Every finding on record at Flannery Oaks Guest House

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection by failing to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to 2 (#15 and #62) of 6 residents on Enhanced Barrier Precautions reviewed in the final sample. Findings: Review of the provider policy titled Enhanced Barrier Precautions Policy & Procedure with a revision date of 04/01/2024 revealed the following, in part: Policy: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP are indicated for residents with any of the following: b. Indwelling medical devices. ii. Indwelling medical device examples include central lines and feeding tubes. 4. EBP is employed when performing the following high contact resident care activities: g. Device care or use (Central line, feeding tube) 5. Personal Protective Equipment (PPE) is to be applied prior to performing the high-contact resident activity according to below. a. Perform hand hygiene. b. Put on a gown and gloves. Review of the Enhanced Barrier Precautions signage revealed the following, in part: Enhanced Barrier Precautions when providing high contact care or cleaning in the environment, staff must: Clean Hands, Wear Gown, Wear Gloves. Examples of high contact care: Device care or use. Resident #15 Review of Resident #15's clinical record revealed the resident was admitted to the facility on [DATE]. Resident #15 had diagnoses which included Encounter Related to Gastrostomy. Review of Resident #15's Care Plan revealed the following, in part: Problem: The resident has a clinical condition that warrants Enhanced Barrier Precautions. Intervention: Utilize gloves and gown when providing care to medical devices (i.e. feeding tube). Review of Resident #15's current Physician Orders revealed the following, in part: 09/03/2024 Enhanced Barrier Precautions: utilize gown and gloves during high-contact care activities for resident's indwelling medical devices every Shift for Percutaneous Endoscopic Gastrostomy (PEG)Tube. On 07/27/2026 at 8:11 a.m., an observation was made of S4LPN administering a medication to Resident #15 through a PEG Tube. An EBP sign was noted outside of Resident #15's door. S4LPN performed hand hygiene and applied gloves. S4LPN did not wear a gown. S4LPN disconnected the enteral feeding from Resident #15's PEG tube, checked residual volume, flushed the PEG tube, administered the medication by the PEG tube, flushed the PEG tube, and reconnected the enteral feeding to the PEG tube. On 07/27/2026 at 8:31 a.m., an interview was conducted with S4LPN. S4LPN stated she only wears gloves when providing care to residents with PEG tubes. S4LPN confirmed she only wore gloves when she administered Resident #15's medication by PEG tube. On 07/28/2026 at 10:05 a.m., an interview was conducted with S3ADON. S3ADON stated EBP was an extra layer of precaution for staff to use when a resident has an indwelling device like a dialysis shunt, PEG tube, Catheter, chronic wounds, and Multi Drug Resistant Organisms. S3ADON stated gowns and gloves are to be used when providing direct care to these residents. S3ADON stated when administering a medication to a resident with a PEG tube, the nurse should wear a gown and gloves. S3ADON confirmed it would not be appropriate for a nurse to administer a resident's medication by PEG tube wearing only gloves. On 07/28/2026 at 10:34 a.m., an interview was conducted with S2DON. S2DON stated when staff are touching and providing direct care to a resident with a PEG tube they should wear a gown and gloves. S2DON stated staff should follow the EBP Policy when providing care to a resident with a PEG Tube. Resident #62 Review of Resident #62's clinical record revealed she was admitted to the facility on [DATE]. Resident #62 had diagnoses which included Urinary Tract Infection. Review of Resident #62's current Physician Orders revealed the following, in part: 07/17/2026 Ertapenem Sodium Injection Solution Reconstituted 1 GM. Use 1 gram intravenously (IV) one time a day for Urinary Tract Infection for 10 Days. 07/20/2026 Enhanced Barrier Precautions: utilize gown and gloves during high-contact care activities for residents with indwelling medical devices. On 07/26/2026 at 1:15 p.m., an observation was made of S6LPN disconnecting the completed Ertapenem antibiotic from Resident #62's Peripherally Inserted Central Cather (PICC). S6LPN performed hand hygiene and donned clean gloves. S6LPN removed the intravenous antibiotic from Resident #62's PICC line without wearing a gown. An Enhanced Barrier Precaution sign was observed on the outside of Resident #62's room door. On 07/26/2026 at 1:21 p.m., an interview was conducted with S6LPN. S6LPN confirmed Resident #62 was on enhanced barrier precautions for her PICC line. S6LPN stated she should have worn a gown when disconnecting the IV antibiotic from Resident #62's PICC line. On 07/28/2026 at 10:21 a.m., an interview was conducted with S2DON. She stated her Enhanced Barrier Precaution expectations were for staff to follow the EBP policy. She confirmed staff should wear a gown and gloves when providing care to a resident with a PICC line.

Based on observation, interviews, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards. The facility failed to ensure staff observed 1 (#31) of 7 residents take their medications.Findings:Review of the facility's policy titled Medication Administration dated 10/2024 revealed in part, the following:Policy: Nursing personnel shall ensure the safe and effective administration of medications.Review of Resident #31's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure.Review of Resident #31's Quarterly MDS with ARD of 05/20/2026 revealed BIMS of 3, which indicated the resident was severely cognitively impaired.An observation was made on 07/26/2026 at 8:55 a.m. of 2 medium sized round pills located on Resident #31's chest.An interview was conducted on 07/26/2026 at 8:56 a.m. with Resident #31. He stated he could not see the pills on his chest. He stated he did not know if he took all of his morning medications. An interview was conducted on 07/26/2026 at 9:00 a.m. with S5LPN. She observed the 2 medium sized round pills located on Resident #31's chest. She confirmed these were medications. She stated Resident #31 must not have swallowed all of his morning medications.An interview was conducted on 07/29/2026 at 9:20 a.m. with S2DON. She stated she expected nursing staff to remain with residents until all medications were swallowed.

Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly sealed, stored, and dated in the refrigerator and dry storage area of the facility's kitchen. This had the potential to affect 100 residents who were served from the kitchen. Findings: Review of the facility's policy, titled, Food Storage Labeling, with a revised date of 10/2018, revealed, in part: The facility will store and label all foods to ensure safety and quality. 7. Food is stored in containers that are sealable, leak proof, durable and undamaged. Review of the facility's policy titled, Food Service Operation Standards for Purchasing, Cooking and Storage, with a revised date of 10/2018, revealed, in part: 3. Storage a. Store food only in designated storage areas 8. Cooling and storing g. Label and store foods with the date and time they were prepared to indicate when to discard An initial tour of the kitchen was conducted on 06/29/2025 at 9:15 a.m. with S18CO. Observations were made of the following items: Dry Storage: 1-gallon, ¾ full of soy sauce, opened, with no opened date and refrigerate after opening on the product label. Refrigerator 1-packet, 1/2 full of sliced deli ham, unsealed. On 06/29/25 at 9:26 a.m., an interview was conducted with S18CO. She confirmed the aforementioned findings, which were observed in the kitchen. She stated all food should be sealed, dated, and stored properly and was not. On 06/30/25 at 8:26 a.m., an interview was conducted with S15DM. She confirmed all food in the dry pantry and refrigerator should be dated, stored, and sealed appropriately.

Based on interviews and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. This deficient practice had the potential to affect a census of 100 residents. Findings: Review of the facility's policy, Quality Meeting Policy and Procedure, dated 04/28/2025 revealed, in part, the following: Purpose: To identify, respond, track and trend, and monitor for improvement of facility potential quality deficiencies. The overall goal is to improve the quality of care for the residents of the facility. Policy: II. Facility will monitor performance by previous performance, established benchmarks, and/or determined by the QAA committee. IV. The quality assessment and assurance committee will meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; such as, identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary. Review of the facility's Quality Improvement Corrective Action Plan revealed in part, the following: Identified Date: 05/20/2025 1. Corrective actions taken by: a. The Nursing Facility Administrator and/or designee have initiated a quality review to determine average call light response times. 2. Identification of at-risk population: All residents have the potential to be affected by delayed call light responses and are considered potentially impacted by the deficient practice. 3. Measures and System Changes to Prevent Recurrence: c. CNAs must ensure that call lights remain within resident's reach at all times, especially after care is completed or following transfers or repositioning. 4. Monitoring and Quality Assurance: a. All direct care staff will be re-in serviced on proper call light placement and the expectation for immediate response. b. The NFA or designee will audit call light weekly to evaluate response times and identify trends requiring corrective action. e. Negative outcomes or recurrent delays in call light response will be reviewed during the Interdisciplinary Team (IDT) meetings for case-based problem-solving. Review of the facility's in-service log revealed in part, the following: Date completed: 06/07/2025 Topics discussed: After care call lights should be placed within reach of the resident whether the resident is in bed or in their wheelchair. If you roll a resident to their room do not forget to clip call light to resident or attach to resident's chair or blanket. Review of the facility's monitoring forms revealed documentation for 06/07/2025 and 06/09/2025. No further documented evidence of monitoring was provided for review upon request. Review of the facility's follow-up documentation revealed in part, the following: Date completed: 06/26/2025 Several residents noted sleeping in chairs without call light. Expectations set and will continue with QA until no further issues noted. No further documented evidence of monitoring was provided for review upon request. On 07/02/2025 at 11:18 a.m., an interview was conducted with S1ADM. He stated that he was responsible for the facility's QAPI program. He stated a QAPI pertaining to call light response time and placement was initiated on 05/20/2025. He stated S4CNAS was responsible for ongoing monitoring of call light response times and call light placement. He stated any identified issues were discussed in the weekly IDT meeting. He confirmed there was no documentation of monitoring after 06/09/2025, no changes were made to the corrective action plan, and he observed call lights not within several residents' reach on 06/26/2025. On 07/02/2025 at 11:35 a.m., an interview was conducted with S4CNAS. She stated she was responsible for completing daily monitoring for call light response times and placement. She stated she had not filled out a monitoring form since 06/09/2025. She stated all issues found during her monitoring rounds were discussed in the weekly IDT meetings. She confirmed she continued to find call lights not within reach and no new changes have been made to the corrective action plan.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 of 2 (#201 and #401) residents reviewed for accommodation of needs. Findings: Review of the facility's policy, Resident Call Light System, dated 09/14/2022, revealed the following, in part: Purpose: To provide a communication system with audible or visual signals to allow residents to call for staff assistance . Procedure 6. When providing care to residents, be sure to positon the call light conveniently within reach for the resident to use. Resident #201 Review of Resident #201's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Transient Ischemic Attack and chronic pain. Review of Resident #201's admission MDS with an ARD of 06/17/2025, revealed a BIMS score of 15, which indicated she was cognitively intact. Review of Resident #201's current care plan revealed the call light was to remain within reach as an established intervention for bowel/bladder incontinence. On 06/29/2025 at 10:00 a.m., an observation was made of Resident #201 in her room. She was sitting upright in a Geri chair with the call light not within her reach. An interview was conducted with Resident #201 at this time and she confirmed the call light was not within her reach. On 06/29/2025 at 10:45 a.m., an interview and observation was conducted with S22CNA. S22CNA confirmed Resident #201 utilizes the call light to request staff assistance. S22CNA observed Resident #201 sitting in a Geri chair in her room and she confirmed the call light was not within Resident #201's reach. Resident #401 Review of Resident #401's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Senile Degeneration of the brain and pain in leg. Review of Resident #401's current care plan revealed she required assistance from staff for ADLs. On 06/30/2025 at 8:47 a.m., an observation was made of Resident #401 in her room. She was sitting upright in a Geri chair with the call light in the center of the bed, not within her reach. An interview was conducted with Resident #401 at this time and she confirmed the call light was not within her reach. On 06/30/2025 at 8:56 a.m., an interview and observation was conducted with S7CNA. S7CNA confirmed Resident #401 utilizes the call light to request staff assistance. S7CNA observed Resident #401 sitting in a Geri chair in her room with the call light in the center of the bed. She confirmed the call light was not within Resident #401's reach. On 06/30/2025 at 1:45 p.m., an interview was conducted with S2DON. S2DON was made aware of the above findings. She confirmed call lights should be within a resident's reach at all times.

Based on record reviews and interviews, the facility failed to develop a Comprehensive Person Centered Care Plan, which met the needs of 2 (#29 and #56) of 20 residents Care Plans reviewed in the final sample. The facility failed to ensure the Comprehensive Care Plan included the following: 1. Resident #29's discharge goals; and 2. Resident #56's physical need for a Mechanical Lift for transfers. 1. Review of Resident #29's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Rheumatoid Arthritis. Review of Resident #29's most recent Care Plan revealed no documented evidence of discharge plans. 2. Review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Hemiplegia, Hemiparesis, Muscle Wasting to Multiple Sites, and Lack of Coordination. Review of Resident #56's most recent Care Plan revealed no documented evidence the resident required use of Mechanical Lift for safe transfers. An interview was conducted on 07/01/2025 at 11:21 a.m. with S3ADON. She confirmed Resident #56 required two person assist with a mechanical lift for transfers. An interview was conducted on 07/01/2025 at 11:59 a.m. with S8LPN. She confirmed Resident #56 required two person assist with a mechanical lift for transfers. She further confirmed she was responsible for the Care Plan and Resident #56's transfer status should be documented in the Care Plan, but was not. An interview was conducted on 07/02/2025 at 8:58 a.m. with S2DON. She confirmed all Care Plans should be developed to each resident's individualized needs. She further confirmed discharge plans should be documented in the Care Plan.

Based on interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality. The facility failed to ensure: 1. Nursing staff adequately conducted full body skin assessments for 1 (#202) of 2 (#75 and #202) residents reviewed for skin injury and; 2. Nursing staff communicated changes in resident status to oncoming nursing staff for 1 (#202) of 2 (#51 and #202) residents reviewed for pain. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2024) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part: 3. Development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with compassion, including increased and ongoing development of self-awareness, sound judgement, [NAME], ethical thing and behaviors, problem solving and critical thinking abilities. 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team. Review of Resident #202's clinical record revealed the resident was admitted to the facility on [DATE] with the following medical diagnoses: Pain, Unspecified and Long Term (Current) Use of Anticoagulants. Review of Resident #202's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2025 revealed a Brief Interview for Mental Status (BIMS) of 13, indicating resident was cognitively intact. Review of Resident #202's current Physician Orders revealed the following, in part: 06/10/2025 weekly body audit completed on 06/22/2025 and 06/29/2025 by S21LPN. 1. On 07/01/2025 at 10:35 a.m., an observation was conducted with S20LPN. Resident # 202 was noted lying in her bed with red gripper socks noted on her feet. S20LPN removed the sock and noted the upper right foot with red bruising, the second toe noted to be dark purple, purple bruising extended to the big toe and 3rd toe, and swelling noted to the right ankle. Resident # 202 reported pain to touch of her right foot. Resident #202 stated the second toe was better because over the weekend it was black. On 07/01/2025 at 11:27 a.m., an interview was conducted with S21LPN. She stated Resident # 202 had weekly skin audits conducted weekly, every Sunday. She stated she completed Resident #202's weekly skin audit on 06/29/2025 and observed no skin issues. She confirmed when conducting the skin audit she did not remove Resident #202's socks and should have. 2. On 07/01/2025 at 11:27 a.m., an interview was conducted with S21LPN. She confirmed she did not report to oncoming staff Resident #202 complained of right foot pain and swelling on 06/29/2025. On 07/02/2025 at 8:45 a.m., an interview was conducted with S24LPN. She stated she received report from the night shift, and was not informed of Resident # 202's right foot pain, swelling, or pending x-ray results and should have been. On 07/02/2025 at 10:06 a.m., an interview was conducted with S25LPN. She stated she provided care to Resident # 202 on the night shift of 07/01/2025. She stated she received report Resident #202 complained of foot pain and had an x-ray completed on 07/01/2025 with results pending. She confirmed she did not report the above information to the oncoming day shift staff on 07/02/2025 and should have. On 07/02/2025 at 10:31 a.m., an interview was conducted with the S2DON. She stated skin audits were conducted weekly on an assigned day. She confirmed Resident #202's body audit was conducted on Sundays. She further confirmed weekly body audits should include visual observation of all the skin including removing the socks to observe the toes. She confirmed nursing staff should report any pending x-ray results or new bruising identified to the oncoming nursing staff.

Based on interviews, observations, and record review, the facility failed to ensure that a resident was provided services to restore as much normal bladder and bowel function as possible for 1 (#351) of 2 (#45, and #351) residents reviewed for Bladder and Bowel Incontinence. Findings: Review of the facility's policy titled Bowel and Bladder Program Policy and Procedure with an effective date of 09/11/2014, revealed the following, in part: Purpose: To potentially improve resident's bladder and/or bowel functional control and promote dignity and wellbeing through a scheduled toileting program. Policy: To implement an individual, organized toileting program after voiding patterns have been established and a potential benefit for scheduled toileting has been identified and deemed medically appropriate. Review of Resident #351's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder, Constipation, and Acute Cystitis. Review of Resident #351's current Care Plan revealed the following, in part: Resident requires staff assistance for Activities of Daily Living care. Interventions included: assist resident with toilet transfers. Review of Resident #351's Progress Notes revealed the following, in part: Brief Interview for Mental Status on 06/25/2025 revealed Resident #351 had a BIMS of 12-indicating moderately impaired cognition. Further review of notes revealed Resident #351 was admitted on [DATE] with an indwelling, Urinary Catheter, but it was removed on 06/27/2025. An interview and observation was conducted on 06/30/2025 at 9:59 a.m. with Resident #351. Resident #351 reported she had her urinary catheter removed last week due to frequent urinary infections and staff had not been assisting her with maintaining her continence. She stated staff refused to assist her to the toilet. Observation of resident revealed she was wearing a urine soaked brief. An interview and observation was conducted on 07/01/2025 at 10:02 a.m. with Resident #351. Resident #351 was wearing an adult brief which was soiled with urine and reported she would prefer to use the toilet but required physical assistance from staff, and stated staff did not assist her with toilet transfers. She further confirmed since admission she has not been assisted to the toilet by staff or been placed on a bowel/ bladder training program. An interview was conducted on 07/01/2025 at 10:36 a.m. with S23LPN. She confirmed Resident #351 was incontinent. She further confirmed Resident #351 was a one person assist to transfer and if she was transferred to bathroom she could use the toilet, but she had never assisted Resident #351 to the toilet. An interview was conducted on 07/01/2025 at 11:05 a.m. with S3ADON. S3ADON confirmed Resident #351 has not been on a bowel or bladder incontinence training program and that Resident #351 called staff for assistance when she is soiled. She confirmed resident was aware when she was soiled and further confirmed Resident #351 can stand to transfer to toilet with staff assistance. An interview was conducted on 07/01/2025 at 3:30 p.m. with S13LPN. S13LPN confirmed Resident #351 has had foul smelling urine. She further confirmed Resident #351 requires staff assistance to transfer to toilet but has not been placed on a bowel/ bladder training program, instead she was placed in a brief. An interview was conducted on 07/02/2025 at 8:54 a.m. with S5 LPN. S5LPN confirmed she was responsible for assessing bowel and bladder continence of Resident #351 upon admission. She reported Resident #351 told her she was soiling in her brief but would like to go on the toilet. S5LPN further confirmed Resident #351 could transfer to toilet with staff assistance, but was never placed on a bowel/ bladder training program, and should have been. An interview was conducted on 07/02/2025 at 8:58 a.m. with S2DON. She confirmed the facility's goal was to provide services to restore as much normal bowel and bladder function as possible for each resident and that the new suggestions for Resident #351 as of 07/01/2025 was for her to use a bed pan despite resident being a one person assist to transfer. She further confirmed resident was never placed on a bowel or bladder training program to restore as much normal function as possible.

Based on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 1 (#201) of 32 residents reviewed in the initial screening for advance directives. This deficient practice had the potential to affect the100 residents that resided in the facility. Findings: Resident #201 Review of Resident #201's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #201's Admit Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact. Review of Resident #201's physical chart revealed no indication of Resident #201's code status. Review of Resident #201's [DATE] Physician Orders revealed: [DATE] CPR (Cardiopulmonary Resuscitation) Review of Resident #201's Electronic Health Record on [DATE] revealed a Full Code Status. On [DATE] at 10:10 a.m., an interview was conducted with S19LPN. She stated in the situation a code would arise, she would follow Resident #201's code status on the physical chart. S19LPN reviewed Resident #201's physical chart and confirmed there was no indication of Resident #201's code status. On [DATE] at 1:51 p.m., an interview was conducted with S2DON. She confirmed the code status should be found in the physical chart and the electronic chart.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#99) of 3 (#98, #99, #100) residents reviewed for closed records. Findings: Review of Resident #99's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/03/2025 revealed Resident #99 was discharged to a Short-Term General Hospital. Review of Resident #99's Nurse's Notes revealed the following, in part: 04/03/2025 at 2:19 p.m. Resident #99 discharged home with wife via personal transportation. On 07/01/2025 at 1:45 p.m., an interview was conducted with S2DON. She stated she expected MDS nurses to complete all assessments to accurately reflect each residents' discharge status. On 07/01/2025 at 2:03 p.m., an interview was conducted with S6LPN. She reviewed Resident #99's Nurse's notes and confirmed he discharged to home/community. She reviewed Resident #99's Discharge MDS with an ARD of 04/03/2025 and confirmed it indicated he discharged to a Short-Term General Hospital. She confirmed Resident #99's discharge status was not coded correctly and should have been coded as discharged to home/community.

Based on record review and interviews, the facility failed to ensure a resident with a mental disorder had an accurate Pre-admission Screening and Resident Review (PASARR) for 1 (#16) of 1 (#16) resident reviewed for PASARR. Findings: Review of Resident #16's Medical Record revealed she was admitted to the facility on [DATE] with a diagnosis, which included Delusional Disorder. Review of Resident #16's Level 1 Pre-admission Screening PASARR completed by a social worker at a local hospital dated 06/20/2024 revealed in part, the following: Section III: Mental Illness - Yes An interview was conducted on 06/30/2025 at 10:00 a.m. with S17SW. S17SW confirmed Resident #16's Pre-admission Level I PASSAR PASARR Screening dated 06/20/2024 did not contain a diagnosis of Delusional Disorder. She reviewed facility records and could not produce documentation of Level II PASARR review was requested, and confirmed it should have been. An interview was conducted on 07/01/2025 at 2:00 p.m. with S2DON. S2DON reviewed Resident #16's Pre-admission Level I PASSAR PASARR Screening dated 06/20/2024. S2DON confirmed it did not contain her diagnosis Delusional Disorder. She confirmed the facility did not resubmit a new resident review, and should have.

Based on record review and interviews, the facility failed to ensure medication administration was accurately documented for 1 (#202) of 2 (#51 and #202) residents reviewed for pain. Findings: Review of Resident #202's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Pain. Review of Resident #202's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2025 revealed a Brief Interview for Mental Status (BIMS) of 13, indicating the resident was cognitively intact. Review of the facilities standing orders revealed an order for Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for general discomfort. Review of Resident #202's June Medication Administration Record (MAR), printed and reviewed on 06/30/2025 at 3:40 p.m., revealed no documentation of an order for Acetaminophen Tablet 325 mg, give 2 tablets by mouth every 4 hours as needed for general discomfort. On 06/29/2025 at 10:11 a.m., an interview was conducted with Resident #202. She stated she had right foot pain and requested Acetaminophen from her nurse for the pain. On 06/29/2025 at 10:11 a.m., an interview was conducted with S21LPN. She confirmed Resident #202 complained of right foot pain and administered Acetaminophen for Resident#202's discomfort. On 06/30/2025 at 3:30 p.m., an interview was conducted with S20LPN. She reviewed Resident #202's physician orders and confirmed she did not have an order for Acetaminophen. She stated the Acetaminophen was a standard order. She confirmed if Acetaminophen was administered the order should have been entered in the computer in order to document the medication administration. On 07/01/2025 at 10:27 a.m., an interview was conducted with S21LPN. She stated on the weekend of 06/21/2025-06/22/2025 and on 06/29/2025, Resident #202 complained of right foot pain and she administered Acetaminophen for discomfort. She stated the Acetaminophen was a standard order. She stated when a standing order was administered, the medication should be added to the orders and placed on the MAR so staff could document the date and time the medication was administered. She confirmed she administered 2 doses of Acetaminophen to Resident #202 and did not documented it. On 07/01/2025 at 1:53 p.m., an interview was conducted with S2DON. She stated medication standing orders were not entered in the computer unless the medication was administered. She confirmed if staff administered Acetaminophen, the medication should have been entered and placed on the MAR, so staff could document the date and time the medication was administered.

Based on observation, record review and interviews, the facility failed to post nurse staffing data on a daily basis which included the total resident census. This deficient practice had the potential to affect the 100 residents residing in the facility. Findings: On 06/29/2025 at 9:08 a.m., an observation was made of the Daily Staffing Reporting Form dated 06/27/2025 with no resident census listed. On 06/29/2025 at 9:43 a.m., an interview was conducted with S16UC. She stated she was responsible for posting the Daily Staffing Reporting Form on the weekends. She stated she turned in the Daily Staffing Reporting Forms to S2DON. On 06/29/2025 at 9:50 a.m., a record review was conducted of the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and revealed no resident census was listed on any of the forms provided. On 06/30/2025 at 8:26 a.m., an interview was conducted with S9UC. She stated she worked Monday through Friday and was responsible for posting the Daily Staffing Reporting Forms in the mornings. She stated S11HR collected the Daily Staffing Reporting Forms at the end of the day. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been. On 07/01/2025 at 9:24 a.m., an interview was conducted with S2DON. She stated the Unit Clerks were responsible for completing the Daily Staffing Reporting Forms and posting it in the main lobby. She stated the Daily Staffing Reporting Form should be completed with the resident census, date, facility name and staffing information. She stated S11HR was responsible for collecting those sheets. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been. On 07/01/2025 at 1:41 p.m., an interview was conducted with S11HR. She stated the Unit Clerks were responsible for completing and posting the Daily Staffing Reporting Form. She stated the Daily Staffing Reporting Form should be complete and accurate. She reviewed the Daily Staffing Reporting Forms dated 06/27/2025 through 06/29/2025 and confirmed the resident census was not completed daily and should have been.

Based on record review and interviews, the facility failed to complete quarterly assessments for 2 (#1, #3) of 3 (#1, #2, and #3) residents reviewed for Resident Assessment. Findings: Review of the facility's policy titled, MDS Policy and Procedure with an effective date of 06/25/2015 revealed the following, in part: Policy Statement: All Minimal Data Set (MDS) are to be completed and transmitted according to the most current Resident Assessment Instrument (RAI) manual. Resident #1 On 01/02/2025, a review of Resident #1's MDS assessment revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 12/18/2024. Further review revealed the MDS assessment was not completed by 01/01/2025. Resident #3 On 01/02/2025, a review of Resident #3's MDS assessment revealed a Quarterly MDS with an ARD of 12/11/2024. Further review revealed the MDS assessment was not completed by 12/25/2024. An interview was conducted on 01/02/2025 at 11:50 a.m. with S4MDS. He confirmed all Quarterly Assessments should be completed within 14 days of the ARD. He confirmed Resident #1's MDS should have been completed by 01/01/2025, but was not completed timely. He further confirmed Resident #3's MDS should have been completed by 12/25/2024, but was not completed timely. An interview was conducted on 01/02/2025 with S2DON. She confirmed Quarterly MDS Assessments should be completed within 14 days of the ARD. She further confirmed Resident #1 and Resident #3's Quarterly MDS Assessments were not completed timely, but should have been.

Based on interviews and record review, the facility failed to protect the residents' right to be free from physical abuse for 1 (#2) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to ensure Resident #2 was free from physical abuse by S5CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy dated 03/05/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure revealed the following, in part: Purpose: Each resident has the right to be free from abuse .No one shall abuse a resident .This policy applies to facility staff Policy: 3. Physical Abuse includes hitting, slapping . A review of Resident #2's clinical record revealed he was admitted to the facility on [DATE]. The resident had diagnoses, which included Vascular Dementia, Depression, and Anxiety Disorder. A review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/2024 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. A review of the facility's Self-Reported Incident Report, dated 12/22/2024, revealed the following, in part: Victim: Resident #2 Accused: S5CNA Allegations: Physical abuse Incident Occurred: 12/22/2024 A review of Resident #2's Nurse's Note dated 12/22/2024 at 8:10 a.m. revealed the following, in part: Resident #2 was upset because he didn't receive coffee on his breakfast tray. Resident #2 threatened to hit S5CNA in the face. Resident #2 hit S5CNA, and S5CNA hit Resident #2. Resident #2 and S5CNA were separated. Resident #2 denies injury. Police, NP, RP, and S1ADM notified. A review of S5CNA's written statement dated 12/22/2024 revealed the following: Resident #2 said he would hit me. Resident #2 hit me, and I responded with my hand, popping Resident #2. A review of S7HK's written statement dated 12/22/2024 revealed the following: Resident #2 slapped S5CNA in the face, and S5CNA hit Resident #2. On 12/30/2024 at 10:50 a.m., an interview was conducted with S7HK. She stated she was working on 12/22/2024, and she witnessed the physical altercation between Resident #2 and S5CNA. She stated Resident #2 hit S5CNA in her face. She stated S5CNA hit Resident #2 on his forehead with the palm of her hand. She stated she separated Resident #2 and S5CNA. She stated S5CNA hitting Resident #2 was abuse. She stated she received in-services on abuse prevention and prohibition on 12/22/2024. On 12/30/2024 at 11:05 a.m., an interview was conducted with S2DON. She stated on 12/22/2024, S1ADM called her and notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated she assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by herself and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated she received the in-service on 12/22/2024 by S1ADM. She stated Resident #2 was assessed daily by herself for 3 days and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified. On 01/02/2025 at 8:30 a.m., an interview was conducted with S1ADM. He stated on 12/22/2024, he was notified of the altercation between Resident #2 and S5CNA. He stated he reviewed camera footage, which revealed Resident #2 hit S5CNA in her face, and then S5CNA hit Resident #2 on his forehead. He stated he saw S7HK separate Resident #2 and S5CNA. He stated S5CNA was sent home as soon as the incident occurred and was terminated. He stated it was never appropriate for a staff member to hit a resident. He stated S2DON assessed Resident #2, and no injuries were noted. He stated police, Resident #2's RP, and state office were notified on 12/22/2024. He stated following the incident all staff received in-services on abuse prevention and prohibition with a posttest given by himself and S2DON starting on 12/22/2024 with 100% completion by 12/25/2024. He stated he received the in-service on 12/22/2024 by corporate. He stated all staff had a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition. He stated Resident #2 was assessed daily for 3 days by S2DON and interviewed by the social worker 3 times a week for 2 weeks to monitor for changes. He stated random residents were interviewed daily for 2 weeks to monitor for further abuse allegations by S2DON, with none identified. He stated in morning meetings, he followed up for 2 weeks to ensure a resident had not voiced concerns of potential abuse, with none identified. On 01/02/2025 at 8:33 a.m., an interview was conducted with Resident #2. He stated on 12/22/2024, he hit S5CNA in the face and S5CNA hit him in the forehead with her hand. He stated S5CNA was taken out of the facility and terminated. He stated S2DON assessed him for injuries and checked on him daily since 12/22/2024. He stated the social worker interviewed him multiple times following the incident. On 01/02/2025 at 9:02 a.m., an interview was conducted with S8SSD. She stated on 12/22/2024, S2DON notified her S5CNA hit Resident #2, after Resident #2 hit S5CNA. She stated if a staff member hit a resident, it was abuse. She stated S5CNA left the facility immediately after the altercation and was terminated. She stated S2DON assessed Resident #2, and no injuries were noted. She stated police, Resident #2's RP, and S1ADM were notified. She stated following this incident all staff received in-services on abuse prevention and prohibition with a posttest given by S2DON and S1ADM starting on 12/22/2024 with 100% completion by 12/25/2024. She stated Resident #2 was assessed daily by S2DON for 3 days and interviewed by herself 3 times a week for 2 weeks to monitor for changes, with none identified. She stated random residents were interviewed daily by herself for 2 weeks to monitor for further abuse allegations, with none identified. On 01/02/2025 at 9:19 a.m., an interview was conducted with S3RN. She stated she received in-services on 12/23/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON. On 01/02/2025 at 9:22 a.m., an interview was conducted with S6RN. She stated she received in-services on 12/22/2024 on abuse prevention and prohibition by S2DON. She stated she completed a posttest and answered questions related to abuse by S2DON. Throughout the survey from 12/30/2024 to 01/02/2025, observations, record reviews, and staff interviews revealed staff received training on the facility's abuse policies and procedures, de-escalating aggressive behaviors, and the effect of staff approach in relation to resident's behaviors. Interviews revealed staff were knowledgeable of the types of abuse and were aware abuse should be reported to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective actions were accomplished for residents found to be affected by the alleged deficient practice include: a. Resident #2 and S5CNA separated. Resident #2 brought to a safe place. S5CNA was escorted outside of the facility. b. Administrator notified. c. Police notified. d. Head to toe assessment completed on Resident #2. e. Resident #2 and S5CNA interviewed and statements received. f. In-service all staff regarding policy and procedure for abuse prevention and prohibition. 2. All residents have the potential to be affected by this alleged deficient practice. 3. The measures put into place to prevent this alleged deficient practice from re-occurring: a. In-service all staff regarding policy and procedure for abuse prevention and prohibition. b. Residents with a BIMS of 9-15 interviewed by staff to ensure that the resident has not felt abused and that each resident feels safe. c. Resident #2 interviewed by social services 3 times a week for 2 weeks to ensure Resident #2 does not have any psychological concerns following the incident. d. Head to toe assessment completed by nurse daily for 3 days to ensure Resident #2 does not have any physical concerns following the incident. 4. Facility will monitor its performance to ensure sustained compliance by the following: a. Administrator and or designee will have a return demonstration through questioning staff on the policy and procedure for abuse prevention and prohibition. b. Administrator and or designee will follow-up in morning meeting and with weekend supervisor for 2 weeks and as needed to ensure a resident has not voiced concerns of potential abuse. c. Additional in-servicing and/or progressive disciplinary action will occur if further noncompliance is noted. 5. Corrective action will be completed by 01/07/2025. 48333

Based on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure: 1.Staff accurately marked a resident was evaluated for PASRR on 2 (#62, #66) of 4 (#8, #36, #62, #66) resident's reviewed for PASRR; and 2.Staff accurately reflected the discharge status for 1 (#91) of 5 (#38, #84, #88, #91, #92) residents reviewed for discharge; and 3.Staff accurately reflected a resident had pressure ulcers for 1 of 1 (#43) resident reviewed for pressure ulcers. 1. Resident #62 Review of Resident #62's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder and Borderline Personality Disorder. Review of Resident #62's clinical record revealed a Level II PASRR with approval dates of 04/03/2024 through 04/02/2024. Review of Resident #62's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. Resident #66 Review of Resident #66's clinical record revealed the resident was admitted to the facility on [DATE] with Diagnoses which included Paranoid Schizophrenia. Review of Resident #66's clinical revealed a Level II PASRR with approval dates of 05/09/2023 through 05/07/2024. Review of Resident #66's yearly MDS with ARD of 02/07/2024 revealed question A1500, Resident evaluated for PASRR, was answered as no. An interview was conducted with S7MDS on 05/14/2024 at 3:20 p.m. She reviewed Resident #62's and Resident #66's clinical records and confirmed both had been evaluated for a Level II PASRR. She reviewed Resident #62's and Resident #66's MDS both dated 02/07/2024. She confirmed both Resident #62's and Resident #66's MDS revealed question A1500, Resident evaluated for PASRR, was answered as no. She confirmed both Resident #62 and Resident #66 MDS was inaccurate. An interview was conducted with S2DON on 05/15/2024 at 2:10 p.m. She confirmed MDS staff were expected to accurately capture resident's information on the assessments. She confirmed the MDS should accurately reflect if a resident was evaluated for PASRR. 2. Resident #91 Review of Resident #91's clinical record revealed the resident was admitted to the facility on [DATE] and discharged to home on 03/19/2024. Review of Resident #91's Discharge MDS with an ARD of 03/19/2024 indicated the following: A2000: discharge date - 03/19/2024; and A2105: Discharge Status - 4. Short Term General Hospital. Review of Resident #91's Nurse Notes revealed a note written on 03/19/2024 at 9:52 p.m. indicated at 10:00 a.m. resident was discharged to home. An interview was conducted on 05/15/2024 at 1:45 p.m. with S13LPN. S13LPN confirmed she was Resident #91's nurse at the time of her discharge. S13LPN confirmed Resident #91 discharged to home from the facility. An interview was conducted on 05/15/2024 at 1:40 p.m. with S6MDS. S6MDS confirmed Resident #91's MDS Discharge Assessment revealed Resident #91 was discharged to the hospital which was incorrect. S6MDS confirmed Resident #91's MDS Discharge Assessment should have been coded correctly. An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. She confirmed she would expect MDS Assessments to be coded accurately and Resident #91's was not. 3. Resident #43 Review of Resident #43's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Cutaneous Abscess of Buttock. Review of the current Physician Orders revealed in part: 04/23/2024-Right Medial buttock Stage 3 clean with wound cleanser, pat dry, apply sodium chloride dressing, and cover with dry dressing until resolved. 05/13/2024 Stage 3 to right heel, clean with wound cleanser, pat dry, paint with gentian violet and leave open to air. Review of current wound log dated revealed Resident #43 had a right buttock Stage 3 with identified date of 02/27/2024, and Unstageable to right heel identified date of 04/27/2024. Review of Resident #'s 43 Admission MDS with an ARD of 03/04/2024 indicated the following: M0100A: Risk determination: has PU/injury, scar, dressing - Unchecked Further review of Section I-Active Diagnoses revealed no diagnosis for Pressure Ulcers. An interview was conducted on 05/15/2024 at 10:26 a.m. with S19WCN. She confirmed Resident #43 had a Right Medial buttock Stage 3 and Stage 3 to right heel. An interview was conducted on 05/15/2024 at 10:38 a.m. with S6MDS. S6MDS confirmed if a resident was receiving wound care and had a current pressure ulcer there should be an active diagnosis for wounds. After reviewing Resident #43's Admission MDS with ARD of 03/04/2024 Section M, S6MDS confirmed Resident #43 did not have an active diagnosis and was not checked for having a pressure ulcer and should have. An interview was conducted on 05/15/2024 at 11:00 a.m. with S2DON. She stated MDS was made aware of new wound care orders and new wounds in the morning meetings and 24 hour communication report sheet. She stated she expected resident's MDS to be accurate. 44590 48537 48912

Based on interview and record reviews, the facility failed to ensure a resident with a newly identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation as required for 1 (#36) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR. Findings: Review of Resident #36's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Psychosis not due to a substance or known physiological condition (Onset Date: 08/25/2017). Review of Resident #36's most recent Level I PASRR Screening and Determination form revealed her previous assessment was performed on 08/18/2017. Review was attempted of Resident #36's Level 1 PASRR Screen and Determination submission following the addition of a new relevant mental illness diagnosis on 08/25/2017 with no documentation available for review. Review of Resident #36's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 0, indicating the resident was significantly cognitively impaired. Further review revealed, in part, the following: Section I: Diagnoses I5950: Psychotic Disorder (other than Schizophrenia) - Checked. I8000: Additional ICD Diagnosis - F29 Unspecified Psychosis not due to a substance or known physiological condition. An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #36's Pre-admission Level I PASRR Screen and Determination was most recently submitted on 08/18/2017. He confirmed on 08/25/2017, Resident #36 received a new diagnosis of a relevant mental illness; Unspecified Psychosis not due to a substance or known physiological condition. He confirmed the facility did not resubmit a new Level I PASRR Screen and Determination with the onset of the new diagnosis.

Based on interview and record reviews, the facility failed to ensure a record of the Level 1 Preadmission Screening Resident Review (PASRR) form was maintained in the resident's record for 1 (#8) of 4 (#8, #36, #62 and #66) residents reviewed for PASRR. Findings: Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, the following; Schizophrenia (Onset Date: 07/27/2006). Review of Resident #8's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/27/2024, indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Further review revealed, in part, the following: Section I: I6000: Schizophrenia - Checked. Review was attempted of Resident #8's Pre-admission PASRR Level 1 Screening and Determination Review Form with no documentation available for review. An interview was conducted on 05/15/2024 at 2:00 p.m. with S1ADM. He confirmed Resident #8 had an active diagnosis of Schizophrenia. He confirmed Schizophrenia was one of the relevant mental illnesses listed on the Level I PASRR Screen and Determination. He confirmed the facility did not have a copy of Resident #8's most recent Level 1 PASRR Screen and Determination. He confirmed the facility had not submitted a Level 1 PASRR Screen and Determination for Resident #8 when she was admitted to the facility on [DATE].

48912 Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet the needs of 2 (#23, #86) residents out of a 25 total sampled residents. The facility failed to: 1. Report Resident #23's urinalysis results to the consulting provider as ordered; and 2. Ensure care plan was comprehensive and individualized for Resident #86 whom exhibited frequent refusals and behaviors. Findings: 1. Review of the facility's policy titled, Notifying Clinicians - Laboratory/Diagnostic Testing Policy & Procedure revealed the following: Procedure: I. Laboratory Services (483.50) d. The facility must promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results . per the ordering physician's orders. Process: III. Once the laboratory . test is completed the results will be reported to the order physician, physician assistant, or nurse practitioner in a timely manner. Review of Resident #23's Clinical Record revealed she was admitted on [DATE] with diagnoses which included Stage 3 Chronic Kidney Disease, Urinary Tract Infection, Unspecified Injury of Unspecified Kidney, Acute Kidney Failure, Disorder of Urinary System, Overactive Bladder, and Personal History of Urinary Tract Infections. Review of the most recent Care Plan the following: Onset: 04/01/2024 Problem: I am at risk for infection returning Intervention: My labs need to be done as ordered by my MD; notify my MD of significant changes Review of the most recent Physician Orders, dated November 2023 through current, revealed the following: 05/09/2024 U/A with C&S - Fax results to urologist fax number Review of the Nurses/Care Team Notes, dated November 2023 through current, revealed the following: On 05/08/2024 at 8:47 p.m. Resident returned from urology appointment with new order for urine culture and to fax results to urologist fax number. Signed by: S3IP Review of Laboratory Results ordered on 05/09/2024 by Resident's urologist for urinalysis revealed the specimen was collected on 05/09/2024, sent to the facility's outside lab company and reported to the facility on [DATE]. On 05/14/2024 at 9:40 a.m., an interview was conducted with S14LPN. After reviewing Resident #23's chart, she stated the results of the UA collected on 05/09/2024 were not in Resident #23's chart at this time. On 05/15/2024 at 9:00 a.m., a telephone interview was conducted with the medical assistance for Resident #23's urologist. She confirmed Resident #23 was seen in the clinic by her urologist on 05/08/2024 and was sent back to the facility with an order for a urinalysis with culture and sensitivity and request of the results to be faxed to the clinic office once received. She stated the clinic still had not received the results of the urinalysis. On 05/15/2024 at 1:27 p.m., an interview was conducted with S2DON. She stated she was responsible for checking for resulted lab tests and ensuring the results are sent to providers once resulted. She stated there is a lab notification log kept at the front nurses' station with the ward clerk. She stated when a nurse gets an order for a lab, they are to notify the ward clerk of the order so they can notify the facility's outside lab company. If the specimen to be collected is urine, the nurse will write on the notification log the date and time the specimen was collected. She stated she checks the log daily to check to see if the lab company has resulted the pending specimen sample(s). She confirmed she did not send the results of Resident #23's urinalysis as ordered by the urologist. 2. Review of Resident #86's Clinical Record revealed he was readmitted on [DATE] with diagnoses which included Bacteremia, Benign Prostate Hyperplasia, Urinary Tract Infection, Retention of Urine, Chronic Kidney Disease, Cystitis, and Gastrostomy Status. Review of the 5 day MDS with ARD of 04/22/2024 revealed Resident #86 had a BIMS of 7, which indicated the resident was severely cognitively impaired. Review of Section GG - Functional Abilities and Goals revealed Resident #86 required partial/moderate assistance with toileting. Review of Section H - Bladder and Bowel revealed Resident #86 had an indwelling urinary catheter. Review of Section K-Swallowing/Nutritional Status revealed Resident #86 had a feeding tube. Review of the most recent Care Plan the following revealed that Resident #86 was not care planned for refusal of care related to his PEG and catheter or behaviors. Review of the Nurses/Care Team Notes, dated March 2024 through current, revealed the following: On 03/27/2024 at 12:49 p.m. Resident #86 refused tube feeding. On 04/01/2024 at 4:45 p.m. Resident #86 was redirected and educated not to pull on his PEG tube or catheter. On 04/09/2024 at 8:28 a.m. Resident #86 noted pulling at catheter. On 04/09/2024 at 8:28 p.m. Resident #86 pulled catheter. On 04/19/2024 at 5:38 a.m. Resident #86 refused bolus feeding. On 04/22/2024 at 8:42 a.m. Resident #86 refused morning feeding. Review of the 24 hour Communication Report log dated 05/01/2024 to current revealed on 05/10/2024 resident #86 refused care and slammed door on CNA hand. On 05/14/2024 at 11:04 a.m., an interview was conducted with S13LPN. She stated Resident #86 constantly puts his indwelling catheter bag in the trash can and she has to constantly educate him to remove the catheter bag from the trash can. S13LPN stated Resident #86 had orders to apply a leg beg every morning, but he often refused to have it applied.S13LPN stated Resident #86 also frequently refused this PEG tube feedings and flushes. She stated she documented refusals of care and behaviors in nurse's notes and sometimes on the 24 hour Communication Report log. On 05/15/2024 at 9:50 a.m., an interview was conducted with S6MDS. She stated she was responsible for care plans. S6MDS stated the process for care plan updating or revisions was for her to get updates in the morning meeting and reviewing the 24 hour Communication Report logs daily. She stated then she would update the care plan by adding interventions. S6MDS confirmed she was not aware of Resident #86's frequent refusals and behaviors. On 05/15/2024 at 2:22 p.m., an interview was conducted with S2DON. She confirmed staff should be documenting refusals of care on the MAR, Nurses' notes, and 24 hour Communication Report log. S2DON confirmed if a resident was frequently refusing care and exhibiting behaviors MDS should be made aware in the morning meeting using the 24 hour Communication Report logs and refusals and behaviors should be properly care planned. After reviewing Resident #86's current care plan, S2DON confirmed Resident #86 was not care planned for frequent refusals and behaviors.

Based on observations, interviews and record reviews, the facility failed to ensure a resident was offered a therapeutic diet when the health care provider ordered a therapeutic diet for 2 (#9 and #78) of 3 (#9, #70 and #78) residents reviewed for nutritional status. Findings: Resident #9 Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Dementia; Alzheimer's; Delusional Disorders; Aphasia; and Dysphagia. Review of Resident #9's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, which indicated resident had severe cognitive impairment. Further review revealed, in part, Resident #9 received a therapeutic diet. Review of Resident #9's current Physician Orders revealed, in part, the following: 02/01/2024: Pudding with Lunch and Dinner; 02/26/2024: Protein Juice with all Meals; and 10/03/2023: Ice Cream with Lunch and Supper. Review of Resident #9's Nutrition Assessment, dated 01/29/2024, revealed, in part, the following: Nutrition Diagnosis: Inadequate energy intake due to condition . Nutrition Interventions: . Receiving ice cream with lunch and supper. Significant weight loss of 5% in 49 days. Continue to encourage intake. Review of Resident #9's Care Plan, revealed, in part, the following: I am at risk for weight loss related to poor intake. (Created 11/15/2023.) I need my meals served as ordered by my physician; and Provide my supplements to me as ordered. Review of Resident #9's meal ticket revealed no documentation of the need for protein juice drink with all meals, pudding with lunch and dinner or ice cream with lunch and supper. An observation was conducted on 05/13/2024 at 12:10 p.m. with S10CNA. Resident #9 was observed in bed with S10CNA seated at bedside feeding her. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray. An observation was conducted on 05/14/2024 at 11:35 a.m. with S12CNAS. Resident #9 was observed seated in her wheelchair in the main dining room. Resident #9's meal tray was observed with no protein juice, pudding or ice cream on the tray. S12CNAS confirmed there was not a protein juice, pudding or ice cream present on Resident #9's meal tray. S12CNAS confirmed she was not aware of any orders for Resident #9 to receive extra items with meals. An interview was conducted on 05/15/2024 at 8:50 a.m. with S4NP. She confirmed Resident #9 had some weight loss since the beginning of the year and should be receiving ice cream with lunch and supper, pudding with lunch and dinner and a protein juice with all meals. She confirmed if she was not receiving the extra food/beverage items as ordered, this could be a contributing factor to her weight loss. S4NP confirmed she would expect staff to follow orders as written. Resident #78 Review of Resident #78's Clinical Record revealed he was admitted to the facility on [DATE]. Further review revealed he was admitted to a local hospice agency on 02/08/2024 with a diagnosis of Muscle Wasting and Atrophy. Review of Resident #78's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, indicated resident had a Brief Interview of Mental Status (BIMS) of 3, indicating resident was severely cognitively impaired. Further review revealed, in part, Resident #78 received a therapeutic diet. Review of Resident #78's current Physician Orders revealed, in part, the following: 03/19/2024: Protein Juice Drink with all Meals; 02/09/2024: Pureed Soup with Lunch and Dinner; and 10/03/2023: Ice Cream with Lunch and Supper. Review of Resident #78's Hospice Plan of Care, dated 02/08/2024, revealed, in part, the following: Problem: Nutrition/Hydration diminished due to disease progression. Goal: For facility staff to adjust to changing nutritional needs, ongoing. Review of Resident #78's meal ticket revealed no documentation of the need for protein juice drink with all meals, pureed soup with lunch and dinner or ice cream with lunch and supper. An observation was conducted on 05/13/2024 at 12:05 p.m. of Resident #78's bedside table sitting next to the bed with his lunch tray sitting on top. No protein juice, ice cream or soup was noted on his meal tray. An observation was conducted on 05/14/2024 at 11:25 a.m. with S10CNA. Resident #78's meal tray was observed arriving to his room without protein juice, ice cream or soup on his meal tray. S10CNA confirmed Resident #78's meal tray did not contain a protein juice, ice cream or soup. S10CNA confirmed Resident #78 did not typically receive those items and she was not aware he should. An interview was conducted on 05/15/2024 at 9:50 a.m. with Resident #78's hospice nurse. She confirmed Resident #78 was one of her patients. She confirmed the hospice agency expected the facility staff to follow all of Resident #78's orders as written. An interview was conducted on 05/14/2024 at 11:40 a.m. with S12CNAS. S12CNAS confirmed the dietary staff were in charge of placing the appropriate food and beverage items on each resident's tray to match their orders. An interview was conducted on 05/15/2024 at 12:40 p.m. with S11DS. S11DS confirmed she was aware of a history of weight loss for Resident #9 and Resident #78 but was not aware of any current dietary addition orders for either of them. S11DS provided a copy of Resident #9 and Resident #78's meal tickets, which did not accurately reflect the resident's current dietary orders. S11DS stated she and S2DON met weekly to discuss residents at high risk for weight loss. S11DS stated during this weekly meeting, S2DON provided her with a list of each resident's orders for additional food and beverage items so she could add it to each resident's meal ticket. S11DS stated the meal tickets were then printed for each resident for the week and were used by her staff to accurately prepare every meal tray leaving the kitchen. S11DS confirmed the dietary staff would not know to add the necessary additions if she were not told of the orders by S2DON. An interview was conducted on 05/15/2024 at 2:10 p.m. with S2DON. S2DON confirmed Resident #9 had the following active orders; pudding with lunch and dinner, ice cream with lunch and supper and protein juice with all meals. S2DON confirmed Resident #78 had the following active orders; protein juice drink with all meals, pureed soup with lunch and dinner, and ice cream with lunch and supper. She confirmed she and S11DS met weekly to discuss residents at high risk for weight loss. S2DON confirmed she was responsible for providing S11DS with any additions or changes in dietary orders during their weekly meeting and she must have missed Resident #9 and Resident #78's. S2DON confirmed she would expect staff to implement all dietary orders as written, especially when a resident had a recent history of weight loss.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 2 (#21, #97) of 10 (#11, #21, #26, #27, #41, #54, #90, #97, #409, and #411) resident sampled for accident hazards by failing to ensure: 1. Resident #21 was transferred with two-person staff assistance with use of a mechanical lift according to the residents' plan of care 2. Resident #97 had an antiskid mat and anti-tippers on his wheelchair according to the plan of care. This deficient practice resulted in an actual harm on 10/02/2020 when Resident #21, who required two-person transfer with use of a mechanical lift, was transferred by S15CNA from her wheelchair to the bed with a mechanical lift without another staff member present. During the transfer, Resident #21's heel protector became caught on the footrest of her wheelchair which forced her left knee to bend uncomfortably. The resident's left knee was unable to bend due to [MEDICAL CONDITION]. An X-ray and CT scan of her left knee was obtained and confirmed a left knee occult fracture. This deficient practice had the potential to affect 30 residents identified by the facility as requiring a mechanical lift for transfers. Findings: Resident #21: Review of Resident #21's record revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the October physician's orders [REDACTED]. 10/03/2020 Left Knee X-ray for Dx Pain 10/14/2020 Schedule CT of the Left Knee due to 10/03/2020 X-ray results recommending a follow up CT. Review of Left Knee X-ray report dated 10/03/2020 revealed the following: Impression: Severe demineralization with possible Lipohemarthrosis is worrisome for occult fracture. Recommend CT. Review of Left Knee CT scan report dated 10/16/2020 revealed the following: Impression: Marked Osteopenia with small Lipohemarthrosis indicative of fracture sequela, however, the fracture is occult. Review of the Facility's Investigation Report dated 10/03/2020 revealed the following: Resident reported to this nurse pain (8/10) to left knee stated the previous day her heel protector had caught on the footrest of her wheelchair while being lifted via mechanical lift into bed and it forced her knee to bend uncomfortably. Left lower extremity normally stiff and unable to bend without outside force. Review of the resident's Quarterly MDS dated [DATE] revealed the following: BIMS=15 which indicated Resident #21 to be cognitively intact. Transfer: self-performance 4. Total dependence Transfer: support provided 3. Two+ persons physical assist Review of the resident's Comprehensive Plan of Care with a goal date of 11/30/2020 included the following problems: 1. Resident is dependent with ADLs incontinent of bladder, transfer assist total. Interventions included: Lift Status-Red-Stop-Total Lift-Mechanical lift required. Assist X2 2. Resident has functional limited range of motion in bilateral lower extremities related to [DIAGNOSES REDACTED]. Interventions included: encourage resident to use assistive device as needed. On 11/04/2020 at 10:49 a.m., an interview was conducted with Resident #21. She stated there was an incident at the beginning of October and she was injured during a transfer from her wheelchair to her bed. She stated she required a two person assist transfer with a mechanical lift. She stated S15CNA transferred her in the lift without a second staff member present. She stated due to her [MEDICAL CONDITION] both of her legs did not bend. She stated during the lift her pressure relief device on her left lower extremity got caught on her wheelchair footrest. She stated S15CNA lifted her up and she felt pain in her knee. She stated the x-ray taken of her left knee revealed a fracture in her kneecap. On 11/09/2020 at 8:46 a.m., an interview was conducted with S1ADM. She stated she found out about the incident on 10/09/2020. She stated on 10/02/2020 S15CNA transferred Resident #21 with a mechanical lift without the assistance of another staff member which resulted in a fracture in Resident #21's left knee. She stated S15CNA should not have transferred Resident #21 without another staff member to assist. On 11/10/2020 at 10:34 a.m., an interview was conducted with S15CNA. She stated she transferred Resident #21 with the mechanical lift by herself on 10/02/2020. She stated as she was lifting Resident #21 from her wheelchair and the resident stated she was uncomfortable and the lift pad needed to be adjusted as one leg was higher than the other. She stated once the pad was adjusted she completed the transfer. She denied seeing Resident #21's heel boot become stuck on the wheelchair. She stated Resident #21 complained of mild discomfort and asked her for an ice pack. She stated she was responsible for transferring Resident #21 by herself without another staff member, and it was a poor decision. She stated she could have gotten another staff member to help her but she just did not. She stated Resident #21 was a two person assist transfer with a mechanical lift. Resident #97 Review of the clinical record for Resident #97 revealed he was admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITIONS], Muscle Weakness, Abnormalities of Gait and Unsteadiness, and Falls. Review of the quarterly MDS with an ARD of 10/09/2020 revealed Resident #97 had a BIMS of 13, which indicated he was cognitively intact. Further review revealed the resident had two or more falls. Review of Resident #97's current Care Plan revealed, in part: Smart Chart - rear anti-tippers to wheelchair. Problem Onset - 06/16/2017 Problem/Need - Resident is at risk for injury related to falls Approaches - 02/22/2020, Antiskid mat placed under wheelchair cushion to assist with sliding out of the wheelchair. Review of the Facility's Investigation Report dated 11/01/2020 revealed, in part, Resident #97 had a fall. He stated he slipped out of his wheelchair. An interview was conducted with S14CNA on 11/09/2020 at 10:57 a.m. She stated Resident #97 required assistance and supervision because he fell a lot. She stated the resident did not have any fall prevention devices in use at this time. She confirmed the resident did not have any fall prevention devices that she knew of in the month of November 2020. An observation was made of Resident #97 on 11/09/20 at 11:02 a.m. He was observed sitting in his wheelchair in his room. The wheelchair did not have rear anti tippers or an antiskid mat in use. An interview was conducted with S30LPN on 11/09/2020 at 11:42 a.m. She stated Resident #97 had a history of [REDACTED]. She observed the resident's wheelchair and confirmed he did not have anti tippers on wheelchair or a nonskid mat under his seat cushion to prevent sliding. She confirmed Resident #97 did not have the antiskid mat or rear anti-tippers on his wheelchair in the month of November 2020. An interview was conducted with S33MDS on 11/09/2020 at 12:15 p.m. She reviewed Resident #97's care plan and confirmed rear anti-tippers were listed as an intervention on the task care plan and an antiskid mat was applied to the wheelchair on 02/22/2020. She stated both the nurse and CNA's should be completing a task each shift indicating whether the devices were present or not. Review of the Completed Care Task for November 2020 revealed, in part, rear anti-tippers and an antiskid mat were documented as being present, which was indicated by the staff member's electronic signature, each shift in November by both the nurse and the CNA's. An interview was conducted with S2DON on 11/09/2020 at 1:23 p.m. S2DON reviewed the completed care task for Resident #97. She stated the CNA and the nurse were responsible for documenting the presence of the anti-tippers and antiskid mat each shift. She said the staff should not have documented the devices as present if they were not. She confirmed the devices should have been applied to the wheelchair when the intervention was implemented. An interview was conducted with Resident #97 on 11/10/2020 at 8:15 a.m. He stated the facility put the antiskid mat and rear anti-tippers on the wheelchair yesterday. He stated he had not had the antiskid mat on his wheelchair for months and he could not remember ever having the rear anti-tippers. He explained he fell on [DATE] when trying to stand and slid out of the wheelchair. He confirmed the antiskid mat was not in place when he slid out of his wheelchair on 11/01/2020.

Based on observations, interviews, and record reviews, the facility failed to ensure pain management was provided to residents who required such services, consistent with the comprehensive person-centered care plan and professional standards of practice during wound care for 3 (#11, #36, and #41) of 5 (#11, #33, #36, #41, and #90) residents reviewed for pain. This failed practice resulted in an actual harm on 11/04/2020 at 10:09 a.m., when a surveyor observed S32RN administering wound treatment to Resident #36. A formal pain scale rating was not completed prior to or during the wound treatment. During the preparation for wound treatment, S32RN voiced that the resident's wound treatment was very painful, and Resident #36 repeatedly asked S32RN and S23CNA if they were going to hurt her. While wound treatment was in progress, Resident #36 yelled out, She is trying to kill me. Her entire body tightened and shook each time S32RN touched the inside of the wound. S32RN continued to cleanse the interior of the wound with a wet gauze. The resident showed verbal and nonverbal signs of pain each time S32RN touched the wound bed and subsided when wound treatment stopped. S32RN did not stop wound treatment to address pain relief or offer pain medication to the resident. This had the potential to affect 24 residents, identified by the facility on the Resident Census and Conditions dated 11/02/2020, who were being treated for [REDACTED]. Findings: Review of the Facility's Pain Screen and Management Policy revealed, in part: All residents who experience routine pain receive a comprehensive pain screening and treatment plan until acceptable level of relief is achieved. All residents have the right to treatment for [REDACTED]. The resident's statements are the most valid measurement of pain. Non-communicative residents are assessed by observation of nonverbal behavior. Potentially Painful Treatment or Procedures: A pain scale rating is completed on the MAR/TAR prior to and during each potentially painful treatment or procedure, such as wound care. The resident will be observed for non-verbal indicators of pain as well as using the pain scale rating. At any time the rating exceeds a three on the pain scale, the resident will be offered medications for pain or the Physician notified of need for pain management as applicable. If the treatment/procedure is in progress, it will be delayed until intervention is effective. Resident # 36 Review of the clinical record revealed Resident #36 was admitted to the facility on [DATE]. Further review revealed the resident acquired the below [DIAGNOSES REDACTED]. 08/20/2020 - Pressure Ulcer of Sacral Region, Stage 3 09/09/2020 - Pressure Ulcer of Sacral Region, Stage 4 Review of the quarterly MDS with an ARD 08/27/2020 revealed Resident # 36 had a BIMS of 0, which indicated severe cognitive impairment. The assessment indicated the resident was usually able to make herself understood and usually understood others. Review of the Physicians orders for Resident #36 revealed, in part: 01/23/2020 - [MEDICATION NAME] 200 mg capsule by mouth twice daily as needed for pain 08/22/2020 - [MEDICATION NAME] 200 mg, give 2 tablets to equal 400 mg by mouth every six hours as needed for pain. 09/18/2020 - [MEDICATION NAME] HCL 50 mg tablet, give one tablet by mouth twice a day for pain at 8:00 a.m. and 8:00 p.m. Review of Resident #36's Treatment administration record revealed, in part, wound treatment was to be performed at 1:00 p.m. Review of Resident #36's Care Plan revealed, in part: Problem Onset: 01/23/2020 Problem/Need - Resident at risk for pain Approaches - Administer medications as ordered An observation was made of wound treatment being administered to Resident #36 on 11/04/2020 at 10:09 a.m. by S32RN with the assistance of S23CNA. She explained Resident #36 had a non-healing sacral Stage 4 pressure ulcer. She stated the wound required treatment four times a week and was very painful. As S32RN and S23CNA were preparing Resident #36 for wound treatment the resident repeatedly asked if they were going to hurt her. The resident was turned from her back to her left side. A formal pain scale rating was not completed prior to wound treatment. Resident #36 yelled out She is trying to kill me and her entire body tightened and shook each time S32RN touched the inside of the wound. S32RN continued cleansing the interior of the wound with a wet gauze. This reaction to pain occurred each time S32RN touched the wound bed and would subside when wound treatment stopped. S32RN did not stop wound treatment to address pain relief or offer pain medication to the resident. After wound care was completed, S32RN was interviewed. She stated she did not think Resident #36 was in that much pain. An interview was conducted with S30LPN, on 11/05/2020 at 8:13 a.m. She stated Resident #36 had a Stage 4 sacral pressure ulcer. She stated the resident would refuse care at times due to pain. She reviewed Resident #36's MAR and stated the resident had scheduled [MEDICATION NAME] 50 mg by mouth twice a day, [MEDICATION NAME], and [MEDICATION NAME] as needed for pain. She stated she never gave the Resident the as needed medications to address pain during wound treatment because the resident received a scheduled [MEDICATION NAME] at 8:00 a.m. each morning. She said [MEDICATION NAME] would not relieve the pain during wound treatment, but would dull it down a little so the resident would not cry out as much during treatment. An interview was conducted with S23CNA on 11/05/2020 at 1:30 p.m. She confirmed she assisted with wound treatment for [REDACTED]. She stated the resident would refuse treatment sometimes or make the staff stop treatment by yelling, get off of me and don't touch me. She stated Resident #26 complained of pain often. Review of the November 2020 Electronic Treatment Record for Resident #36 revealed a pain score of 10/10 during wound treatment on 11/02/2020. Treatment was initialed by S26MRD, which indicated she completed the task. Review of Resident #36's Medication Administration Record for the above treatment completed by S26MRD revealed the resident did not receive as needed [MEDICATION NAME] or [MEDICATION NAME] to address pain associated with wound treatment. An interview was conducted with S26MRD on 11/06/2020 at 9:07 a.m. She confirmed she had been present for the wound treatment on Resident #36 on 11/02/2020. She stated the treatment was difficult because the resident would yell out and she would have to sweet talk her to calm her down. She confirmed the treatment was painful. She denied administering pain medication to the resident to assist with pain relief during wound treatment on 11/02/2020. Review of Resident #36's Nurse's Notes signed by S24LPN revealed, in part: 09/07/2020 - Resident #36 refused wound care treatment today. She was saying, You're killing me. Stop. 10/16/2020 - While doing wound treatment Resident #36 stated stop. Leave me alone. Do not touch me. Review of Resident #36's Electronic Treatment Record from September 2020 to present revealed a pain score of 0 to 10, with 0 indicating no pain and 10 indicating severe pain, during wound treatment on the following dates. Wound treatment was scheduled for 1:00 p.m. Treatment was initialed by S24LPN, which indicated she completed the task. 09/21/2020 - 7/10 09/22/2020 - 5/10 09/24/2020 - 3/10 09/25/2020 - 3/10 09/28/2020 - 5/10 09/29/2020 - 3/10 09/30/2020 - 4/10 10/02/2020 - 4/10 10/04/2020 - 4/10 10/05/2020 - 4/10 10/26/2020 - 7/10 10/30/2020 - 5/10 Review of Resident #36's Medication Administration Record for the above listed treatments completed by S24LPN revealed the resident did not receive as needed [MEDICATION NAME] or [MEDICATION NAME] to address pain associated with wound treatment. Review of Resident #36's Weekly Wound Assessment Report completed by S24LPN revealed, in part: 09/14/2020, 09/28/2020, 10/12/2020, and 10/19/2020 the resident's pain intensity was documented as moaning and pain management was documented as ineffective. On 10/26/2020, the pain intensity was documented as crying and the pain effectiveness was documented as ineffective. An interview was conducted with S24LPN on 11/06/2020 at 10:25 p.m. S24LPN explained Resident #36 would scream out Stop you are killing me during wound treatment. S24LPN confirmed Resident #36 did not have adequate pain control during wound treatments. She stated the resident would verbally tell you the treatment was hurting her. She stated the resident would refuse treatment sometimes because of the pain it caused. She stated the resident received [MEDICATION NAME] twice a day scheduled and denied administering other as needed medications for wound treatments. She confirmed the resident's pain management was never effective when she administered wound treatment. An interview was conducted with S25NP on 11/06/2020 at 10:48 a.m. She stated she was aware Resident #36 had severe pain during wound treatment. She confirmed the resident was prescribed scheduled [MEDICATION NAME] twice a day as well as needed [MEDICATION NAME] and [MEDICATION NAME]. She stated she was unaware the resident was not receiving the as needed medications to address pain during wound treatments. An interview was conducted with S2DON on 11/09/2020 at 9:41 a.m. She stated if a resident received wound treatment that caused pain the resident should be medicated prior to the treatment. She stated, if a resident received [MEDICATION NAME] at 8:00 a.m., the wound treatment should be started 30 minutes to an hour after medication administration. She stated this was to ensure the medication was effective to treat pain. She confirmed if a resident cried out in pain during wound treatment the nurse should stop and address the resident's pain. Resident # 41 Review of the clinical record revealed Resident #41 was admitted to the facility on [DATE]. She was diagnosed with [REDACTED]. Review of quarterly MDS with an ARD of 09/04/2020 revealed Resident #41 had a BIMS of 3, which indicated severe cognitive impairment. The resident displayed short and long-term memory problems, was severely impaired in making decisions, and had disorganized thinking. Resident #41 rarely to never made herself understood. Review of Resident #41's Medication Administration Record from September 2020 through present revealed, in part, an order dated 06/02/2020 for [MEDICATION NAME] 20 mg/ml oral syringe, give 1 ml by mouth every 1 hours as needed for pain/dyspnea. Since the order date of 06/02/2020, [MEDICATION NAME] was administered once, which was on 11/05/2020. Review of Resident #41's Electronic Treatment Record from September 2020 to present revealed, in part, Resident #41's pressure ulcer to the left back received wound treatment three times a week from 09/01/2020 to 09/16/2020 and daily from 09/18/2020 to present. Review of Resident #41's Care Plan revealed, in part: Onset - 11/16/2018 Resident at risk for pain Administer medications as ordered An interview was conducted with S29CNA on 11/12/20 at 9:32 a.m. She stated Resident #41 was able to make noises and/or push away. She stated Resident #41 usually indicated she was in pain if she was placed on the pressure ulcer. An interview was conducted with S6CNA on 11/12/2020 at 9:38 a.m. She said Resident #41 would make noises and/or push away indicating she was in pain if she was turned onto her left back where the pressure ulcer was located. An observation was made on 11/12/2020 at 9:50 a.m. of wound care being administered to Resident #41 by S33MDS with the assistance of S28MDS. S33MDS stated Resident #41 had a Stage 4 pressure ulcer to her left lower back area. S33MDS used a cotton tip applicator to apply medication to the interior wound bed. As S33MDS applied medication, Resident #41's body flinched and she attempted to move her body away from S33MDS. S33MDS removed the cotton tip applicator in order to get more medication. She then again applied medication to the interior of the wound bed. Resident #41 again flinched and attempted to move away. S33MDS continued to apply the medication and said, I know I know, as the resident flinched. S33MDS did not stop wound care and address the resident's pain. Immediately following wound care both S33MDS and S28MDS confirmed Resident #41 flinched and moved away from wound care indicating the treatment was painful. Both confirmed the resident was not medicated for pain prior to wound treatment and that medication was not administered once the resident nonverbally indicated pain during treatment. An interview was conducted S3ADON on11/12/2020 at 11:53 a.m. She stated if a nurse observed a resident flinch, or move away in pain during wound treatment she should stop the treatment, and provide pain medication to the resident. She reviewed the MAR and confirmed the resident received pain medication one time since September 2020, which was on 11/05/2020. Resident #11 Review of record revealed Resident #11 was admitted to the facility on [DATE] with the following diagnoses, in part, Pain, Unspecified, Pain in right ankle and joints of right foot, and fractured right tibia. Review of Resident #11's MDS with an ARD of 10/26/2020 revealed Resident #11 had a BIMS of 2 indicating the resident was severely impaired. Further review revealed Resident #11 had one Stage IV (full thickness skin loss with exposed bone, tendon or muscle) pressure ulcer. Review of Resident #11's Care Plan revealed, in part, a problem addressing the potential for pain with approaches to observe onset and severity of pain and to administer pain medications as ordered. Review of Wound Assessment Report dated 10/26/2020 revealed, in part, Resident #11 had a Stage IV Pressure Ulcer to her Left Hip that measured 3.00cm long x 3.00cm wide x 1.00cm deep. Review of Resident #11's physician's orders [REDACTED]. Review of Resident #11's eTAR for November 2020 revealed on 11/10/2020, S19LPN documented Resident #11's pain was a 2 on the 0 to 10 pain scale, which indicated Resident #11 had mild pain during her wound care. Review of Resident #11's eMAR for November 2020 revealed, in part, no documentation [MEDICATION NAME] 325mg tablet, take 650mg po Q 4 hours prn pain was administered. In an interview on 11/12/2020 at 1:00pm, S19LPN stated Resident #11 wiggled from side to side when he performed her wound care on 11/10/2020. S19LPN stated he documented Resident #11's pain a 2 on her eTAR. S19LPN stated although he assessed and documented Resident #11 to be in pain, he completed Resident 11's wound care without administering her prescribed pain medication. In an interview on 11/12/2020 at 3:12pm, S3ADON confirmed S19LPN documented Resident #11's pain a 2 during her wound care. S3ADON also confirmed S19LPN failed to stop the wound care and administer pain medications to Resident #11 when she exhibited signs of pain.

Based on record review, interview and observation the facility failed to ensure residents were provided the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well being. a) The facility failed to ensure a resident received appropriate dental services to prevent pain for 1 (#5) of 2 (#5, #122) residents with dental problems out of 24 ((#117, #95, #79, #70, #52, #91, #84, #116, #126, #121, #69, #14, #86, #128, #124, #58, #1, #74, #63, #125, #5, #85, #34) interviewable residents. The facility failed to ensure: 1. an order dated 4/27/10 for a referral to a dentist was followed (#5); 2. the resident was referred to a dentist after the facility dentist, on 5/3/10, examined the resident and found: resident stated she has been having pain in area of root tip #5; numerous areas of decay; nothing I can do for patient here at nursing home. 3. an order dated 7/20/10 to refer resident #5 to "LSU School of Dentistry for evaluation and extractions if necessary" was followed (#5); 4. a 11/30/10 order for a dental referral for painful teeth and gums was followed (#5); 5. the MDS assessment dated [DATE] was accurate revealing the resident had tooth fragments; 6. ensure nurses assessed the resident for dental pain and difficulty chewing (#5); 7. the SSD was immediately notified of the residents need for dental services (#5); 8. the SSD obtained dental services for the resident (#5). The resident continues to experience recurring mouth and tooth pain which beginning approximately May 2010 and has had to change her diet from chopped meat to a mechanical soft diet with pureed meats due to her broken teeth, mouth pain, and difficulty chewing. b) The facility failed to ensure appropriate positioning was maintained for 1(#127) of 1(#127) residents that triggered for positioning. c) The facility failed to ensure a resident's pain was managed consistent with the resident's goals and preferences for 1 (#34) of 24 residents(#127,#74,#34,#95,#79,#70,#52,#91,#84,#46,#116,#126,#121,#69,#14,#86,#128,#124,#58,#1,#63,#125,#5,#85) interviewed for pain. d) The facility failed to ensure a resident that was on [MEDICATION NAME] therapy was being monitored by daily PTT/INR labs for 1 (#74) of 3 (#54, #74, and #92) residents that were triggered for post hospitalization care. Findings: Resident #5: During an interview on 6/6/2011 at 10:47 a. m. with resident #5 she stated she had tooth/mouth pain due to broken teeth. She also stated she had chewing problems because of these broken teeth. She further stated she had talked to someone at the Governor's office about 3 months ago to try to get dental care. On 6/9/11 at 10:15 a.m. an interview with resident #5, revealed she has had mouth pain for "some time." She also stated "I told the nurse." The resident reported she had notified S6 Accounts Manager that she had mouth/tooth pain. . During an interview on 6/9/11 at 3:00 p.m. with resident #5, she stated she has quit complaining of tooth pain because she has had it so long. Another interview on 6/10/11 at 8:45 a.m. with resident #5, revealed she continued to have mouth pain. An observation on 6/6/2011 at 10:50 a.m. revealed resident #5, had a tooth broken off at the level of the gum on the top right side of her mouth and a tooth broken off at the level of the gum on the bottom left side of her mouth. An observation on 6/8/11 at 12:00 p.m. revealed resident #5 was having her meal in her room. Her plate was noted to have 3 of the 4 items remaining uneaten. The items remaining on her plate were pureed beans, a piece of cornbread, and cooked cabbage. A piece of cake was also noted in a cup on the side of her plate uneaten. An interview was conducted with resident #5 at that time. She stated during that interview, that she only ate her creamed potatoes and drank her milk. She also stated she had trouble eating because the right side of her mouth was sore where a tooth was broken. She continued to say that she wished she had dentures and would like to have her broken teeth removed so she would not have pain. Review of the periodic oral exam of resident that was done by the facility dentist on 5/3/10 revealed the following: "Periodic exam. Exam in room. Patient is not wearing partials at time of exam. Poor oral hygiene. Patient stated she has been having pain in area of root tip #5. Numerous areas of decay. No swelling clinically. Nothing I can do for pt (patient) here at NH (nursing home)...." A Review of the Physicians Orders for resident #5 revealed the following: 1. An order dated 4/27/10 for a referral to a dentist 2. An order dated 7/20/10 to refer resident #5 to "LSU School of Dentistry for evaluation and extractions if necessary". 3. An order dated on 11/30/10 for a dental referral for painful teeth and gums. A review of the dietary Departmental Notes dated 4/22/2010 reveals that resident #5 requested that she receive a chopped meat diet and the request was honored. A review of the physician progress notes [REDACTED]. States she can only use two teeth to chew now." A review of the physician's order [REDACTED]. A physician's order [REDACTED].#5. Review of the MDS 2.0 quarterly review assessments dated 9/16/2010 and 7/1/2010 revealed the resident was coded as having chewing problems. Review of the MDS 3.0 dated 2/22/2011, revealed the resident was coded under the Oral/Dental Status section as having no natural teeth or tooth fragments. During an interview on 6/9/11 at 10:00 a.m. with S10MDS nurse, she confirmed that on the MDS 3.0 dated 2/22/11 Oral/Dental Status, that the resident was coded as having no natural teeth or tooth fragments. She also confirmed that this information was incorrect. During an interview on 6/10/11 at 10:10 a.m. with S10MDS nurse, she again confirmed that the annual MDS 3.0 dated 2/22/2011 was coded wrong for Oral/Dental. She also stated she had assessed resident #5 ' s mouth and noted that she had broken teeth. During an interview on 6/9/11 at 10:15 a.m. with S2DON she confirmed that the dental evaluation dated 5/3/10 noted that resident #5 had been having mouth pain. She also stated S6SSD would be responsible for getting residents dental services. During an interview on 6/8/11 at 12:11 p.m. with S7SSD, she stated she was working with S6 Accounts Manager to find funds to get dental services for resident #5. She continued to say that resident #5 was scheduled to see the dentist who comes to the facility on his next visit which was either the 13th or the 20th of June. S7SSD stated she became aware of resident #5's tooth pain just last week when she was told by S6 Accounts Manager. She further stated she did not have any documentation showing what she had done to get resident #5 dental services. When asked if she keeps an appointment book, log or computer record of residents regarding dental services she stated she did not. She stated she usually put the name of resident who needed to be seen by the dentist on her desk calendar. Review of the calendar at that time revealed resident #5 ' s name did not appear on it. S7SSD confirmed that resident #5 was not on her calendar for dental services. During an interview on 6/9/11 at 11:00 a.m. with S7SSD, she confirmed that the dental assessment dated [DATE] by the dentist showed resident #5 had tooth pain. She also confirmed that she was unaware of the tooth pain until S6 Accounts Manager told her about it at the beginning of last week. S7SSD stated she had not made any dental arrangements for the resident. An interview on 6/10/11 at 9:45 a.m. with S7SSD, she stated she has never received any orders for a dental referral for resident #5. She stated that if an order was received for dental services, a copy would be made and given to her. She said she did not recall getting anything for resident #5 concerning her teeth. She was unaware of the former SSD ' s process for handling referrals for dentist but her process was to put the referrals on a calendar on her desk. She stated she started as SSD in September of 2010. She confirmed that there was an order for [REDACTED]. She further stated that the nursing staff would be the one to notify her of orders for dental services. During an interview on 6/10/11 at 9:12 a.m. with S26ST, she stated she evaluated the resident " a couple of weeks ago " to determine if she had swallowing problems. She stated she did the evaluation because she became aware that resident #5 had changed her diet from a mechanical soft diet to a mechanical soft diet with pureed meats. She further stated that the resident did not have swallowing difficulties but rather chewing problems and speech therapy was not needed. She stated she found out about resident #5 ' s change in diet from the 24 hour nursing staff report. She further stated that she was told by the resident that she needed to change her Mechanical Soft to a Mechanical Soft with pureed meat diet because she had chewing difficulties. S26ST then stated she was aware that the resident had dental caries at that time because she was informed by the nurse on duty. During an interview on 6/10/11 at 10:00 a.m. with S14LPN, she stated she had written a request for a mechanical soft diet in the nursing 24 hour report book because resident #5 had requested this diet due to chewing problems. She also stated she was not aware of the physician's orders [REDACTED]. When asked if she had assessed the resident's complaints of chewing, she became silent and did not respond. During an interview on 6/10/11 at 10:18 a.m. with S2DON she confirmed that orders were written on 4/27/10, 7/20/10 and 11/30/10 for resident #5 for dental referrals. She was also made aware that the resident was on a regular diet when she was admitted to the facility and was made aware that at the residents request that the diet was changed from a chopped meat diet, to a mechanical soft and as recent as May 2011 to a pureed meat diet. She stated she was not here at that time but confirmed that this was a problem and the resident did not receive an outside dental referral. She also stated she has no documentation that S7SSD had involved the family to pay for outside dental services and any other interventions utilized to assist resident #5 in receiving dental care. The facility failed to provide dental services for a resident with broken teeth, mouth pain and difficulty chewing after Physician order [REDACTED]. This resulted in the residents having continued mouth pain which required a change in her diet from Chopped Meat to Mechanical Soft with pureed meats. Resident #127: Resident #127 [DIAGNOSES REDACTED]. According to his last MDS dated [DATE], revealed he was non verbal, had severally impaired cognitive skills and required total dependent for all his activities of daily living. Review of a nurses note dated 05/30/11 revealed the resident was transferred to the hospital because of a elevated heart rate of 160 and diminished breath sounds. Review of the Hospital emergency room records revealed his [DIAGNOSES REDACTED]. Review of the resident's Plan of Care dated 12/04/11 through 07/08/11, Potential for Injury, revealed approaches as siderails up X 2, with Bolster pads when in bed, R/T Spastic involuntary movement secondary to [MEDICAL CONDITION], Tilt Wheelchair(W/C) when out of bed, Posture Straps when in W/C, seat belt when in wheelchair and assist resident to comfortable position in chair that prevents rising. An observation was made of Resident #127 on 6/6/11 at 10:30 a.m. The resident was lying in his bed with the head of the bed elevated at a 45 degree angle. Both side rails were elevated, with a thick plastic pad covering the side rail against wall. On the siderail open to the room, the plastic pad was half way off the bed, hanging on the floor. The resident was lying crooked across the bed, his head in the bend of the bed, with all of his arm sticking through the side rail. During another observation of Resident #127 on 06/6/11 at 1:25 p.m., the resident was observed sitting up in a positional wheelchair next to the nurses station. He did not have positional shoulder straps or seat belts on at the time. The resident was slumped down in the chair with his head crooked to the left side and his right shoulder against the right side of the wheelchair. His right arm was extending out over the side of the wheelchair. His wheelchair was positioned in the walk way between two hallways, with visitors and staff passing in close proximity. On 06/06/ at 1 p.m. an interview with S28LPN was conducted. She stated Resident #127 required padded side rails because he moved around in bed a lot. An interview was conducted with S25CNA on 06/07/11 at 1:30 p.m. She stated that they always used positioning straps and a waist seat belt on Resident #127 when he was up in his wheelchair. This was to prevent him from slipping. An interview was conducted with S2DON on 6/8/11 at 10:45 a.m. She stated he required padded siderails when he was in bed and required positioning straps at all times when he was in the wheelchair because he thrashed around so much. Resident #34: Review of the Diagnosis/History list for resident #34 dated 10/19/2010 revealed in part the following Diagnosis: [REDACTED]. During an interview on 6/8/11 at 7:51 a.m. with resident #34 in the dining room, she was asked how she was doing. She stated that she had called several times last night for help because she was in so much pain and no one came. She then stated that someone finally came in the early morning. She also stated this happens quite frequently. She further stated that she saw the doctor the day before and told him about being in so much pain and that he changed her pain medication to four times a day instead of three times a day. During an interview on 6/8/11 at 9:57 a.m. with resident #34 in her room, she stated she had spoken with her doctor yesterday and requested pain medication at night to relieve her back pain. She stated she called for pain medication, by using her call button, at about 1 a.m. and then again at about 3 a.m. on 6/8/11. She stated the "girl never got it for me. She came in, turned everything off and took off." She stated she did not get medication for her pain until the LPN gave it to her in the morning with the rest of her medications. During an interview on 6/9/11 at 9:30 a.m. with resident #34 she stated that on 6/8/11 after midnight, she had requested pain medicine several times and was not given any. She also stated the pain was in her back and kept her awake "all night. It just tore me up " . Review of the physician's orders [REDACTED]. Review of the New physician's orders [REDACTED]. During an interview on 6/8/11 at 10:25 a.m. with S14LPN, she stated that she was made aware by resident #34 that she had requested pain medication during the night and did not receive it. S14LPN confirmed that there was an order dated 6/7/11 for pain medicine [MEDICATION NAME] 5-325 mg tablet one tablet after midnight as needed for pain. She further confirmed that there was no documentation of resident #34 receiving pain medication, other than her routine doses, until she administered it on 6/8/11 at the scheduled time of 8 a.m. During an interview on 6/9/11 at 11:20 a.m. with S2DON, she stated she was aware that resident #34 had complained that she had not received her pain medication on 6/8/11. She stated she did not have any information nor had she investigated the incident. She further stated that S3ADON might have information regarding the incident. During an interview on 6/9/11 at 11:22 a.m. with S3ADON, she stated she had no written investigation regarding the incident. She stated she spoke with the LPN who was on duty the night of the incident and had also spoken with resident #34. She also stated she believed the resident was confused. Record review of the MDS 3.0 dated 5/27/11 was coded under section C Cognitive Patterns, with a BIMS (Brief Interview for Mental Status) score of 12 (cognitively intact). Resident #74: Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/23/11 resident #74 had an left ankle Sydesmotic Open reduction and Internal Fixation. On 02/28/11, according to MD orders, resident #74 was placed [MEDICATION NAME] 6 mg one tablet by mouth daily and daily PTT/INRs. Review of resident #74's clinical records and MD orders the following was revealed; 02/28/11 MD order stated daily INR. 03/01/11 PTT- 23.1 (H) INR- 2.21 (done by the facility) 03/02/11 PTT- 19.5 (H) INR- 1.76 (done by the facility) 03/03/11- no documentation of labs done . 03/04/11- no documentation of labs done. 03/05/11- no documentation of labs done. 03/06/11- no documentation of labs done. 03/07/11- no documentation of labs done. 03/08/11-INR- 2.3 (done by the Nurse Practitioner). 03/09/11- no documentation of labs done. 03/10/11- no documentation of labs done. 03/11/11- no documentation of labs done. 03/12/11- no documentation of labs done. 03/13/11- no documentation of labs done. 03/14/11- no documentation of labs done. 03/15/11- no documentation of labs done. 03/16/11- no documentation of labs done. 03/17/11- no documentation of labs done. 03/18/11- no documentation of labs done. 03/19/11- no documentation of labs done. 03/20/11- no documentation of labs done. 03/21/11- no documentation of labs done. 03/22/11- no documentation of labs done. 03/23/11- no documentation of labs done. 03/24/11 PTT- 34.5 INR-3.78 stated continue to hold [MEDICATION NAME]. Daily INR 03/24/11 MD order stated to d/c daily PT/INR-repeat INR on 04/05/11 An interview was held with S27WardClerk on 06/08/11 at 3:40 p.m. She said that the nurses took off the MD orders on the chart. She said that if there was an order for [REDACTED]. S27Ward Clerk said that she had checked the lab book and there was no documentation for no daily PTT/INR to be done for Resident #74. An interview was done with S2DON on 06/09/11 at 8:45 a.m. She said that the protocol for residents having labs drawn was for the nurse who took the MD order off to write the lab ordered in the lab book so it could be drawn. Another interview was held with S2DON on 06/09/11 at 11:45 a.m. She confirmed that the PTT/INRs' were not done according to the MD orders and resident #74's labs were not monitored as they should have been. An interview was held with the facility's Nurse Practitioner on 06/09/11 at 11:25 a.m. She said that she did not know why there were so many discrepancies with the PTT/INT lab work being done work. She also said that she could not go back and do anything about the missing lab work.

Based on observation, record review and interview, the facility failed to provide routine dental services from an outside source for 1 (#5) of 2 (#5, #122) residents with dental problems out of 24 ((#117, #95, #79, #70, #52, #91, #84, #116, #126, #121, #69, #14, #86, #128, #124, #58, #1, #74, #63, #125, #5, #85, #34) interviewable residents. The facility failed to ensure: 1. an order dated 4/27/10 for a referral to a dentist was followed (#5); 2. the resident was referred to a dentist after the facility dentist, on 5/3/10, examined the resident and found: resident stated she has been having pain in area of root tip #5; numerous areas of decay; nothing I can do for patient here at nursing home. 3. an order dated 7/20/10 to refer resident #5 to "LSU School of Dentistry for evaluation and extractions if necessary" was followed (#5); 4. a 11/30/10 order for a dental referral for painful teeth and gums was followed (#5); 5. the SSD obtained dental services for the resident (#5). The resident continues to experience recurring mouth and tooth pain which beginning approximately May 2010 and has had to change her diet from chopped meat to a mechanical soft diet with pureed meats due to her broken teeth, mouth pain, and difficulty chewing. Findings: During an interview on 6/6/2011 at 10:47 a. m. with resident #5 she stated she had tooth/mouth pain due to broken teeth. She also stated she had chewing problems because of these broken teeth. She further stated she had talked to someone at the Governor's office about 3 months ago to try to get dental care. On 6/9/11 at 10:15 a.m. an interview with resident #5, revealed she has had mouth pain for "some time." She also stated "I told the nurse." The resident reported she had notified S6 Accounts Manager that she had mouth/tooth pain. . During an interview on 6/9/11 at 3:00 p.m. with resident #5, she stated she has quit complaining of tooth pain because she has had it so long. Another interview on 6/10/11 at 8:45 a.m. with resident #5, revealed she continued to have mouth pain. An observation on 6/6/2011 at 10:50 a.m. revealed resident #5, had a tooth broken off at the level of the gum on the top right side of her mouth and a tooth broken off at the level of the gum on the bottom left side of her mouth. An observation on 6/8/11 at 12:00 p.m. revealed resident #5 was having her meal in her room. Her plate was noted to have 3 of the 4 items remaining uneaten. The items remaining on her plate were pureed beans, a piece of cornbread, and cooked cabbage. A piece of cake was also noted in a cup on the side of her plate uneaten. An interview was conducted with resident #5 at that time. She stated during that interview, that she only ate her creamed potatoes and drank her milk. She also stated she had trouble eating because the right side of her mouth was sore where a tooth was broken. She continued to say that she wished she had dentures and would like to have her broken teeth removed so she would not have pain. Review of the periodic oral exam of resident that was done by the facility dentist on 5/3/10 revealed the following: "Periodic exam. Exam in room. Patient is not wearing partials at time of exam. Poor oral hygiene. Patient stated she has been having pain in area of root tip #5. Numerous areas of decay. No swelling clinically. Nothing I can do for pt (patient) here at NH (nursing home)...." A Review of the Physicians Orders for resident #5 revealed the following: 1. An order dated 4/27/10 for a referral to a dentist 2. An order dated 7/20/10 to refer resident #5 to "LSU School of Dentistry for evaluation and extractions if necessary". 3. An order dated on 11/30/10 for a dental referral for painful teeth and gums. A review of the dietary Departmental Notes dated 4/22/2010 reveals that resident #5 requested that she receive a chopped meat diet and the request was honored. A review of the physician progress notes [REDACTED]. States she can only use two teeth to chew now." A review of the physician's order [REDACTED]. A physician's order [REDACTED].#5. Review of the MDS 2.0 quarterly review assessments dated 9/16/2010 and 7/1/2010 revealed the resident was coded as having chewing problems. Review of the MDS 3.0 dated 2/22/2011, revealed the resident was coded under the Oral/Dental Status section as having no natural teeth or tooth fragments. During an interview on 6/9/11 at 10:00 a.m. with S10MDS nurse, she confirmed that on the MDS 3.0 dated 2/22/11 Oral/Dental Status, that the resident was coded as having no natural teeth or tooth fragments. She also confirmed that this information was incorrect. During an interview on 6/10/11 at 10:10 a.m. with S10MDS nurse, she again confirmed that the annual MDS 3.0 dated 2/22/2011 was coded wrong for Oral/Dental. She also stated she had assessed resident #5 ' s mouth and noted that she had broken teeth. During an interview on 6/9/11 at 10:15 a.m. with S2DON she confirmed that the dental evaluation dated 5/3/10 noted that resident #5 had been having mouth pain. She also stated S6SSD would be responsible for getting residents dental services. During an interview on 6/8/11 at 12:11 p.m. with S7SSD, she stated she was working with S6 Accounts Manager to find funds to get dental services for resident #5. She continued to say that resident #5 was scheduled to see the dentist who comes to the facility on his next visit which was either the 13th or the 20th of June. S7SSD stated she became aware of resident #5's tooth pain just last week when she was told by S6 Accounts Manager. She further stated she did not have any documentation showing what she had done to get resident #5 dental services. When asked if she keeps an appointment book, log or computer record of residents regarding dental services she stated she did not. She stated she usually put the name of resident who needed to be seen by the dentist on her desk calendar. Review of the calendar at that time revealed resident #5 ' s name did not appear on it. S7SSD confirmed that resident #5 was not on her calendar for dental services. During an interview on 6/9/11 at 11:00 a.m. with S7SSD, she confirmed that the dental assessment dated [DATE] by the dentist showed resident #5 had tooth pain. She also confirmed that she was unaware of the tooth pain until S6 Accounts Manager told her about it at the beginning of last week. S7SSD stated she had not made any dental arrangements for the resident. An interview on 6/10/11 at 9:45 a.m. with S7SSD, she stated she has never received any orders for a dental referral for resident #5. She stated that if an order was received for dental services, a copy would be made and given to her. She said she did not recall getting anything for resident #5 concerning her teeth. She was unaware of the former SSD ' s process for handling referrals for dentist but her process was to put the referrals on a calendar on her desk. She stated she started as SSD in September of 2010. She confirmed that there was an order for [REDACTED]. She further stated that the nursing staff would be the one to notify her of orders for dental services. During an interview on 6/10/11 at 9:12 a.m. with S26ST, she stated she evaluated the resident " a couple of weeks ago " to determine if she had swallowing problems. She stated she did the evaluation because she became aware that resident #5 had changed her diet from a mechanical soft diet to a mechanical soft diet with pureed meats. She further stated that the resident did not have swallowing difficulties but rather chewing problems and speech therapy was not needed. She stated she found out about resident #5 ' s change in diet from the 24 hour nursing staff report. She further stated that she was told by the resident that she needed to change her Mechanical Soft to a Mechanical Soft with pureed meat diet because she had chewing difficulties. S26ST then stated she was aware that the resident had dental caries at that time because she was informed by the nurse on duty. During an interview on 6/10/11 at 10:00 a.m. with S14LPN, she stated she had written a request for a mechanical soft diet in the nursing 24 hour report book because resident #5 had requested this diet due to chewing problems. She also stated she was not aware of the physician's orders [REDACTED]. When asked if she had assessed the resident's complaints of chewing, she became silent and did not respond. During an interview on 6/10/11 at 10:18 a.m. with S2DON she confirmed that orders were written on 4/27/10, 7/20/10 and 11/30/10 for resident #5 for dental referrals. She was also made aware that the resident was on a regular diet when she was admitted to the facility and was made aware that at the residents request that the diet was changed from a chopped meat diet, to a mechanical soft and as recent as May 2011 to a pureed meat diet. She stated she was not here at that time but confirmed that this was a problem and the resident did not receive an outside dental referral. She also stated she has no documentation that S7SSD had involved the family to pay for outside dental services and any other interventions utilized to assist resident #5 in receiving dental care. The facility failed to provide dental services for a resident with broken teeth, mouth pain and difficulty chewing after Physician order [REDACTED]. This resulted in the residents having continued mouth pain which required a change in her diet from Chopped Meat to Mechanical Soft with pureed meats.