m., R62 was laying in her bed using her personal cellular telephone. R62 continued to state she did not have an activities calendar in her room and had never received one for the month of January 25. R62 stated she had no way of knowing what activities were going on in the facility. R62 verbalized that she not had any visitors today. R62 stated this is what I do all day, just lay here in this bed. R62 further stated she wished she had an activities calendar, was invited to actives throughout the day, and had visits from the staff. During an interview on 1/28/25 at 12:28 p.m., nursing assistant (NA)-F stated the life enrichment team was in charge of handing out activity calendars to each resident. NA-F further stated the life enrichment team had daily activities in the community room and R62 enjoyed attending them at times. During an interview on 1/28/25 at 2:38 p.m., life enrichment director (LED) confirmed calendars were handed out to each resident on the first of every month. LED stated life enrichment staff were expected to go to R62's room and invite her to group activities. LED further stated she was not aware R62 did not have an activities calendar in her room and that R62 had not been invited to any group activities. LED indicated staff do not document when a resident completed an activity so she had no way of knowing what activities R62 had been invited to. LED confirmed R62's activity interests. During an interview on 1/29/25 at 10:33 a.m., director of nursing confirmed the above findings and stated no documentation was completed to indicate residents received activities throughout the day. DON stated her expectation was staff were to invite and engage all resident in daily activities. Requested facility for the Activities Program, however, one was not provided.

Based on interview and document review, the facility failed to ensure newly admitted residents received 30 day physician visits for the first 90 days for 1 of 1 residents (R30) reviewed for 30 day physician visits. Findings include: R30's admission Minimum Data Set (MDS) dated [DATE], identified R30 had no cognitive impairment and had diagnoses which included chronic kidney disease (CKD), an indwelling catheter, and a history of urinary tract infections. R30 required moderate assistance with activities of daily living (ADL's) bathing, transfers, and toileting. R30's facesheet indicated R30 was admitted to the facility on [DATE]. R30's medical record lacked evidence R30 was seen by a physician since admission. During an interview on 1/27/25 at 6:29 p.m., R30 stated he had not seen a physician since he was admitted to the facility. R30 further stated he had requested to see a physician and staff avoided him when he asked. R30 indicated he had seen a nurse practitioner however had wanted to see a physician. During an interview on 1/29/25 at 10:08 a.m., nurse manager (NM)-B stated R30 had been seen three times by a nurse practitioner (NP) since admission however, R30 had not been seen by a physician since admission. During an interview on 1/29/25 at 10:38 a.m., administrator and director of nursing (DON) confirmed the above findings. Administrator stated her expectations were residents received physicians visits every 30 days for the first 90 days after admission. Review of facility policy titled Physicians Services, modified 11/19, the frequency of physicians visits would consist of at least every 30 days for the first 90 days after admission.

Based on observation, interview and document review, the facility failed to ensure the resident's ability to self-administration of medications (SAM) was assessed prior to leaving medications with the resident for 3 of 3 residents (R33, R267, R9) reviewed who had medications in their rooms. R33 R33's admission Minimum Data Set (MDS) dated [DATE], identified R33 had no cognitive impairment and diagnoses which included: muscle weakness, depression, and diabetes. R33 required moderate assistance with personal hygiene such as combing hair and shaving. R33's care plan dated 12/26/24, revealed R33 had an activity of daily living (ADL) self-care performance deficits due to encephalopathy, aspiration, urinary tract infection (UTI) dysphasia, and cognitive impairment. R33 wanted to be clean and well-dressed. R33 required one assist for dressing, grooming, and hygiene. The care plan lacked information regarding self-administration of medication or medications that were kept in the resident's room. During an observation on 1/27/25 at 12:41 p.m., Nystatin powder (medication used to treat fungal skin infections) was located on the table next to the bed. R33 indicated his Nystatin powder is always there. Review of orders dated 1/21/25 revealed an order for Nystatin 1000 units/gram powder applied topically daily and twice a day as needed. No order to leave medication at bedside. Review of assessments revealed a lack of an assessment to self-administer medication. During an interview on 1/27/25 at 6:21 p.m., registered nurse (RN)-A, verified Nystatin power was on the side table next to the bed. RN-A indicated it must have been left out by mistake and removed the Nystatin powder. RN-A locked up the Nystatin powder in the medication cart. During an interview on 1/28/25 at 8:41 a.m., RN-B indicated Nystatin powder should not be have been left on the nightstand as it was a medication. RN-B verified R33 did not have an order for medications to be left at the bedside. R267 R267 quarterly MDS dated [DATE], identified R267 had no cognitive impairment and diagnoses of malnutrition, hypertension, and vascular disease. R267 required maximal assistance with personal hygiene including combing hair and shaving. R267's care plan revised on 11/22/24, revealed R267 chose not to self-administer medications. Care plan directed staff to administer medications per orders. During an observation on 1/28/25 at 12:19 p.m., R267 had refresh eye drops (for dry eyes) present on the side table. On the nightstand, R267 had one bottle of Tums (treatment for heartburn) 1000 mg, one bottle of antacids (used to neutralize acid in the stomach), one roller-ball anti-itch hydrocortisone (decrease inflammation/ itchy skin), and one hydrocortisone 1% cream (a cream to treat skin conditions such as itchy or inflamed skin). Review of signed orders dated 1/24/25, revealed R267 did not have orders for medications to be left at bedside. R267 did not have an order for Tums or refresh eye drops. R267 did have an order for hydrocortisone cream however, no order for the medication to be left at the bedside. Review of the electronic medication administration record (EMAR) for January 2025, revealed hydrocortisone cream 2.5% apply to perineal area topical two times per day, order start date of 1/20/24. No self-administration order or order to be left in the room was noted. No order for Tums, antacids, or refresh eye drops on the EMAR. Further review of EMAR for January 2025, revealed, artificial tears ophthalmic solution 0.1-0.3 %, install 1 drop in both eyes as needed for dry eyes, four times a day. Medication was discontinued on 1/20/25. Review of assessments revealed R267 did not have an assessment to self-administer medications. During an interview on 1/28/25 at 2:42 p.m. licensed practical nurse (LPN)-B confirmed R267 had no orders for medications to be left at the bedside. LPN-B confirmed eye drops were on the side table, one bottle of Tums 100 mg, one bottle of antacids, one roller-ball anti-itch hydrocortisone, and one hydrocortisone 1% cream on the nightstand. Progress note from 1/28/25 at 8:09 p.m., revealed: resident was found to have one bottle of Tums, one bottle of antacids, one roller-ball anti-itch, hydrocortisone tube and refresh eye drops in the room. Writer explained why we could not let him keep the medication in there, and that they would be given to his daughter to take home. Writer then called the daughter to explain the situation and let her know that nurse practitioner would be informed and see if at all possible to have these medications ordered as needed so facility staff could administer them. R9 R9's MDS dated [DATE], identified R9 had no cognitive impairment and needed moderate assistance with activities of daily living. R9 had diagnoses which included hypertension, arthritis, and pain in right leg. During an observation on 1/27/25 at 12:13 p.m., Aspercream with lidocaine (medication used for pain relief) was noted on the bedside table. During an observation on 1/28/25 at 8:54 a.m., Aspercream with lidocaine continued to be next to the bed on the bedside table. During an observation on 1/28/25 at 12:28 p.m., aspercream with lidocaine continued to be next to the bed on the bedside table. R9 care plan revised on 10/7/24, revealed R9 chose not to self-administer medications, except for aspercream. Review of R9's assessments revealed R9 did not have an assessment to self-administrator medications. Review of signed orders dated 11/12/24, revealed aspercream lidocaine external cream 4% (for pain relief) apply to affected area(s) topically as needed for pain apply 2 grams twice a day to painful area and apply to lower legs topical in the morning for pain apply two grams to each lower leg before compression stockings. No orders for self-administration of medications was noted. Review of EMAR for January 2025, revealed staff signed off the administration of Aspercream Lidocaine external cream 4% apply to lower legs topically in the morning for pain apply two grams to each lower leg before compression stockings, order start date was 12/12/23. EMAR lacked orders to leave medication at bedside. During an interview on 1/27/25 at 12:13 p.m., R9 stated she kept the aspercream with lidocaine at the bedside otherwise R9 would forget to apply it. R9 indicated the cream had always been on the bedside table. During an interview on 1/27/25 at 6:19 p.m.,. RN-A reported the nurse would complete the self-administration order for a resident to self-administrate a medication in their room. RN-A revealed staff put on the aspercream for R9. RN-A verified R9 did not have an order to self-administer the medications. RN-A verified R9 did not have a self-administration assessment completed. RN-A verified that R9 had aspercream with lidocaine was left on her bedside table. During a follow-up interview on 1/28/25 at 4:41 p.m. director of nursing (DON) indicated if a resident was assessed to be able to self-administer medications, it would have been identified in the care plan, otherwise medications were kept in the medication cart. DON verified R33, R267 and R9 did not have self-administration assessments completed. A policy titled Medication Administration Policy dated May 2021 revealed Procedure: 17. Medication would not be left at beside unless resident had an order for self-administration of medications and had been assessed to be safe to do so and the care plan reflected the resident's ability.

Based on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R17) who had a recent fall with a significant injury in the facility and remained at high risk for falls. Findings include: R17's significant change Minimum Data Set (MDS) dated [DATE], identified R17 had severe cognitive impairment and had diagnoses which included anxiety disorder, dementia, and left humerus (bone in the arm) fracture. Identified R17 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. Identified R17 had one fall with a major injury since last assessment. R17's significant change Care Area Assessment (CAA) dated 12/27/24, identified R17 had one fall since prior assessment. Identified R17 had a fall while using a standing lift and fractured her left humerus Identified R17 remained at high risk for falls related to dementia, cognitive impairment with agitation and depression. Further identified R17 was now to use a full body lift for transfers. R17's Fall Risk Screening Tool dated 12/21/24, identified R17 was at high risk for falls related to a recent fall which resulted in a fracture of the left humerus. Identified R17 now required a full body lift with assist of two. R17's care plan revised 12/27/24, identified R17 had a history of falls with fractures and was at risk for further falls related to mobility/balance problems. R17's interventions included: Reassess for standing lift when appropriate, keep bed in lowest position, and place wheelchair next to bed when in bed. Identified R17 wore a sling to left arm and required assistance with dressing, toileting and transfers. R17's care sheet undated, identified staff were to place R17's wheelchair next to bed. Review of R17's progress notes from 12/14/24 to 12/15/24, identified the following: -12/14/24 at 2:40 p.m., NA was transferring R17 in a standing lift when R17 let go of the bar and NA lowered 17 to the floor, called for assistance and used a full body lift to place R17 into bed. -12/15/24 at 10:14 a.m., R17 complained of increased pain in left shoulder, Xray and sling to left shoulder were ordered. -12/15/24 at 12:58 p.m., Fracture to left Humeral head and neck. During an observation on 1/28/25 at 3:03 p.m., R17 was lying in bed and wheelchair was five feet from R17's bed facing the opposite direction. During an observation on 1/29/25 at 7:11 a.m., R17 was lying in bed and wheelchair was in the bathroom approximately 10 feet from R17's bed. During an interview on 1/29/25 at 7:15 a.m., nursing assistant (NA)-A stated R17 had a recent fall and broke her left arm. NA-A stated R17's wheelchair was to be placed next to R17's bed as a fall intervention. During an interview on 1/29/25 at 7:20 a.m., nurse manager (NM)-A verified R 17's bed was lying in bed and the wheelchair was in the bathroom which was approximately 10 feet from R17's bed. NM-A stated R17 was at risk for falls and had a recent fall with a fracture. NM-A further stated her expectation was that the wheelchair would have been placed next to R17's bed. During an interview on 1/29/25 at 8:03 a.m., director of nursing (DON) verified R17 had a recent fall with a fracture. DON verified R17's wheelchair was to be placed next to the bed when R17 was in bed. DON stated her expectation was that the care plan would have been followed to help prevent future falls. Review of a facility policy titled Fall Prevention and Management Program Policy revised 4/21, identified all residents were to be assessed for fall risk and nursing staff would implement interventions according to resident specific risk factors. Further identified care plans would indicate the resident specific interventions to prevent falls . .

Based on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R62) whose care plan was reviewed. Findings include: R62's significant change Minimum Data Set (MDS)dated 12/24/24, identified R62 had no cognitive impairment and had diagnoses which included depression and malnutrition. R62 required extensive assistance with activities of daily living (ADL's) which include bed mobility, transfers, and toileting. R62's clinical nutrition assessment dated [DATE], identified R62 was on a regular diet and was independent with eating after set up. R62's care plan revised 12/30/24, identified R62 had limited physical mobility and self-care deficits related to failure to thrive, protein malnutrition and weigh loss. R62's intervention included: R62 needed to get up in her wheelchair for all meals. R62's care sheet dated 1/17/25, identified R62 was to be up in wheelchair for all meals. During an observation on 1/28/25 at 12:20 p.m., nursing assistance (NA)-F entered R62's room with R62's meal tray. NA-F set R62's meal tray on the bedside table and asked R62 if she wanted to be boosted up in bed prior to eating. NA-F boosted R62 up in bed, elevated the head of the bed and pushed R62's bedside table over R62's bed. NA-F asked R62 if she wanted the head of bed up higher so R62 could eat better. R62 indicated she did and NA-F raised the head of her bed. NA-F told R62 what was on her tray and left R62's room. During an interview on 1/28/25 at 12:28 p.m., NA-F stated staff were to expected to get R62 up into her wheelchair for all meals. NA-F further stated she did not ask R62 to get up into her wheelchair because, R62 would probably refuse anyway. NA-F reviewed the care sheet for R62 and indicated the care sheet stated R62 was to be up in her wheelchair for all meals. During an interview on 1/28/25 at 3:10 p.m., registered nurse (RN)-C confirmed R62 was to be up in her wheelchair for all meals. RN-C stated staff were to report if R62 refused to get up in her wheelchair. During an interview on 1/28/25 at 4:39 p.m., household coordinator (HC) confirmed that R62 was to be up in her wheelchair for all meals for repositioning and quality of life. HC indicated R62's careplan and caresheet stated R62 was to be up for all meals. During an interview on 1/29/25 at 10:33 a.m., director of nursing (DON) confirmed the above findings and stated it was her expectation that staff would follow residents care plans. DON stated she would expect staff to report any refusals to the RN and document the refusal. Requested a careplan policy, however, one was not provided.

Based on interview and document review, the facility failed to implement a system to ensure medications were available to administer as ordered for 2 of 2 residents (R61, R57) identified who did not receive medications as ordered. Findings Include: R61 R61's admission Minimum Data Set (MDS) dated [DATE], identified R61 had moderate cognitive impairment and diagnoses which included: Crohn's disease (chronic condition that causes inflammation of gastrointestinal tract), heart failure and chronic kidney disease. During an observation on 1/27/25 at 4:38 p.m., trained medication aide (TMA)-A set up R61's medications. TMA-A indicated R61 was to receive Creon (medication that replaces digestive enzymes in body) however it was not available to administer, so would contact the pharmacy to order it again. R61's Discharge Orders And Information hospital form dated 12/30/24, included the following: -Creon 24000-76000 units oral capsule, take one capsule by mouth three times daily. R61's January Electronic Medication Administration Record (EMAR) identified the following: -Creon Oral Capsule Delayed Release Particles 24000-76000 Unit. Give 1 capsule by mouth with meals for pancreatic insufficiency, from January 22 at 1200 p.m. to January 28 at 8:00 a.m., it was not administered 18 times. Review of R61's progress notes from 1/22/25, to 1/27/25, identified the following: -1/24/25 at 5:05 p.m., Creon Oral Capsule, no supply, called pharmacy and informed nurse. -1/27/25 at 4:46 p.m., Creon Oral Capsule, need to be reordered. R61's progress notes lacked documentation R61's provider had been notified R61's Creon medication was not available. During an interview on 1/28/25 at 10:16 a.m., clinical coordinator registered nurse (RN)-B confirmed R61's Creon was not available, and had not been administered since 1/22/25. RN-B stated she became aware that morning that R61 was out of Creon medication, and would make sure it was available to give later that day. RN-B indicated the facility's usual process was to reorder medication when the medication ran out from pharmacy. RN-B stated she would need to contact director of nursing (DON) to see if anything else could be done. During a telephone interview on 1/28/25 at 12:37 p.m., pharmacy consultant (PC)-A stated the expectation was if a resident was out of a medication, to contact the pharmacy, and if not available to try a different pharmacy. PC-A also expected the facility to contact the physician to see if the medication should be held until received, or if a different medication should be administered, and document. PC-A stated that if R61 did not have Creon as ordered, R61 could have gastrointestinal (GI) upset. PC-A indicated if a resident did not receive Zoloft as ordered, they may be fine, or it may affect their depression, or cause anxiety. During a telephone interview on 1/28/25, at 11:54 p.m., nurse practitioner (NP)-A confirmed she was familiar with R61's care and had not been notified R61 was not receiving Creon as ordered. NP-A stated if R61 did not have Creon medication available to administer, her expectation was that pharmacy would be notified, and if still unavailable that she or triage would be contacted because it was important residents receive their medications as prescribed. During a follow up interview on 1/29/25 at 8:45 a.m., RN-B stated R61's Creon had been ordered and would be delivered that day. RN-B indicated they notified R61's provider of R61's missed Creon medication, and they spoke to PC-A who advised them to monitor for possible effects of gastrointestinal symptoms from R61 not receiving receiving the Creon as ordered, so R61 would be monitored. 48740 R57 R57's quarterly MDS dated [DATE], identified R57 had moderate cognitive impairment and diagnoses which included: hypertension, depression Alzheimer's, aphasia, and seizure disorder. During an observation on 1/28/25 at 9:01 a.m., TMA-E went to set up R57 medications. TMA-E went to take Zoloft (for depression) 25 Milligram (mg) out of the medication cart. TMA-E was unable to locate the medication in the medication cart. TMA-E indicated the medication could have been in the medication room and would check and if unable to locate the medication, then the pharmacy would be contacted. During an interview on 1/28/25 at 1:46 p.m., TMA-E verified that R57 did not have the Zoloft medication in the medication cart but was able to locate the medication in the medication room and was able to give the medication. TMA-E indicated the process would be to reorder the medication according to the date on the medication card. If a resident missed a medication the facility would make the pharmacy aware the medication was currently out and needed to be refilled. The nurse was responsible for updating the physician on the missed medication dose. TMA-E verified the EMAR reflected R57 and did not receive Zoloft 25 mg on 1/26/25 and 1/27/25. Review of the EMAR revealed that R57 did not receive Zoloft 25 mg on 1/26/25 and 1/27/25. Review of the signed physician orders signed 1/27/25 revealed R57 had an order for Zoloft 25 mg, take one tablet by mouth daily. After review of the progress notes from 1/25/25 to 1/27/25, revealed the pharmacy and physician were not updated that R57 missed two doses of Zoloft 25 mg. During an interview on 1/28/25 at 2:52 p.m., RN-B indicated the facility process to reorder medication was to pull the sticker on the medication card when the medication was low and fax the sticker to the pharmacy. It was the responsibility of the floor nurse to let the provider know a medication dose was missed. RN-B indicated she was unaware R57 had missed two doses of Zoloft 25 mg on 1/26/25 and 1/27/25. During a joint interview on 1/28/25 at 2:56 p.m. with director of nursing (DON) and medical director (MD), DON stated facility's usual process was a medication was not available to administer, the TMA would inform the nurse, the pharmacy would be called and a refill form would be completed. DON confirmed she had been made aware earlier that day that R61 had been out of Creon medication since 1/22/25. DON stated they had discovered it was an insurance reason why R61's Creon medication had not been sent, and the facility would be purchasing the medication for R61, so would be available. MD stated he would expect the resident's provider would be contacted if a medication was not available to administer, so they could determine if the resident could wait for the medication to be filled, or if it needed to be urgently refilled. MD stated R61's Creon was not a life threatening medication, they had assessed R61, who did not have diarrhea, which could have been a symptom of not receiving the Creon, so he felt R61 had not suffered consequences of not receiving the medication. DON also confirmed R57 had been out of Zoloft medication to administer, but the medication was now available. MD stated R57 did not suffer any consequences of the two missed Zoloft doses as 25 mg. was a low dose. The facility policy titled Medication Administration Policy revised 5/21, identified the policy was to ensure safe, effective and timely drug therapy, to provide for an accurate and concise documentation system. The policy included that the eight rights of drug administration would be followed when administering all medications: right resident, right drug, right dose, right dosage form, right route, right time, right reason and right documentation. The policy included instruction to fax or call the pharmacy for medications, and if medication was not available the emergency kit may be used according to policy. The policy did not identify instruction of what to do if medication was not available to administer from the emergency kit, or to notify the resident's provider if a medication was not available to administer.

Based on interview and document review, the facility failed to ensure 2 of 3 residents (R1, R3) were free from ongoing staff to resident sexual abuse. This resulted in an immediate jeopardy (IJ) situation for R1 who sustained psychosocial harm related to staff to resident abuse. The IJ began on 4/23/22, when nursing assistant (NA)-A sexually abused R1, which was identified by the facility on 4/26/22. In addition, R3 stated NA-A applied lotion to her in a sexual manner making her uncomfortable. The campus administrator, care center administrator and the director of nursing (DON) were notified of the IJ on 5/4/22, at 4:25 p.m. The IJ was removed; and the deficient practice was corrected on 4/26/22, prior to the start of the survey and was cited as past non-compliance. Findings include: R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact and required extensive assist for activities of daily living (ADL's). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 5/3/22, at 1:47 p.m. R1 stated NA-A was her aid since 2021. NA-A gave her Jacuzzi baths and would tell R1 she was beautiful. NA-A always kept her covered until about a month ago. NA-A started telling R1 she had beautiful breast and the touching started recently. On 4/23/22, around 9:00 p.m. NA-A touched R1's nipples and asked if it felt good. NA-A stated R1 had the breasts of an [AGE] year old and liked her titties. R1 then punched NA-A in the shoulder and knocked NA-A off his balance. NA-A apologized and stated he would never do it again. Further, NA-A told R1 he watched her when she slept and would tell her she looked beautiful while she slept. R1 expressed loosing sleep and was having nightmares that NA-A wanted to have sex with her because of NA-A's actions. The undated, facility incident investigation file identified facility staff interviewed NA-A on 4/27/22. NA-A admitted to saying R1 had nice breasts and her breasts looked like the breasts of an [AGE] year-old. NA-A made comments about R1's breasts more than once. The investigation also identified R1 was interviewed and reported NA-A had caressed her breasts and touched her nipples. The statement about her having breast of an [AGE] year old, made R1 very angry and unsafe. R1 asked NA-A to stop. R1's Associated Clinic of Psychology (ACP) consultation note dated 5/2/22, identified R1 had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 stated nursing assistant (NA)-A touched R1 on the breast. NA-A did tell the police and the campus administrator that he did touch R1's breast and he had a crush on her. R1 had trouble sleeping the first three nights after the incident along with nightmares. R1 was in the dining room on 5/2/22, and saw a staff member that resembled NA-A (but was not NA-A) and she had some heightened anxiety and fear. On 5/4/22, at 12:18 p.m. the human resources director (HRD) confirmed he was present for the facility's interview with NA-A on 4/27/22. NA-A stated he did make statements to R1 about her breasts and how nice they looked. On 5/4/22, at 12:27 p.m. the campus administrator confirmed she was present for interview with NA-A on 4/27/22. NA-A stated he did make statements to R1 about her breasts and how nice they looked. During interview on 5/4/22, at 12:40 p.m. FM-A stated he/she spoke to R1 the evening of 4/25/22. R1 told FM-A a staff member touched her breasts inappropriately and had made inappropriate statements to her about how nice her breasts looked which was very upsetting for R1. FM-A notified the facility of the incident the following day on 4/26/22. On 5/4/22, at 12:51 p.m. DON confirmed she was present for interview with NA-A on 4/27/22. The DON stated NA-A did make statements to R1 about her breasts and how nice they looked. R3: R3's quarterly MDS dated [DATE], identified R1 was cognitively intact and required assistance for ADL's. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During interview on 5/3/22, at 2:11 p.m. R3 (who's room was near R1) stated on 4/23/22, she heard R1 yelling at NA-A to stop. R3 talked to R1 the following day and R1 stated NA-A touched her breasts and nipples, which was why she was yelling at him the night before. R3 stated NA-A also touched her inappropriately when NA-A was cleaning her up and applying lotion to her buttocks. When NA-A applied the lotion he did it in a massaging manner which made her uncomfortable. The undated facility's incident investigation file for R3, identified the facility interviewed R3 on 5/3/22. R3 reported NA-A rubbed cream and lotion on her buttocks for a long time during cares. R3 reported being uncomfortable with NA-A's actions since other staff did not rub cream and lotion as long as NA-A did. On 5/3/22, at 3:30 p.m. the campus administrator and clinical coordinator stated they were present for R3's interview on 5/3/22. R3 told them she felt as though NA-A was enjoying applying lotion on her buttocks for a long period of time which, looking back, made her feel uncomfortable. On 5/4/22, at 10:35 a.m. NA-A was interviewed via telephone. NA-A would not answer the surveyors questions about R1 or R3, but instead stated R1, is crazy, she is totally crazy and I don't want to talk about it anymore. On 5/4/22, at 1:55 p.m. R3 stated she was inappropriately touched on multiple occasions by NA-A, specifically when lotion was being applied to her. There was a time a few months prior which really stood out. NA-A applied lotion to her buttocks and NA-A lingered on her buttocks much longer than he needed to and it became very uncomfortable. The facility policy Vulnerable Adult Abuse Prevention Plan revised 7/21, identified abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The policy stated abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy also indicated institutional abuse was a form of abuse that occurred in an institutional setting, specifically a residential facility such as a nursing home. The past noncompliance IJ began on 4/23/22. The IJ was removed and the deficient practice corrected by 4/26/22, after the facility implemented a systemic plan that included the following actions: suspending and then terminating NA-A, interviewing all residents in regards to NA-A cares, completing facility-wide education on abuse and the facility abuse policy, updating the plan of care of R1 to include having a female with a male when male was assisting with cares; mental health consult and guidance; give R1 time to vocalize grief and anxiety related to concern and educated staff to those changes, assisting R1 to acquire services to address change of condition concerns related to NA-A.

Based on interview and document review, the facility failed to assess complaints of a urinary tract infection [MEDICAL CONDITION] for 1 of 2 residents (R1) reviewed who had indwelling urinary catheters. The facilities failure to assess for signs of infection and notify the practitioner, resulted in actual harm for R1, when she required hospitalization for septic shock due to UTI. Findings include: R1's annual Minimum Data Set ((MDS) dated [DATE], included, cognitively intact and required extensive assist to total dependence for activities of daily living (ADL). R1's quarterly MDS dated [DATE], identified an indwelling urinary catheter and was cognitively intact. R1's face sheet printed 2/4/21, identified [DIAGNOSES REDACTED]. R1's urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) worksheet dated 4/21/20, included, R1 was incontinent of urine and at risk for UTI (urinary tract infection). R1's quarterly Bowel, Bladder, and Skin Risk report dated 1/11/21, included, an indwelling catheter for [MEDICAL CONDITION] bladder (lack of bladder control due to a brain/spinal cord or nerve problem), the catheter was to be changed monthly, a urologist had been consulted, and a, Risk/benefit discussion has been completed and documented in the care plan (risks [MEDICAL CONDITION] and death). The assessment also identified a UTI on 6/26/20, history of symptoms of UTI was listed as difficulty voiding. R1's care plan was marked as being current or updated. R1's care plan revised on 10/13/20, identified R1 was at risk for dehydration, had a history of [REDACTED]. Staff were directed to encourage fluid intake, observe for signs of dehydration, concentrated urine, strong urine odor, signs of urinary track infection such as pain, burning with urination, blood-tinged urine, cloudiness, deepening of urine color, increased pulse, increased temperature, foul smelling urine, fevers, chills, altered mental status and change in behaviors and eating patterns. The care plan did not identify R1 had been informed of the risks of infection,[MEDICAL CONDITION] or death due to the urinary catheter, as indicated by the 1/11/21 quarterly assessment. R1 progress noted dated 12/25/20, at 12:04 a.m. included (R1) stated, I know I have a UTI. R1 could not express anything more except that she knew she had a UTI due to her history of having UTI's. The nurse called the provider and received an order to obtain a UA/UC (urine analysis/urine culture) after changing the catheter first. R1's urine was dark yellow and she had low output. R1's laboratory report from UA/UC dated 12/25/20, indicated both bacteria and blood in the urine. R1 progress note dated 12/29/20, at 3:38 p.m. included the lab result from UA/UC indicated R1 had a UTI and the nurse practitioner (NP) ordered an antibiotic called Marcobid 100 mg twice a day (BID) for 5 days. R1 was started the antibiotic on 12/28/20. R1 progress note dated 1/21/21, at 11:38 a.m. included, Writer received a message from res (resident) (family member, (FM)-A) stating that (R1) is telling her she has a UTI. Per discussion with the night nurse, res reported the same last night. Nurse and staff thoroughly cleansed res peri area and res reported relief. Writer gave (FM-A) info about colonization, the risk of introducing bacteria each time a new specimen is obtained and the risk of bacterial resistance. Informed her of plan to improve comfort with peri care versus testing for UTI as res does not have s/s (signs/symptoms) of infection. However, the medical record did not identify any assessment of R1's urinary status had been completed to determine if she had any symptoms. R1 progress note dated 1/22/21, at 5:07 p.m. included (R1) asked what to do if she thinks she has a UTI and the nurse advised her to report it to staff so the staff could assess her. However, no assessment or vital signs were charted. There were no further notes in R1's record to identify if staff were monitoring for signs of UTI. R1's progress note dated 2/1/21, at 10:37 a.m. included, At 0930 (9:30 a.m.) aide notified writer that resident is vomiting and convulsing (shakiness). Writer observed resident convulsing and vomiting, pinkish emesis, color of AM medication administered. Resident noted grinding teeth, and stiff arms; could not clearly respond when was asked how she is feeling. VS (vital signs) assessed and found elevated HR (heart rate of 155 (normal 60-100), BP (blood pressure 142/89, T (temperature) 98, R (respirations) 14, O2Sat (oxygen level) 91 (RA) (room air) (normal 95% -100%). Writer notified NP (nurse practitioner) and suggest resident to be sent to ER (emergency room ) due to [MEDICAL CONDITION](fast heart rate) and increase vomiting. R1's emergency room report dated 2/1/21, at 1:15 p.m. included R1 was admitted to the intensive care unit (ICU) with a [DIAGNOSES REDACTED]. Upon arrival, R1's temperature was 101.5, pulse 123, and blood pressure 100/61. A UA with microscopic was performed and indicated a large amount of blood and many bacteria. Further, the ER report indicated R1 had a full bladder upon arrival and when the Foley catheter was removed it was noted in the urethra not the bladder, appeared quite old, the balloon was partially filled, and the catheter was not draining. R1 had over 800 ml (milliliters) retained in her bladder that was dark and cloudy. R1 required a central line placed for fluids and antibiotics. The patients Foley (urinary catheter) was misplaced and 'disintegrating' when evaluated in the ED, and she also had old stool caked over her back. Friend notes that she has been complaining about feeling she had a urinary tract infection for the last week or 2 and was quite upset to hear that she did have a UTI, as per the friend's report urinalysis has been refused from the care facility. R1's progress note dated 2/1/21, at 4:02 p.m. included R1 had been admitted to the hospital with [REDACTED]. When interviewed on 2/3/21, at 1:23 p.m. nursing assistant (NA)-D stated (R1) complained about having urine issues and UTI's a lot and when looking at (R1)'s urine it was cloudy, stinky, and dark in the past two weeks. NA-D further stated R1 had low output of urine, 150 cc to 200 cc, during the shift. NA-D stated she had reported R1's urinary symptoms to the nurse several times over the past couple weeks. She did not know if the nurse had followed up on this concern. When interviewed on 2/3/21, at 1:31 p.m. licensed practical nurse (LPN)-C stated the morning R1 was sent to the hospital she was complaining of having a UTI. LPN-C did note R1 did not have any urine output in the catheter bag that morning. LPN-C had not done an assessment of the catheter, urine characteristics, and had not asked the resident about any specific urinary symptoms. LPN-C stated she should have done a thorough assessment. When interviewed on 2/3/21, at 2:58 p.m. infection preventionist (IP) nurse stated the expectation when a resident complains of having a UTI would be for the nurse to complete a urinary assessment, check their temperature, and check for any pain. The IP did not know if this was done for R1, but could not find any documentation an assessment had been completed, or the provider notified. When interviewed on 2/3/21, at 3:14 p.m. the director of nursing (DON) stated the expectation when a resident complains of having a UTI would be checking a temperature, check for symptoms, and do an assessment of the urinary system. DON verified the nurses did not complete any urinary assessments regarding R1's UTI complaints. Further, the DON stated the staff have to follow the policy/infection criteria and if a resident exhibits 1, 2, or 3 symptoms, then the staff call the doctor and get an order to obtain a UA/UC. But if no symptoms, then staff should encourage fluids. There was no difference if a resident was unable to verbalize symptoms, or history of UTI without being able to verbalize specific symptoms. When interviewed on 2/4/21, at 9:11 a.m. clinical coordinator, LPN-A stated, residents would only be started on routine monitoring for infection after starting an antibiotic. She had been informed by the night nurse on the morning of 1/21/20, that R1 had felt she had a UTI, but felt better after cleaned up. LPN-A felt she was, colonized, with bacteria and did not want to keep putting her on an antibiotic. We need to make sure antibiotics are prescribed appropriately because of our antibiotic stewardship program. They only update MD and get antibiotic orders if they fit the criteria with symptoms for infection. R1 could not state symptoms, but they had not documented if she had been assessed for symptoms at that time. The night nurse should have done an assessment. When interviewed on 2/4/21, at 11:27 a.m. LPN-B stated she had removed R1's catheter on 1/3/21, the catheter was normal in appearance and R1 did not complain of any UTI symptoms at that time. When interviewed on 2/4/21, at 11:39 a.m. FM-A stated, R1 was complaining she had a UTI back on 1/21/21, she was trying to advocate for R1 and reported this to staff, and asked if she could be tested . However, staff told her if she was put on antibiotics they would not be effective anymore. She had asked staff to explain to R1 why she could not be tested for a UTI. FM-A stated, R1 knows her body, but has a hard time articulating to staff what is wrong and FM-A has to rely on staff to do the appropriate assessments to determine R1's needs. R1 has had UTI's in the past and knows when she has one, even if she cannot articulate particular symptoms. When interviewed on 2/4/21, at 12:20 p.m. registered nurse (RN)-A stated, R1 had been complaining about a UTI hurting her for a month. She had spoken to LPN-A about R1's complaints several times, but LPN-A, told me I don't need to get a UA. RN-A had not done an assessment to determine any symptoms of UTI. I think when we treated her in December, it was not sufficient. When asked for a facility policy for UTI's, the administrator supplied the form, Carepath: Symptoms of Urinary Tract Infections [MEDICAL CONDITION] on 2/4/21 and verified the staff utilize the form to make the decision on when to call the doctor to obtain a UA/UC. The Carepath: Symptoms of Urinary Tract Infections [MEDICAL CONDITION] form, not dated, indicated the path starts with symptoms: painful urination, lower abdominal pain or tenderness, blood in urine, new or worsening urinary frequency, urgency, or incontinence. The next path, take vital signs and if any of the following criteria are met the staff are to call the doctor: temperature greater than 100.5, apical pulse greater than 100 or less than 50, respiratory rate greater than 28/minute or less than 10/minute, B/P less than 90 or greater than 20 systolic, oxygen saturation less than 90%, or resident unable to eat or drink.

Based on interviews and record review, the facility failed to provide adequate supervision for one of six residents, (R1), reviewed when the facility assessed R1 to need the assistance of two staff persons for turning, repositioning and incontinence care, updated the care plan, however the facility did not provide staff with the updated care plan. R1 was harmed when R1 fell from her bed during care provided by one staff, suffered laceration, contusion and bruising of the right side of the face, neck and chest. Findings include: R1's medical record was reviewed. R1 was admitted to the facility for long term care with the [DIAGNOSES REDACTED]. R1 was incontinent of bowel and bladder. R1's care plan was last reviewed on February 10, 2017 and indicated R1 required two staff assistance with repositioning, turning, bed mobility, personal hygiene, and dressing. The nursing progress note dated [DATE] at 7:55 a.m. indicated R1 fell from her bed during care at 4:45 a.m. One staff assisted R1 with incontinence care, involving tuning and repositioning. R1 fell from the bed and hit her head against the night stand resulting in bleeding from the right side of the head that resulted in a laceration measured at 4 centimeters (cm) by 1.5 cm by 1.0 cm. and a hematoma measured at 8 cm by 4 cm. The indicated bleeding stopped after staff applied pressure. A hospice nursing progress note dated [DATE] indicated R1 had facial swelling and bruising in addition to a laceration above the right eye due to a fall. The hospice nursing note indicated R1 continued to bleed at the time of the hospice nurse's visit. The hospice nurse contacted the hospice physician regarding R1's wound and associated pain management. R1's pain medication was increased from as needed to three times daily for acute pain due to a laceration above the right eye and pain with the dressing change. Hospice physician progress notes [REDACTED]. The note indicated R1 had prominent facial hematoma, with tenderness, under the right eye, measured at 8 cm by 4 cm. The director of nursing (DON) was interviewed on [DATE] at 3:30 p.m. and stated R1 required two staff persons for repositioning, bed mobility, personal hygiene, and dressing. The DON stated the staff did not use the updated care plan, which required of two staff persons when R1 fell from the bed in her room. The administrator was interviewed on [DATE] at 4:13 p.m. and stated the care plan used by NA-F did not match R1's updated care plan, which required assistance of two persons for repositioning, bed mobility, transfer and dressing. The administrator stated the nursing assistant's care plan was not updated with the latest changes to R1's care plan. R1's family member was interviewed on [DATE] at 4:00 p.m. and stated she was notified of R1's fall in the morning. The family member stated R1 was still bleeding hours later when she visited her at the facility. Photo taken and provided by family member indicated the resident was still bleeding hours after the fall. Nursing assistant (NA)-F was interviewed on [DATE] at 11:09 a.m. and stated he was assigned to R1 during his night shift. NA-F stated he noticed during routine rounds that R1 was incontinent. NA-F stated R1 required assistance of one staff per the care sheet (Kardex) provided by the facility. NA-F stated, during incontinence care, he rolled R1 to the right side and was providing incontinent care when she fell off the bed and hit her head. NA-F stated he was not aware R1 required assistance of two staffs and was following the guidance of the nursing assistant's care plan, which the facility provided, and used by all nursing assistants. NA-F stated he had training abuse and neglect as well as providing care to vulnerable adults. NA-F stated he was later re-educated on the revised care plan. The clinical nurse manager (NM)-M was interviewed on [DATE] at 11:38 a.m. and stated she changed R1's care plan due to increased weakness and inability to assist staff during turning, repositioning and bed mobility. NM-M stated R1's care plan was updated to require assistance of two persons during turning and incontinence, but she forgot to update the care sheet used by the nursing assistants. NM-M stated R1's fall may have been prevented with the updated care plan because one staff was required to be on one side of the bed for R1's turning and repositioning. NM-M stated it was her responsibility to ensure the care plan used by all staff was accurate at all times. R1's death certificate indicated the R1's died three weeks later and the death was due to inanition, complication of blunt force facial trauma, and fall. The facility's policy and procedure on Care Plan, dated [DATE] indicated the care plan will ensure the resident has the appropriate care to maintain or attain the highest level of practicable function possible for the resident. The policy and procedure indicated the care plan is to be updated based on resident's care needs and current at all times. The facility's policy and procedure on Care Plan, dated [DATE] did not include how changes on care plan would be communicated to staff to ensure adequate education on changes to a resident's care. The facility's policy and procedure on Vulnerable Adult Abuse Prevention Plan dated [DATE] indicated the facility will provide a safe and protective environment for all residents and ensure the risks to residents are minimized.

Based on observation, interview, and document review the facility failed to address and implement appropriate pain management interventions to minimize pain for 2 of 3 residents (R16, R47) reviewed for pain which resulted in actual harm to R16. Findings include: R16's pain management plan did not comprehensively address how to communicate with R16 to determine her pain level and the effectiveness of implemented interventions, including pain medication. The assessment failed to identify non-pharmacological interventions which were may have been effective in minimizing or managing R16's pain. This resulted in actual harm to the resident. R16 was receiving hospice care and had [DIAGNOSES REDACTED]. On 3/21/13, at 10:15 a.m. a licensed practical nurse (LPN)-B and nursing student (NS)-A were observed transferring R16 out of a recliner and into a wheelchair. R16 cried out "I can't do it! I have so much pain in my lower back! I can't do it! I can't do it!" R16 had visible facial grimacing and resisted LPN-B and NS-A when they attempted to use the transfer belt to assist her to a standing position. LPN-B told the resident she would get her some pain medication, and then without informing the resident what would happen next, LPN-B and NS-A took hold of the transfer belt, counted to three, lifted up on the transfer belt and brought her to a standing position. R16 again displayed facial grimacing and moaned "OooAhh!" R16 was then pivoted and placed in her wheelchair. At 10:20 a.m. R16 was given as needed (PRN) [MEDICATION NAME] 2.5 milligrams (mg) according to physician orders. On 3/21/13, at 12:00 p.m. R16 was administered a scheduled dose of [MEDICATION NAME] 2.5 mg. At 12:45 p.m. the resident was seated in a wheelchair in the dining room. The resident who was very hard of hearing but could read. The resident reported to the surveyor that she experienced pain in her lower back with transferring, movements, and when sitting up. R16 reported her current pain as 10 out of 10 (0 being no pain and 10 being the worst pain.) R16 stated she did not want to let the nurses know, because they would "have it out for her" if she complained too much. R16 could not recall having received anything for pain that morning, but did not think so, as she continued to have pain. LPN-B stated in an interview on 3/21/13, at 12:56 p.m. that R16 was on hospice, and received [MEDICATION NAME] PRN for pain, which was primarily in her lower back. LPN-B stated R16 vocalized pain and also showed signs of pain like facial grimacing. At 12:57 p.m. trained medication aide (TMA)-A stated R16 had received PRN and scheduled [MEDICATION NAME] that morning, as well as a scheduled dose at 12:00 p.m. TMA-A stated the nurse was responsible for following up with R16 regarding the effectiveness of the medication. LPN-B verified she had not followed up with the resident, but confirmed that if asked, she would have been able to report her pain using a 0 to 10 scale. TMA-A administered [MEDICATION NAME] 2.5 mg PRN at 1:20 p.m. to R16, and nursing assistant (NA)-A brought R16 to her room from the dining room. A transfer from the wheelchair to the toilet was observed. While assisted to stand R16 was heard to moan "OooAhh!" When the resident emerged from the bathroom, visible facial grimacing was observed. Without communicating plans to assist the resident from the wheelchair into the bed, NA-A took R16's feet, twisted them up and onto the bed. R16 started to moan, had increased facial grimacing, and immediately rolled away from the NA, onto her right side, and pulled her legs into her stomach. NA-A was then behind the resident, and again without communicating with the resident, NA-A attempted to lift up R16's legs to place a pillow underneath her legs. R16 screamed "Oooouucch!" and the NA proceeded to place another pillow between the resident's legs. The resident again shouted out in pain. At no time during the observation did NA-A communicate with R16 regarding her verbal and non-verbal symptoms of pain. NA-A was interviewed on 3/21/13, at 1:34 p.m. and reported he frequently worked with R16, and she required minimal assist of one staff with transferring. NA-A reported he did not think the resident was experiencing pain, rather was "nervous" because the surveyor was present in the room. The NA had noticed a difference in the resident that day. She appeared more confused and although she usually she recognized him, she did not know who he was or what he was doing. NA-A stated R16 often verbalized her pain by letting him know if she had pain in her back and/or legs. NA-A stated that the moaning, groaning and stating "ouch," was not pain, but more "nerves." The NA confirmed the expectation was for staff to utilize written communication with the resident, but "sometimes she can hear you, so I didn't today." At 2:16 p.m. the NA's shift was ending for the day. He stated it was difficult to tell if R16's moaning was related to pain or "behaviors" and that was why, "I usually tell the nurse." The NA said he had not informed the nurse after the resident was moaning, groaning, and shouting "Ouch!" during cares. When interviewed on 3/21/13, at 3:14 p.m. LPN-B confirmed NA-A had not reported R16's pain with transferring or repositioning in bed. LPN-B stated the pain in R16's lower back during the day shift was new as of the past few days. The lower back pain usually occurred overnight, however, the LPN confirmed R16 was very vocal this morning about her pain. The observation of the transfer at 10:15 a.m. was discussed with the LPN. When asked why the LPN and NS-A continued to move the resident when she was resisting and shouting out in pain, the LPN stated it was because it was unusual for R16 to have pain at that time of day. The LPN said they should have stopped and not gone any further until the until the source of pain was addressed and/or minimized. LPN-B reported that non-pharmacological interventions had not been identified to minimize R16's pain other than repositioning. The LPN verified R16 received hospice care and new pain issues had not been communicated to the hospice nurse, but would be after the interview. When interviewed on 3/22/13, at 7:26 a.m. LPN-C reported R16 experienced a lot of lower back stiffness on the overnight shift. LPN-C identified the pain as being related to transferring and repositioning, when going from a lying to a sitting position and into the wheelchair, and the resident's pain had recently become more intense. LPN-C reported gentle rubs/massages to R16's lower back prior to standing or repositioning, minimized, but did not eliminate the pain. The LPN used the marker board to communicate with the resident, including to inquire whether administered pain medication during the night had been effective. R16 requested to go from the dining room to her room on 3/22/13 at 1:00 p.m. NA-G brought the resident into the hallway adjacent to the resident's room. R16 asked NA-G, "Are you my aide?" NA-G replied, "I will let your aide know you want to go to your room." NA-G left R16 and R16 asked another resident, "What did she say to me?" At 1:07 p.m. NA-D informed a registered nurse (RN)-A that R16 was having some pain when the resident stood up to go for lunch. NA-D was brought R16 to her room and asked, "Are you having pain?" R16 did not respond to the question. RN-A reminded NA-D, "She can't hear you, you need to use the marker board." RN-A took the marker board and wrote, "Do you have pain in your legs right now?" R16 shook her head "no." The RN left the room and NA-D assisted the resident to use the bathroom. When assisted off the toilet at 1:13 p.m. the resident cried out. Without being informed of what was happening, R16's shoes were removed and her feet and legs were swung onto the bed. With facial grimacing during the transfer R16 stated "OooAhh! OooAhh!" NA-D stated, "See? She does that." R16 was then asked, "Does that hurt?" The resident did not respond, but rolled onto her right side, pulled her lower extremities toward her chest, and continued to exhibit facial grimacing. Without explanation, NA-D stood behind R16 and lifted the resident's legs off the bed and placed a pillow under her legs, at which time the resident grimaced and called out, "Ow!" The resident continued to grimace when the NA, without explanation, placed a second pillow between her legs. R16 continued to exhibit facial grimacing, moaned, and began crying. NA-D then obtained the marker board and pointed to the question "Do you have pain in your legs right now?" written by RN-A. She replied that she did not have pain in her legs, paused for a few seconds and stated, "It's in my lower back." NA-D then informed RN-A of R16's pain at 1:20 p.m. RN-A stated she would check the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At 1:33 p.m. TMA-A administered [MEDICATION NAME] 2.5 mg. During the observation no non-pharmacological interventions were tried and staff did not consistently communicate with the resident. At 1:38 p.m. R16 continued to moan and grimace while lying on her right side as she clenched the call light with her right hand. TMA-A was interviewed at 1:40 p.m. and said if a resident had pain he informed the nurse, who instructed the TMA what to give the resident. The only non-pharmacological interventions used for R16 was repositioning. NA-D stated at 1:46 p.m. that when R16 was having pain she let the nurse know right away, however, she had not let RN-A know about R16's pain prior to lunch because she was "busy and forgot." NA-D was unaware of any non-pharmacological interventions for R16's pain except repositioning. When asked if repositioning contributed to the resident's pain, NA-D said that then medications were used. After the interview at 1:47 p.m. R16 continued to clench the call light cord and grimaced. At 1:56 p.m. R16 was observed to reposition herself on her back and bend her knees while continuing to clench the call cord. At 2:29 p.m. the resident was lying on her back with her legs slightly twisted to the left and still tightly held the call cord. At 2:34 p.m. R16 was lying on her back when NA-D and TMA-A entered her room. Again without explanation, they removed the pillows from beneath her legs. R16 grimaced and pulled her left leg toward her chest. TMA-A stated to the NA-D that R16 was in pain. The resident was then told that the two staff were going to turn her, but the marker board was not used. NA-D was going to use the board, but there was no eraser available. TMA-A again told the resident what they were going to do, and the resident appeared to understand, as she participated in turning to the right side and then onto her back. When verbally asked to turn to the right side again, with assistance and some participation, the resident turned to the side. The TMA was positioned behind the resident and without informing her, she attempted to separate the resident's legs to place a pillow. The resident cried out and told the TMA, "I could kick you!" The surveyor intervened and suggested staff use the marker board to inform the resident what they were going to do. When the marker board was used and a pillow was shown to the resident, she appeared to understand. She began participating by separating her legs for the pillow, although she continued grimacing. When interviewed on 3/22/13, at 2:48 p.m. RN-A stated she was unaware of any further pain concerns since the PRN dose was given at around 1:30 p.m. RN-A verified the staff was expected to inform the nurse as soon as possible when a resident reported or exhibited signs or symptoms of pain. RN-A confirmed she had instructed TMA-A to administer the pain medication and that it was her responsibility to follow up regarding the effectiveness of the intervention. The RN reported she had not done so, and should have. She also said the staff should have tried to relieve R16's pain before continuing. RN-A confirmed medication and repositioning were the only measures used to treat the resident's pain, however, moving the resident was also contributing to her pain. On 3/22/13, at 4:52 p.m. RN-A and household coordinator (HC)-A were interviewed. RN-A stated it was the first she had heard R16's pain had increase in intensity or frequency. RN-A stated that when she observed R16 she looked "tense." When she asked the resident if she was having pain she said she did not know, "but when I touched her she expressed pain, so we gave her some [MEDICATION NAME]." RN-A stated she just initiated a 5-Day Pain Assessment. HC-A reported that the marker board worked best with communicating with R16. On 3/25/13, at 8:48 a.m. R16 was observed sitting a new Broda chair in the dining room. There was a communication board at the dining room table. At 9:06 a.m. NA-C wheeled R16 down to her room. At 9:08 a.m. LPN-B wrote on the marker board, "Are you having pain?" R16 replied, "Yes, in my lower back." LPN-B wrote, "We are getting you some pain medication. Would you like to wait or lay down now?" At 9:11 a.m. TMA-A administered R16's PRN [MEDICATION NAME]. R16 asked, "How long?" LPN-B wrote, "How long would you like to wait?" R16 stated, "As soon as possible." At 9:14 a.m. LPN-B wrote, "Would you like to lay down now?" R16 answered, "Yes." NA-C put a transfer belt around R16's waist and began speaking to the resident by asking how she was doing, however, there was no response from the resident. R16 stood and pivoted onto the bed. NA-C took out R16's hearing aid, removed her shoes, and then without explanation, swung the resident's legs onto the bed. R16 moaned, rolled onto her right side, and pulled her lower extremities to her chest. While positioned behind the resident, the NA attempted to pick up the resident's legs without explanation or gestures. R16 screamed "Ouch!" with facial grimacing, NA-C stopped what he was doing and put a blanket over R16 and the resident's face relaxed. When interviewed on 3/25/13, at 9:25 a.m. NA-C stated he was trained to communicate with R16 by standing directly in front of her so she could see him, talk into her ear with the hearing aid, and use the marker board. NA-C stated when R16's hearing aid was out, "She can still hear us." NA-C confirmed the expectation was that staff explained procedures, which included repositioning movements. NA-C stated, "I don't remember if I told her I was putting a pillow between her legs or swinging her legs into bed." NA-C confirmed he did not use gestures or the marker board to communicate with the resident. When interviewed on 3/25/13, at 9:59 a.m. LPN-B stated staff were trained on offering alternative pain management interventions like hot packs, cold packs, gentle back massage, etc. LPN-B stated R16 was unable to hear staff if they were not standing in front of her when communicating. The staff were expected to explain procedures to R16 by standing in front of her, speaking into her right ear, and by writing on the marker board. LPN-B confirmed R16 could not hear if her hearing aid was not in, "staff really do need to be standing in front of her to complete a procedure." When interviewed on 3/25/13, at 1:37 p.m. RN-A, stated staff were expected to use a marker board and act out gesture what they were doing if necessary. RN-A reported it was unacceptable for staff to not explain a procedure involving movement with R16, because she already had pain and movements could make it worse. R16 plan of care revised on 8/6/12, noted "I have chronic pain or potential for pain related to DJD ([MEDICAL CONDITION] joint disease), spinal stenosis, history of torn rotator cuff (shoulder injury), Zenkers diverticulum, choledocholisthasis. I will voice a level of comfort through the review date. Administer medications per orders. Assess me for pain per policy, monitor the effective of pain interventions, observe for [MEDICAL CONDITION] pain r/t (related to) Zenkers diverticulum abdominal pain that may be r/t gall bladder stones and keep medical provider informed." R16's plan of care did not address any non-medication interventions to help manage pain, location of pain, or how to identify effectiveness of pain interventions. R16's communication care plan dated 8/9/12, addressed that R16 was very hard of hearing. It directed staff to use the maker board to communicate with R16 if she was having a hard time understanding. It instructed staff to, "Speak in a loud slow tone towards my left hear. Make sure my left hearing aid is in and working. Check for wax in my ears and remove PRN (as needed), speak face to face because I also like to read lips." A physician order [REDACTED]. Progress Notes on 2/5/13, at 5:09 a.m. identified R16 requested medication for back pain. A PRN dose of [MEDICATION NAME] was given at 3:30 a.m. and noted R16 returned to sleep. On 2/7/13, the PO indicated R16's [MEDICATION NAME] 2.5 mg was increased to include a scheduled dose every six hours, in addition to the hourly PRN dose. A 5 Day Pain Flow Sheet was initiated on 2/8/13, due to a change in condition. The site indicated for pain was back, the non-verbal sounds or vocal complaints were identified as moaning, facial expression or body movements such as, "Not sleeping." It identified the pain intensity on a scale from 0 to 10 with 0 being no pain and 10 being the worst pain indicated R16 rated her pain "8-10." Scheduled [MEDICATION NAME] was given and was effective as R16 was eventually able to sleep. R16's Care Area Assessment (CAA) dated 2/12/13, triggered for a communication problem and identified a hearing impairment. It noted the only use of communication devices were hearing aids, although it gave the option to check that a communication board/writing were used. The CAA for pain identified R16 was recently enrolled in hospice, and complained of lower back pain and pain in lower legs. [MEDICATION NAME], Tylenol, and [MEDICATION NAME] gel were used, as well as PRN [MEDICATION NAME] for breakthrough pain. It was noted the resident required ongoing observation and assessment of effectiveness of pain medications. The Pain Evaluation and Management assessment completed on 2/12/13, identified R16 reported frequent pain in her lower back. It noted, "She describes the worst pain in the last five days as severe. Will continue to partner with hospice, assess resident for pain, administer scheduled and as needed [MEDICATION NAME] as ordered." Pain had limited her day to day activities and no non-medication interventions for pain had been implemented in the past five days. A Progress Note dated 2/25/13, R16 had more back pain at night. It noted she was up to the toilet at 4:00 a.m., calling out for help at 5:00 a.m. due to back pain. It noted a PRN dose of [MEDICATION NAME] was given. A Progress Note dated 3/17/13, at 10:14 p.m. indicated R16 had leg and lower back pain. It noted R16 was crying during ambulation and stated, "'My back and legs hurts so bad.'" Facial grimacing and moaning were noted. Interventions noted were, "Stopped walking and gave PRN [MEDICATION NAME] at 4:40 p.m." It concluded the medication as effective as R16 stopped crying and stated pain decreased one hour after medication. A voice mail was left for therapy staff to assess ambulation program. A Progress Note dated 3/19/13, at 7:15 a.m. identified R16 had pain, could not sleep, and was administered PRN [MEDICATION NAME]. The medication was effective, as resident was able to return to sleep. A physician order [REDACTED]. The facility's Pain Assessment and Management policy modified on 9/10, identified that with new onset of pain a Pain Data Collection form would be completed. It directed to document current intervention for pain including current pain medication intervention and non-medicinal interventions. It also noted that staff should document results of the pain control flow sheet for PRN medications using provided pain scale of zero to ten. For residents on scheduled pain medications, document effectiveness routinely. R47 was not provided an assessment or treatment for [REDACTED]. On 3/21/13, at 10:00 a.m. R47 when asked how he was doing, the resident pointed to his left jaw. The resident stated that his gums on the lower left side were bothering him. The following morning at the breakfast meal, the resident was asked how his mouth felt and the resident did not answer verbally, but made a downward pointing motion. R47's left jaw area appeared swollen and he was drooling. R47's tablemate stated, "He can hardly talk" or chew, and said the problem had been going on for the past week. When asked about it further, R47 reported staff was aware of the problem. At 9:55 a.m. a dietary server DS-(A) heard the tablemate advising R47 that he should tell the nurse again about his jaw pain. DS-A then inquired how R47's mouth pain was, and the resident shook his head negatively. The server informed the surveyor that they had changed the resident's cereal to softer varieties, and that nursing staff was aware of the jaw pain. A trained medication aide (TMA)-B was asked about R47's jaw pain on 3/22/13, at 3:20 p.m. and was aware the resident had jaw pain, but had not been directed to administer anything for pain by the nurse. When asked whether R47's mouth pain had been reported to a nurse, the TMA said the nurse was aware of the resident's pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. RN-C was then asked what had been done for R47's mouth pain and the nurse stated she had been "busy" and had done "nothing" about the resident's mouth pain other than to review the resident's medications. The RN stated the review of medications revealed the resident was prescribed [MEDICATION NAME] for [DIAGNOSES REDACTED] (facial nerve pain). The RN was unsure whether the clinical nurse manager (RN-B) had been notified of the resident's pain. RN-B stated at 3:25 p.m. "Is he having that again?" RN-B stated someone had reported to her that day of R47's mouth pain, but nothing further had been done. At 3:30 p.m. RN-C verified R47 had not received any pain medication for complaints of jaw pain, but the RN had since talked to the resident. R47 reported he did not have pain at rest, but had "sharp" jaw pain when eating, and the [MEDICATION NAME] was helpful. The RN had since initiated a 5-day pain assessment. When asked how the inside of the resident's mouth appeared, the RN stated she had not examined the inside of R47's mouth. On 3/25/13 at 9:10 a.m. R47 reported he was fine, but that his tongue hurt when eating. The resident stuck his tongue out and a build-up of a white/off-white matter was noted on the tongue. Because the resident was eating creamed cereal, the surveyor asked him to swallow and stick his tongue out again. There was no change in the appearance of the tongue. At 11:00 a.m. RN-D stated stated the night nurse had placed a call to R47's physician as the nurse suspected R47 may have had thrush (fungal infection). Progress notes dated 3/15 to 3/22/13 were reviewed. A culinary progress note dated 3/19/13 at 2:52 p.m., indicated it was easier for R47 to drink than chew. A nursing progress note at 9:20 p.m. on 3/22/13 revealed R47 had refused dinner because they did not feel like eating. There was no documentation during this time period to indicate staff had assessed and/or determined if R47 was having mouth/jaw pain that was affecting the desire and ability to eat. There was no documentation to indicate R47's physician had responded promptly to the facility's notification regarding R47's mouth pain. A review of documentation revealed there was no contact from R47's physician on 3/22 or 3/23 and 3/24/13 regarding R47's pain, despite the facility having contacted the physician. A review of RN-C's 3/22/13 documentation regarding R47's mouth assessment revealed R47 rated the mouth/jaw pain as sharp and 8 to 9 out of 10 while eating. The pain was present upon eating and there was no pain when not eating. Documentation revealed there were no white-off-white patched noted on R47's tongue and that the physician had been contacted about the mouth pain. A nurses progress note dated 3/24/13 at 3:41 p.m. revealed R47 was complaining of sharp tongue and jaw pain at a level of 7-9 out of 10. The note revealed that a fax was sent to the physician about the pain and that R47 was given Arthritis Strength Tylenol 1000 mg, which was noted as effective. The night nurse's documentation was reviewed and revealed that at 8:04 a.m. the nurse contacted R47's physician about mouth pain, noting the pain was worse with eating and made eating difficult. The note revealed the physician would come to the facility and evaluate the resident. There was no indication the physician had responded to the facility's notifications of R47's mouth/jaw pain. Documentation reviewed indicated R47 had no pain at the time of a pain assessment or quarterly Minimum Data Set completed on 1/23/13. The care plan developed on 11/8/11 directed staff to report to the physician and problems with chewing or swallowing. The care plan was revised on 11/23/11 to indicate R47 had upper/lower partials, but declined to wear them. Another revision dated 5/4/12 indicated R47 had the potential for pain due to occasional bouts with [DIAGNOSES REDACTED].