Every finding on record at Glenwood Healthcare Center

Based on resident interview, staff interview, record review and observation, the facility failed to ensure an environment that was free from accident hazards over which the facility has control. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #1, #7, #64, #72, #79 and #42. Facility Census: 90. Findings included: a) Resident #42 On 06/16/2026 at 9:50 am, Resident #42 was observed in bed with fall mat propped up against the opposite wall of her room. At 10:03 AM during an interview with Licensed Practical Nurse (LPN) #62, entered the room and was asked about the fall mat. She stated she did not think it was permitted to be in use with the table. She moved the resident's bed to the lowest position and left the room to get her some medication. When she returned she stated she had asked her superior and was wrong, then proceeded to put the resident's fall mat to the right side of her bed. Review of Resident #42's care plan page 1 and 2 revealed the following: Focus The resident has had multiple falls related to poor cognition, poor, safety awareness. Date initiated 11/09/23, Revision on 04/07/25 Interventions/Tasks (include but are not limited to) Bed in low position (initiated 07/16/26, revision 05/15/26) Devices: include fall mat to right side of the bed (initiated 11/21/24, revision 05/15/26) Review of Resident's physician orders reveal the following: Devices: Broda chair, cushion to Broda chair, Dycem to Broda chair, perimeter mattress, fall mat to right side of bed, raised toilet seat, hipsters as resident will allow, palm posey as resident will allow. Order Date 05/015/26 b) Resident #1 On 06/15/26, Resident #1 reported the facility had removed the screws from the window so his windows could go all the way up. The screws were observed laying on the window sill. The resident's second story room had two, large windows overlooking the lake. The resident reported he liked the windows open to keep his room cool. A potential accident hazard of a resident trying to leave the facility via the window or fall out of the window was identified. Nursing staff reported to another surveyor there were three (3) 'wanderers' on that hallway. Resident #1 has capacity and a Brief Interview for Mental Status (BIMS) score of fifteen (15). On 06/15/26 at 5:15 PM, the open windows were confirmed by the Administrator and Interim Director of Nursing, The Interim Director of Nursing stated, We will get them nailed. the Administrator reported that they were coming now to fix it. On 06/16/26 at 3:06 PM, Licensed Practical Nurse #121 reported the fallowing residents were elopement risks and wanderers on Resident #1's hallway to a surveyor team member: Resident #7, incapacitated, BIMS score: 00. Resident #64, incapacitated, BIMs score: 4. Resident #72, incapacitated, BIMS score: 3. Resident # 79, incapacitated, BIMS score: 6.

Based on observation and staff interview the facility failed to ensure proper handwashing and glove use was being utilized during meal service. This was found during the annual survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 91. Findings include:a) Review of policy for Food preparationPolicy statement- All foods are prepared in accordance with the FDA Food CodeProcedures reads in part:All staff will practice proper handwashing techniques and glove use.Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contaminationReview of policy for Meal DistributionPolicy Statement: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner.Procedures read in part:Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining.On 06/16/2026 at around 11:30 AM, during tray line observation of the first (10) of (10) meals prepared and served, the cook with gloved hands placed lettuce, tomato, cheese and the pickle onto the plate. She did not wash her hands, change gloves or use utensils to prevent cross-contamination. After the 10th plate, District Manager (#8) verified the cook was not using utensils to prevent cross-contamination, stopped the tray line and instructed the cook to change gloves, wash hands and obtain utensils to use to prevent cross-contamination. Staff interview with cook (#92) confirmed she did not use tongs or other utensils during meal plating, reporting, I didn't think about using tongs since I have gloves on.

Based on record review, staff interview and observation, the facility failed to ensure residents' dignity and respect were maintained during meal service in the dining room. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #88 and #77. Facility Census: 90. Findings included: a) Resident #88 On 06/15/26 at 12:20 PM, during observation of the dining room, Resident #88 was observed at a table with a visitor eating his lunch meal. The resident's catheter bag was hanging from the bottom of his wheelchair uncovered. At 12:10, Nurse Aide #119 confirmed the catheter was not covered and stated, Yes ma'am. The facility's policy and procedure for Catheter Drainage Bag and Tube Maintenance stated, g. Drainage bags will be covered when the resident is out of the room for dignity and infection prevention. b) Resident #77 On 06/15/26 at 12:20 PM, during observation of the dining room, Resident #77 was observed being assisted by Activities Leader #78 with her meal. The resident's plate of food and drinks were left on the serving tray and the lid from her meal was on the table beside the resident's food with trash from the tray in it. Activities Leader #78 confirmed the resident's food and drink were not removed form the service tray and stated, Oh.

Based on record review and staff interview, the facility failed to ensure care plans were reviewed and revised for three (3) residents. The issues included resident's a resident receiving a thirty (30) day notice of discharge, a resident's dialysis weight being documented in the medical record and a resident receiving tube feedings. Resident identifiers: #2, #8 and #59. Facility Census: 90. Findings included: a) Resident #59 An interview with the resident on 06/15/26 at 3:37 PM revealed Resident #59 had capacity to make her own medical decisions and reported that she would like to discuss the possibility of a discharge home. Resident #59 reported she had never attended a care plan meeting and stated that she was unsure as to what it was of if she had been invited. Review of the resident's records showed a copy of an invitation to a care plan meeting dated 05/13/26 in the chart. There is no evidence in the chart that a care plan meeting was held that day. Interview with Social Worker #12 on 06/17/26 at approximately 11:30 AM revealed there was no note written on the day of the care plan and only a signature page with three (3) staff signatures. No explanation was included regarding whether the resident attended or did not attend nor the reason why. Findings included: b) Resident #2 On 06/16/2026 at 9:10 AM, during the initial interview, the resident reported she wanted to go home or to another nursing facility. The resident stated, I want out people. and reported no other nursing facility would take her. Resident #2's care plan was reviewed. The resident's care plan stated, Resident wishes to be discharged to the community when able, Resident will verbalize/communicate an understanding of the discharge plan, Resident will be discharged to appropriate location based upon physical/cognitive status, Discuss feelings and concerns of resident, and resident representative, with impending discharge, and Establish a pre-discharge plan. Evaluate progress and revise plan as needed. Referral to Take me Home program (TMH) per Resident's request: Resident declines the assistance Referrals made to other SNF's per Resident's request: needs could not be met. Referral made to Communicare behavioral SNF with Resident's agreement. The resident's care plan also stated, Behavioral agreement completed with Resident. Resident provided 30 day discharge due to continued behaviors. Date Initiated: 03/31/2026. 06/17/26 at 11:05 AM, Social Worker #32 reported that there had been multiple attempts to discharge the resident to another facility upon the resident and family's request. Social Worker #32 reported the resident was not discharged because the resident won her appeal to stay in the facility. Social Worker #32 stated the care plan just wasn't updated apparently. and I took it out. On 06/17/26 at 12:45 PM, the Administrator confirmed the resident's care plan and stated, It was over 30 days. On 06/17/26, the resident's care plan was reviewed for nutrition. The resident's care plan stated, Obtain weight per practitioner order. Use facility weights not dialysis dry weights. Date Initiated: 04/30/2026. The resident's physician's order stated, May obtain weights and labs from dialysis center. All weights documented in the medical record from 02/20/26 were all dry dialysis weights. Dialysis dry weights were documented after care plan date of 04/20/26 on 06/08/26, 05/26/26, 05/11/26, and 05/04/26. On 06/17/26 at 12:35 PM, Resident #2's care plan was reviewed and confirmed with the Interim Director of Nursing. The Interim Director of Nursing reported the process is to use dialysis weight, but the resident refuses. On 06/17/26 at 12:45 PM, the Administrator confirmed the resident's care plan and weights. c) Resident #8 On 06/16/26, during the initial interview process, Resident #8 reported she was no longer receiving tube feedings and she was not on a puree diet. The resident's physician order was for a regular diet with regular liquids and a med pass product (2 Calorie) six (6) times a day. Medication is given via a percutaneous endoscopic gastrostomy tube. The resident received water via enteral tube. The resident's care plan stated, Administer tube feeding and water flushes as ordered.TF: Osmolite 1.5 237ml QID to provide 948ml total volume, 1420kcal; 75ml water flush before and after each feeding QID for a total of 1320ml. On 06/17/2026 at 3:23 PM, the care plan and orders were reviewed with the Administrator and confirmed.

Based on record review, staff interview, resident interview and observation, the facility failed to ensure a resident was able to utilize adaptive equipment for safe fluid intake appropriately. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #51. Facility Census: 90.Findings included:a) Resident #51 On 06/15/26 at 12:25 PM, during the dining room observation, Resident #51 had a two-handled cup with a lid and could not get his thickened drink to come out. The hole in the adaptive cup was located on the top side of the cup instead of the bottom. The hole in the cup was not positioned where the resident could get a drink. The resident attempted several times to get a drink. Nurse Aide #119 confirmed the resident was unable to get a drink and turned the cup around so the resident could get a drink following state surveyor intervention. On 06/16/26 at 12:10 PM, Resident #51 was observed in the dining room attempting to get a drink. When the state surveyor asked the resident what was wrong, Resident #51 answered, Can't drink. The resident was attempting to drink from the side of the cup where the hole was located beside the handle and trying to move the lid when he could not get a drink. Nurse Aide in Training #117 confirmed the resident could not get a drink and stated, I'll help you, (resident's name). The resident was able to get a drink from the adaptive cup following state surveyor intervention. On 06/16/26 at 12:30 PM, Interim Director of nursing confirmed the cup and lid and reported staff education for the adaptive cup would be initiated. On 06/16/26 at 3:40 PM, the Speech-Language Pathologist reported the cup was intended to decrease bolus size because the resident takes large drinks. The resident's order stated, Two-handled cup for all meals. The resident's tray card stated, Two Handled Cup with CONCAVE LID.

Based on document review and staff interview, the facility failed to notify the Ombudsman of a Resident's discharge from the facility and return to home. This was true for Resident #97. Resident identifier: #97. Facility Census: 90. Findings included: Findings inclueded: a) Resident #97 Resident #97 was discharged to home on [DATE]. On 06/16/26 a review of resident's medical chart showed no documentation of notification of discharge to Ombudsman for Resident #97. b) During an interview with the facility Administrator on 06/17/26 at 12:51 PM, she acknowledged that the social worker did not complete a notification to the ombudsman for the resident at that time. She stated the social worker was unaware the ombudsman needed to be notified and that they subsequently received in-service training.

Based on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was updated for a resident with a new diagnosis of dementia after admission to the facility. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #8. Facility Census: 90.Findings included: a) Resident #8 On 06/15/26, during Resident #8's initial record review, the Preadmission Screening and Resident Review (PASRR) was reviewed. The resident's admission date to the facility was 10/11/25. The resident's primary diagnosis listed in the medical chart was Sjogren syndrome, Unspecified. A diagnosis of Dementia in other Diseases Classified Elsewhere, Unspecified Severity, With Other Behavioral Disturbance was added to the medical record on 10/24/25. Dementia was not marked on the resident's most recent PASRR dated 10/28/25. On 06/16/26 at 2:15 PM, the Interim Director of Nursing reviewed the PASRR and confirmed dementia was not indicated on the PASRR and stated that she would check for an updated PASRR. No additional information was given to the state surveyor.

Based on record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was accurately completed on admission to the facility for a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD). Resident Identifier: #8. Facility Census: 90. Findings included: a) Resident #8 a) On 06/15/2026, during Resident #8's initial record review, the Preadmission Screening and Resident Review (PASRR) was reviewed. The resident's admission date to the facility was 10/11/25. The resident's medical record documented a diagnosis of Post-Traumatic Stress Disorder (PTSD) on 10/11/25. b) PTSD was not marked on the resident's most recent PASRR dated 10/28/25. On 06/16/26 at 2:15 PM, the Interim Director of Nursing reviewed the PASRR and confirmed PTSD was not indicated on the PASRR and stated that she would see if there was an updated PASRR. No additional information was given to the state surveyor.

Based on observation, record review, and staff interview, the facility failed to ensure a safe, clean, comfortable, home-like environment. Packaged terminal air conditioner (PTAC) units contained dirt and debris. These were random opportunities for discovery. Resident identifiers: #1, #57, #23. Facility census: 80. Findings included: a) PTAC units On 02/10/25 at 11:44 PM, the packaged terminal air conditioner (PTAC) unit in Resident #57's room was observed to have debris, including an adhesive bandage, in it. On 02/10/25 at 12:04 PM, the PTAC unit in Resident #23's room was observed to have debris in it. On 02/10/25 at 12:07 PM, the PTAC unit in Resident #1's room was observed to have dirt in it. On 02/11/25 at 10:35 AM, the Housekeeping Manager and Regional Manager confirmed the dirt and debris in the PTAC units for Residents #57, #23, and #1. They stated PTAC units are cleaned by the Maintenance Department. On 02/11/25 at 10:50 AM, the Maintenance Director stated the PTAC units are cleaned every three (3) months. He confirmed the dirt and debris in the PTAC units for Residents #57, #23, and #1 and stated the units would be cleaned. The Maintenance Director was asked when these units were last cleaned. He provided paperwork documenting the units had been cleaned on 12/10/24.

Based on observation, record review and staff interview, the facility failed to provide appropriate care and services regarding indwelling catheter care. This was a random opportunity for discovery. Resident identifier: #23. Facility census: 80. Findings included: a) Resident #23 The facility's policy titled Catheter Care, with approval date 03/01/24, gave instructions to check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder. On 02/10/25 at 11:56 AM, Resident #23 was observed lying in bed with his bed in the lowest position. The resident's indwelling catheter urine collection bag was lying on the floor. There was a plastic basin under the resident's bed, but the indwelling catheter urine collection bag was not in the basin. The indwelling catheter urine collection bag was identified on the bag as a Sterigear Fig Leaf lite brand. This brand had a cover attached to the front of the bag to protect the resident's dignity by preventing the urine in the bag from being viewed by others. During a second observation on 02/10/25 at 4:10 PM, Resident #23's indwelling catheter urine collection bag continued to be lying on the floor. This was confirmed by Registered Nurse (RN) #3. During an interview on 02/11/25 at 2:29 PM, the Administrator stated she believed the dignity cover attached to the front of the urine collection bag was folded under the collection bag, which prevented the collection bag from lying on the floor. The Administrator was informed that the dignity cover was not folded under the collection bag when observed by the surveyors. The Administrator confirmed the facility's policy did not give instructions to fold the dignity cover under the collection bag. Review of the Fig Leaf lite collection bag product fact sheet provided by the facility stated the built-in, attached cover was to hide fluid from view to restore patient dignity and improve the environment for caregivers and visitors. The product fact sheet gave no information regarding use of the attached cover as an infection control measure. During an interview on 02/12/25 at 2:19 PM, the Infection Preventionist (IP) stated plastic basins are kept under urine collection bags in case the bags fall off the bed.

Based on record review and staff Interview, the facility failed to revise the care plan for Resident #49 in the area of weight management. Resident identifier: #49. Facility census: 80. Findings included: a) Resident #49 Multiple care areas in the care plan had interventions that included weight management and monitoring 02/12/25 9:20 PM, the Director of Nursing (DON) confirmed Resident #49 had an order for no weights in February. The DON confirmed there was no documented weight for January and there were multiple areas in the care plan for weights to be obtained and monitored. The DON stated, Just about every care plan. The DON reported the patient had multiple refusals for weights to be obtained and had requested no weights.

Based on record review and staff interviews, the facility failed to ensure medical records were maintained accurately for two (2) of 27 residents. The facility did not obtain clarification for duplicate orders for bilateral posy palm protectors for Resident #30. Resident #12 had an incorrect order regarding PO (by mouth) medications. Resident identifiers: #12 and #30. Facility census: 80. Findings include: a) Resident #12 During record review on 01/11/25 at approximately 10:00 AM Resident has an order stating NPO(nothing by mouth). Further record review revealed an order placed on 02/08/25 for Amoxicillin-Pot Clavulanate Tablet 875-125 MG Give one (1) tablet by mouth two times a day for bacterial infection for five (5) days Pneumonia -start date-02/08/2025 2100 Further record review of the Medication Administration Record (MAR) revealed the medication was given on 02/08/25 PM and on 02/09/25 AM and PM and on 02/10/25 AM. Review of the MAR gave the indication that the medication was given by mouth. During an interview, on 02/11/25 at 10:30 AM with Registered Nurse (RN) # 71, the RN stated the order was not reviewed by clinical team and assured the medication was not given by mouth. 02/11/25 10:40 AM during an interview with Registered Nurse (RN) #3 the RN stated she gave the medicine crushed via peg tube. The RN said, She takes nothing by mouth, I give all meds via peg tube. 51553 b) Resident #30 On 02/10/25 3:50 PM, a palm protector for the left hand was observed on Resident #30. No palm protector for the right hand was observed. Bilateral palm posey/protectors were ordered for Resident #30. The orders stated, Patient to have palm posey/protector daily to prevent skin breakdown on bilateral hands 2-4 hours. and Bilateral upper extremity palm guards for 6-8 hours daily. Two observations by the State Surveyor for no right palm protector occurred on 02/10/25 and 02/11/25. On 02/11/25 10:45 AM, duplicate orders for bilateral posey palm protectors wearing schedule with different times for Resident #30 were confirmed by Licensed Practical Nurse ( LPN) #39. LPN #39 was unable to state palm protector wearing schedule when asked by the State Surveyor. LPN #39 stated, I'm not sure .I would have to look at the order.

Based on observations and staff interview, the facility failed to appropriately dispose of a soiled brief for #46. This was a random opportunity for discovery during the Long - Term Care Survey process. Facility Census: 80 Resident identifier: #46 Findings included: a) Resident #46 02/10/25 11:32 AM the surveyor observed Resident #46 being provided ADL care by Nurse Aide (NA) #75 behind the curtain. The surveyor waited outside the doorway and noticed a soiled brief was placed on the fall mat on the left side of the bed by NA #75. The fall mat was lying on the floor. 02/10/25 11:36 AM Unit manager Registered Nurse (RN) # 71 was coming down the hall by the surveyor. The surveyor asked about the brief and now soiled linens that were observed placed on the fall mat by NA# 75. RN# 71 went into the room and saw the soiled brief and soiled wash cloths were on the fall mat. RN #71 came back to the door to this surveyor and stated They(NA's) should not be placing any soiled items on the bare floor. 02/10/25 11:41 AM this surveyor observed NA #75 place soiled items in a trash bag and clean floor mat.

Based on Record Review, Staff Interview and Observation, the facility failed to provide posey palm protectors bilaterally as ordered for Resident #30 to prevent further avoidable reduction of range of motion (ROM). Resident identifier: #30. Facility census: 80. Findings included: a) Resident #30 Medical record review revealed bilateral palm posey/protectors were ordered for Resident #30. Two (2) observations for no right palm protector for Resident #30 were completed on 02/10/25 and 02/11/25. On 02/11/25 10:45 AM, no right palm protector was observed on Resident #30. On 02/11/25 10:45 AM, Licensed Practical Nurse ( LPN) #39 confirmed no palm protector on the right hand for Resident #30. LPN #39 stated, I'm not sure about it. I will have to find it. LPN reported later that staff found the palm protector in laundry and an order for the resident to wear the palm protectors for 6-8 hours was confirmed.

Based on observation, record review, and staff interview, the facility failed to ensure oxygen therapy services were administered in accordance with professional standards of treatment. Resident #42 and Resident #73's oxygen flow rates were not set at the physician prescribed rates. In addition, Resident #42's oxygen concentrator was not functioning properly. These were random opportunities for discovery. Resident I=identifiers: #42 and #73. Facility census: 80. Findings included: a) Resident #42 On 02/10/25 at 12:12 PM, Resident #42 was observed to be wearing oxygen by nasal cannula at a flow rate of 1.5 liters per minute (LPM). Review of Resident #42's physician's orders showed an order written on 05/25/23 for Oxygen 2 LPM via nasal cannula continuously every shift for shortness of breath. On 02/11/25 at 9:00 AM, Resident #42 was again observed to be wearing oxygen by nasal cannula at a flow rate of 1.5 LPM. On 02/11/25 at 10:45 AM, Registered Nurse (RN) #47 confirmed Resident #42's oxygen was set to 1.5 LPM and should have been set to 2 LPM. RN #47 attempted to increase the resident's oxygen to 2 LPM but the oxygen concentrator was not working properly and would not stay at 2 LPM. RN #47 stated she would obtain a new oxygen concentrator for the resident. b) Resident #73 On 02/10/25 at 11:19 AM, Resident #73 was observed to be wearing oxygen by nasal cannula at a flow rate of 2 liters per minute (LPM). Review of Resident #73's physician's orders showed an order written on 10/15/24 for O2 [oxygen] at 4L via NC [nasal cannula] continuous for SOB [shortness of breath] or s/s [signs and symptoms] of hypoxia. On 02/11/25 at 9:16 AM, Resident #73 was again observed to be wearing oxygen by nasal cannula at a flow rate of 2 LPM. On 02/11/25 at 10:27 AM, Registered Nurse (RN) #47 confirmed Resident #73's oxygen was set to 2 LPM and should have been set to 4 LPM.

Based on observations and staff interview, the facility failed to ensure they ahdered to safe and sanitary infection control practices. Direct care staff member was observed throwing a soiled brief and linens on a fall mat that was lying on the floor in the resident's room. This was a random opportunity for discovery during the Long - Term Care Survey process Resident identifier: #46. Facility census: 80. Findings included: a) Resident #46 02/10/25 11:32 AM the surveyor observed Resident #46 being provided ADL care by Nurse Aide (NA) #75 behind the curtain. The surveyor waited outside the doorway and noticed a soiled brief was placed on the fall mat on the left side of the bed by NA #75. The fall mat was lying on the floor. 02/10/25 11:36 AM Unit manager Registered Nurse (RN) # 71 was coming down the hall by the surveyor. The surveyor asked about the brief and now soiled linens that were observed placed on the fall mat by NA# 75. RN# 71 went into the room and saw the soiled brief and soiled wash cloths were on the fall mat. RN #71 came back to the door to this surveyor and stated They(NA's) should not be placing any soiled items on the bare floor.

Based on observations, resident interviews and staff interview the facility failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: # 4 and #51 Facility Census: 79. Findings included: a) Resident #51 During an interview on 12/18/23 at 10:41 AM, Resident #51 stated the food was awful, very bland and no variety. The resident said, They do not follow the menu. And I get things on my dislikes list like fish and carrots. I have a bad allergic reaction to Shrimp so I don't eat anything from the water. During an observation on 12/19/23 at 12:32 PM, Resident #51's noon meal tray had egg noodles, meatballs on the plate, no vegetables or no roll. and a bowl of peaches. During an immediate interview Nurse Aide (NA) #23 acknowledged Resident #51 received no vegetable and/or roll on her noon time tray. During a review of the dietary menu the substitute vegetable was Spinach half (1/2) cup. During an interview on 12/19/23 at 12:36 PM, the Administrator was made aware of the Resident #51 not receiving a vegetable and a roll. During an interview, on 12/19/23 at 12:53 PM, the administrator produced the noon tray meal ticket, it was void of a substitute vegetable. She stated, We took her a salad for her vegetable. The Administrator was unable to tell me what the substitute vegetable was or if it was available. b) Resident #4 During an observation on 12/18/23 at 11:52, Resident #4's meal tray ticket stated the following: -Pureed chicken pot pie -pureed dinner roll/bread -marinated green bean salad -ground pineapple tidbits During an immediate interview with Licensed Practical Nurse (LPN) #102 they acknowledged the tray had sliced peaches and pears, it was void of the ground pineapple tidbits. During an interview on 12/18/23 at 1:40 PM, the Administrator acknowledged the menu was not being followed for the Renal Dysphasia Diet for Resident #4.

Based on observation, resident interview and staff interview the facility failed to serve food that was palatable and at an accurate temperature. This failed practice had the potential to affect more than an isolated number of residents. Resident Identifiers: Resident #51. Facility Census: 78. Findings Included: a) Resident Interview During an interview on 12/18/23 at 10:41 AM Resident #51 stated the food was awful, very bland and had no variety. The food was always cold. They did not follow the menu. And they got things on their dislikes list like fish and carrots. Resident #51 said I have a bad allergic reaction to Shrimp, so I don't eat anything from the water. b) Test Tray On 12/19/23 at 11:49 AM two (2) state surveyors tasted the noon time meal for palatability. The Noon meal consisted of the following: Meatballs with egg noodles Sliced Carrots Rosemary Roll Spiced Peaches the roll was tasteless and not palatable. There was no rosemary seasoning on the rolls. During an interview on 12/19/23 at 11:51 AM the Culinary Aide #78 stated the aides put the butter and rosemary on before they started to rise, we needed to put something on them after they baked. On 12/19/23 at 11:49 AM Culinary Aide #78 tested the noon meal tray with the facility thermometer. The temperatures were as follows: Meatballs: 149 degrees Carrots: 110 degrees Spiced Peaches: 140 degrees Culinary Aide #78 stated the peaches are served warm, they are spiced peaches we cook them on the stove in the flavoring. Culinary Aide #78 acknowledged the temperature of the carrots was not acceptable to serve to the Residents.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These were random opportunities for discovery: a half-consumed bottle of diet soda was on the medication cart, and an improper wearing of a mask in a resident care area. Facility census: 78. Findings included: a) Housekeeper #30 On 12/18/23 at 10:20 AM on [NAME] Hall it was noted that Housekeeper #30 was standing inside the doorway of room [ROOM NUMBER] with her mask not covering her nose and upper lip. When asked about the mask not being worn properly Housekeeper #30 shook her head back and forth before placing the mask over her nose and mouth. On 12/19/23 at 1:04 PM, ED #56 was informed of the above findings. b) Medication cart on [NAME] Hall On 12/18/23 at 10:30 AM it was noted a half-consumed bottle of diet soda was on the medication cart. This was verified with Clinical Manager Registered Nurse (CMRN) #92. CMRN #92 removed the diet soda from the medication cart. On 12/18/23 at 10:37 AM, Licensed Practical Nurse (LPN) #35 stated the soda was for a resident and was not hers. On 12/19/23 at 12:09 PM, the Executive Director (ED) #56 said the soda belonged to Resident #78. She went on to say LPN #35 told her she buys a soda for Resident #78 to take with her medications. During an interview on, 12/19/23 at 12:54 PM, Resident #78 had just received her lunch and was asked how the lunch was and Resident #78 stated it tasted good. It was noted a regular soda (not a diet soda) was on her table. Resident #78 was asked if the nurses normally give her soda to take her medications with. Resident #78 stated she has her own soda because that is all she drinks. Resident #78 was asked if she drinks diet or regular soda. Resident #78 said she never drinks diet only regular. On 12/19/23 at 1:02 PM ED #56 was informed of the interview with Resident #78. ED #56 said she did not think Resident #78 was reliable enough to know if she was given soda or was drinking her own. Resident #78 at this time was able to make her preference know for what kind of soda she liked and that she has her own on her bedside table.

Based on observations, and staff interviews, the facility failed to ensure the environment remains as free of accident hazards as is possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of Residents. Facility census 76. Findings included: a) Housekeeping Closet During a tour on 08/29/23 at 8:23 AM, the keys to the housekeeping closet were noted to still be in the keyhole on the door knob. There was not a housekeeper in sight looking down two (2) hallways. At 8:39 am on 08/29/23 Infection Control Staff (ICS) #55 walked by and removed the keys from the door knob on the housekeeping closet. On 08/29/23 at 11:00 AM, the Administrator was informed of the above events. On 08/29/23 at 3:11 PM, the Administrator provided sign-in sheets with staff signatures regarding educational information about hazardous materials and storage. b) admission Observation Unit During the initial tour of the admission Observation Unit (AOU) on 08/29/23 beginning at 8:12 AM the treatment cart was observed unlocked and unattended. During the observation time this surveyor continued to be centrally located around the area of treatment cart, there was no nurse in the area. During an interview on 08/29/23 at 8:19 AM, Licensed Practical Nurse (LPN) #46 acknowledged the treatment cart was left unlocked and unattended and should not have been. .

Based on medical record review, observation, and staff interview, the facility failed to provide services in accordance with the written care plan for one (1) of five (5) sample residents reviewed. The facility failed to implement the interventions in Resident #46's care plan related to elopement. This failure resulted in actual harm to the resident when he eloped from the facility, was missing for several hours, and was injured during the elopement. Resident identifier: #46. Facility census: 54. Findings include: a) Resident #46 1. Medical record review, on 03/25/15 at 1:00 p.m., found on 03/24/15 at 10:00 p.m., Licensed Practical Nurse (LPN) #30 documented Resident #46 was dressed and ambulating in the hallway. According to the note, the resident was, "Alert and verbal but is confused, which is normal for resident. Resident approached this nurse and stated, 'I want out of here. ' " The nurse noted she told the resident it was 10:00 p.m., dark, and chilly outside, and that the staff would be here with him throughout the night. The nurse noted she asked the resident if there was anything she could get for him, to which the resident replied again, "I want out of here." According to the note, the resident turned and walked down the hallway. LPN #30 noted she then went into room [ROOM NUMBER]-C to continue with her medication pass. 2. Documentation in the nursing progress notes, at 11:20 p.m. on 03/24/15, revealed a nursing assistant (NA) reported to LPN #30 that Resident #46 was not in his room, and the resident's window was open. A review of the nursing progress note, dated 03/25/15 at 9:00 a.m., written by LPN #22, revealed a staff member located the resident outside of the facility. The local ambulance service was already on-site and they transported Resident #46 to an acute-care hospital emergency room for evaluation of his condition. 3. A review of a staff member's statement on the evident/incident report revealed NA #56 came on duty at 10:00 p.m. on 03/24/15, and started his rounds at 10:45 p.m. NA #56 wrote that he reached Resident #46's room at about 11:20 p.m., and the resident was not in his room. The window was open, and the window shade was moved to the side. The NA noticed the cold air was coming through the window. Review of NA #18's statement of the event/incident report, found NA #56 came and showed NA #18 that Resident #46 was not in his room. NA #18 told NA #56 to start looking in all the rooms for Resident #46. She told NA #56, she would go and notify the nurses. The report revealed NA #18 reported to the nurses that Resident #46 was missing. LPN #30 notified administrative staff and called nine -one-one ( 911). 4. A review of the resident's care plan, on 03/25/15 at 1:44 p.m., revealed an initial care plan was written on 03/04/15, created on 03/20/15, and revised on 03/25/15. The focus indicated the resident was an elopement risk/wanderer as evidence by (AEB) disoriented to place. The goal was the resident would not leave the facility unattended through the review date. The resident's safety was to be maintained through the review date. The care plan interventions were: -- Assess for fall risk, -- Distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, and books. -- Provide intervention like having a conversation with him about his family, cars, and coffee. The care plan directed staff to document wandering behaviors and attempted diversion interventions in the behavioral log, and " Identify whether the pattern of wandering was purposeful, aimless, or escapist? Is resident looking for something? Provide structured activities, toileting, walking inside and outside, reorientation strategies, including signs and pictures." On 03/25/15 at 1:10 p.m., the director of nursing (DON) was asked to provide Resident #46's behavior log. In an interview on 03/27/15 at 9:10 a.m., the DON stated she had looked for the behavior log documentation and found that none of her staff was implementing the care plan interventions related to elopement. She confirmed she had no evidence to provide. The DON stated she did an in-service immediately with her staff on 03/25/15. 5. In an interview with Acute-Care Hospital-Registered Nurse (ACHRN) #58 on 03/25/15 at 7:10 p.m., she stated the resident had an elevated Troponin level, probably related to the resident lying down, as this could cause high Troponin levels. The ACHRN stated the resident was diagnosed with [REDACTED]. He had the [DIAGNOSES REDACTED]. She stated the resident continued to be confused. He had a petechiae (pinpoint-sized hemorrhages of small capillaries) rash on his back. The RN said the resident was receiving [MEDICATION NAME] (an antibiotic) two (2) grams intravenously, and receiving normal saline (an intravenous fluid). In an interview with the ACHRN #57 on 03/26/15 at 8:45 a.m., the ACHRN stated the resident had bilateral bruises and abrasions on the backs of his hands, a laceration to his left elbow, and the 4th digit (toe) on his foot was [MEDICAL CONDITION] and blue. 6. Observation of Resident #46 in the acute-care hospital, on 03/26/15 at 8:50 a.m., revealed the resident was lying in bed. He had bruising/abrasions on the backs of both hands. Abrasions were noted on his upper forearms and his left elbow had a dressing that was intact. Observation of the 4th digit of his right foot found it was blue and [MEDICAL CONDITION] (swollen). The resident also had abrasions on both lower legs. 7. Resident #46's hospital information was reviewed on 03/26/15 at 11:16 p.m. On 03/25/15, the physician's primary impression was acute rhabdomyolysis, acute exacerbation of dementia, a three (3) centimeter (cm) laceration to the left elbow with delayed presentation. The physician wrote, "... laceration appears to be more than 10 -12 hours old. There is granulation tissue throughout the entire borders of the laceration. This is very deep and the bony structure of the olecranon (bony projection of the ulna) is visualized." The physician wrote, "I do not feel that I need to close the left elbow. This is a delayed closure and there may be contaminants that I currently do not see. The area may need to be evaluated by a surgeon or orthopedic surgeon at this time ..." The physician also noted, "Patient has significant scratches all over the upper and lower extremities. He is only complaining of left elbow pain. The left elbow has sanguinous drainage ... There is a petechiae rash of the trunk as well as the extremities. The resident had to undergo conscious sedation in order for a lumbar puncture to be performed. The lab report revealed a white blood cell (WBC)(WBC - fight off infection) count of 15.4 (normal WBC is 4.0-10.5), A high WBC count indicated infection, inflammation, trauma. The resident's Troponin I was .10, normal is 0.00- 0.05. Troponin I are proteins in the blood. Trauma causes the Troponin to be elevated. Resident's CK-MB ([MEDICATION NAME] kinase [MEDICAL CONDITION] band) was 20.1 ng (nanogram - is one billionth of a gram) /ml (milliliter) normal is 0.1 - 6.3 ng/ml. This test determines whether there is heart damage or skeletal muscle damage " 8. In an interview with LPN #30, on 03/26/15 at 12:48 p.m., she stated Resident #46 was dressed in his day clothes, and he ambulated to where her medication cart was at 10:00 p.m. She stated the resident told her, "I want out of here." The LPN stated she told the resident it was dark, chilly outside, and that staff would be with him throughout the night. She said, "I asked the resident if he wanted anything." The LPN said the resident stated again, "I want out of here." She said after that, the resident turned and walked down the hallway. When asked what she did next, she stated, "I went into room [ROOM NUMBER]- C to continue with my med pass." When asked if she identified that Resident #46 might be going to elope, she stated she did not identify that he was going to leave. When asked if she implemented any of the care plan interventions related to elopement when the resident said, "I want out of here," the LPN said she did not attempt any interventions related to elopement. She stated, "I continued with my medication pass." 9. In an interview with Maintenance Supervisor (MS) #55 on 03/27/15 at 10:00 a.m., he described how he found Resident #46 in the woods. He stated he had gone out to help search for Resident #46 at 8:00 a.m. on 03/25/15. The MS said he had gone to the upper employee parking lot and noticed the resident when the resident stood up, at approximately 9:00 a.m. The MS stated he went to where the resident was in the woods. When asked about the resident's condition, the MS said the resident had no shoes on, had scratches on his upper and lower extremities, and had a cut on his left elbow. The MS stated he walked with the resident out of the woods, where there was an all-terrain vehicle (ATV) waiting to take the resident to a ambulance, which was waiting to take the resident to the hospital for evaluation. .

Based on record review, staff interview, and observation, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. The tri-fold door on the health care unit, which is used by ambulance crews to enter and exit the facility, was found to not be closing properly. When facing the door, the left side of the tri-fold door would close automatically as it was intended to do; however, the right side of the tri-fold door would stick in the open position and would have to be closed manually by facility staff. The tri-fold door was not maintained in constant view of facility staff, nor did the WanderGuard system alarm if a resident wearing a WanderGuard passed through the opened half of the door way. This created the potential for serious harm and/or death related to the risk of elopement. Residents #48, #34, #45, and #3 were identified by facility staff as being at risk for elopement. Each resident wore a WanderGuard on their person. The purpose of the WanderGuard was to lock exit doors if the resident was within a certain amount of space of the door, and to alarm should the resident attempt to open the door. Additionally, the WanderGuard should alarm and alert staff if a resident left the facility through an open doorway equipped with the WanderGuard system. It was confirmed the tri-fold door was equipped with the WanderGuard system, but when the right side of the door (the right side identified when standing facing the door) would stick and not close properly, the WanderGuard system did not alarm when a resident wearing a WanderGuard passed through the open half of the door. This placed four (4) of four (4) residents (Residents #48, #34, #45, and #3), identified by the facility at risk for elopement in an immediate jeopardy situation. The facility's Executive Director and the Director of Nursing were notified of the immediate jeopardy on 03/03/15 at 7:10 p.m.. The Immediate Jeopardy began at 5:20 p.m. on 03/03/15, when the door was observed standing open. Facility staff had no idea how long the door had been open. The WanderGuard system was found to not alarm when a WanderGuard was passed through the door at 5:40 p.m. on 03/03/15. The facility provided a plan of correction to the state agency at 7:40 p.m. on 03/03/15. The plan of correction read as follows: " The tri fold door across from the nurses' station in health care was found to be sticking. The DON (Director of Nursing) had a head count performed between 5:48 p.m. and 6:00 p.m. on 03/03/15 to determine no elopement of residents. The DON at 6:45 p.m. on 03/03/15 stood watch by the door until staff was secured to continuously watch the door to prevent elopements. At 6:55 p.m. on 03/03/15 the Executive Director instructed the staff not to leave the door. There will be an employee posted at the door continuously until the door is fixed. The Director of Maintenance was called in to work on the door. The maintenance person on duty began working on the door at 7:10. At 7:42 p.m. on 03/03/15 the Surveyors; (Name of Surveyors), (Name of Executive Director), Executive Director, (Name of DON), DON, (Name of Maintenance Director), Dir of Maintenance, and (Name of Maintenance Worker), Maintenance observed the door opening and closing several times. The DON tested the WanderGuard alarm system as well. The door would not open and when she went through the door with the WanderGuard the alarm sounded. The DON and Executive Director posted staff at the door for a 24 hour period as a further safety measure at 7:42 p.m. on 03/03/15. " The state agency observed for implementation of the plan of correction and found it properly implemented. At 7:52 p.m. on 03/03/15, the state agency accepted the plan of correction and abated the immediate jeopardy. Resident Identifiers: #48, #34, #45, and #3. Facility Census: 58. Findings Include: a) At approximately 5:20 p.m. on 03/03/15, the right side (right side identified when standing facing the door) tri- fold door on the healthcare unit (the door used by ambulance crews when picking up and returning residents) was observed open. Employee #35, Licensed Practical Nurse, was asked if the door should be open. She stated it should not be, and closed the door. At approximately 5:30 p.m. on 03/03/15, the Director of Nursing (DON) confirmed the door was not working properly. She was asked if the door would alarm if a resident who was wearing a WanderGuard walked out the open door. The DON said she felt it would alarm. She was asked to provide a WanderGuard, and was asked to open the door. At approximately 5:40 p.m. on 03/13/15, a surveyor walked through the right side of the tri-fold door with a WanderGuard in her hand. No alarm sounded to alert facility staff that someone with a WanderGuard had walked out the open door. The DON was advised to ensure they could account for all of the facility's residents. This process began at 5:48 p.m. on 03/03/15 and ended at approximately 6:00 p.m. All residents were accounted for. During this process, the DON stated she was unable to determine how long the door had been open. She indicated she did not know who the last person was to go out the door, so she did not know how long it remained open. Observation revealed the door had a sign taped to it which indicated the door had been sticking, and to make sure the door closed. The door was also observed open earlier in the day, on 03/03/15 at 9:30 a.m. At this time it was promptly closed by facility staff. (During this observation the door was kept in view by the surveyor the entire time). The door was also observed standing open on 03/02/15 at approximately 2:25 p.m. It was kept in view by the surveyor until it was closed by facility staff at approximately 2:30 p.m. on 03/02/15. Maintenance was asked to come and look at the door shortly after every resident was accounted for, at approximately 6:00 p.m. on 03/03/15. The maintenance worker who came to look at the door indicated he was not aware of any problems with the door. He looked at the sign posted on the door, and asked why the sign was there. He denied having any knowledge of the door not working properly until that time. On 03/06/15 at 11:15 a.m., the Executive Director (ED) was asked to enter the nurses' station to see if she could visualize the right side of the door (the right side when standing facing the door). She confirmed she could not. The ED indicated, from the nurses' station, she could not see the side of the door which was not closing properly. .

Based on record review, resident observation, resident interview, and staff interview, the facility failed to prohibit the neglect of two (2) of five (5) sampled residents. The facility neglected to ensure optimal management of Resident #59's pain to prevent undue pain and mental anguish. Since July 2014, facility staff had consistently neglected to assess Resident #59's pain for location, nature, and severity before the administration of medication and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. This constituted actual harm for Resident #59. For Resident #7, the facility staff neglected to take appropriate actions to implement the Registered Dietitian's recommendations. The facility staff also neglected to notify the physician promptly of the resident ' s weight loss; therefore, delaying his ability to assess and/or provide interventions to prevent additional weight losses. As the facility failed to implement the dietitian ' s recommendations and failed did not promptly notify the physician to assess and/or provide interventions to prevent further weight loss, the weight loss could not be determined to be unavoidable. This represented actual harm to Resident #7. Additionally, the facility staff failed to adequately monitor Resident #7 ' s skin during weekly skin assessments and while providing treatments. Resident #7 developed an avoidable pressure ulcer, which also constituted actual harm for Resident #7. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, " A possible tiny non-bstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. " While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, "The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]." She had another CT of the abdomen completed on 08/19/14. The impression for this was, "A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid." On 09/08/14, she also had an X-ray of the abdomen which indicated, " No acute Findings or Bowel Obstruction." They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. "Severe" was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a "...large protrusion noted at the umbilicus (navel) area warm/tender to touch." At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident ' s brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, "My belly is going to bust." LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m.. Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, "You all are not helping me, I want the police." She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, "You all aren't helping me, I want the police." Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to assess the severity of Resident #59's pain did not assess the effectiveness of the resident ' s scheduled pain medication to determine if a PRN dose [MEDICATION NAME] was needed. Resident #59 was not administered her PRN [MEDICATION NAME] on 12/28/14. e. 12/30/14: Resident #59's MAR indicated [REDACTED]. 7) January 2015 Review of Resident #59's medical record for January 2015 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 01/18/15: Resident #59's MAR indicated [REDACTED]. b. 01/31/15: Resident #59's MAR indicated [REDACTED]. 8) February 2015 For the month of February 2015, Resident #59 received no doses of her PRN pain medication. Additionally, Resident #59 had not voiced any complaints of pain except on 02/09/15. On 02/09/15, Resident #59 complained of abdominal pain and nausea, but refused her PRN pain medications. There was no evidence the facility had a process

Based on record review and staff interview, the facility failed to ensure two (2) of seven (7) sampled residents received the care and services needed to maintain each resident's highest practicable well-being. The facility consistently failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. The facility also failed to consistently assess Resident #59's pain for location, nature, and severity before the administration of medication and/or failed to reassess her pain for the effectiveness of the pain medication after administration. The failure to ensure optimal pain management for Resident #59 constituted actual harm. For Resident #7, the facility failed to evaluate the resident for the need and/or administered insulin coverage if required, according to physician's orders. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, " A possible tiny non-obstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. " While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, "The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]." She had another CT of the abdomen completed on 08/19/14. The impression for this was, "A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid." On 09/08/14, she also had an X-ray of the abdomen which indicated, " No acute Findings or Bowel Obstruction." They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. "Severe" was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a "...large protrusion noted at the umbilicus (navel) area warm/tender to touch." At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident's brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, "My belly is going to bust." LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m.. Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, "You all are not helping me, I want the police." She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, "You all aren't helping me, I want the police." Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to assess the severity of Resident #59's pain did not assess the effectiveness of the resident's scheduled pain medication to determine if a PRN dose [MEDICATION NAME] was needed. Resident #59 was not administered her PRN [MEDICATION NAME] on 12/28/14. e. 12/30/14: Resident #59's MAR indicated [REDACTED]. 7) January 2015 Review of Resident #59's medical record for January 2015 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 01/18/15: Resident #59's MAR indicated [REDACTED]. b. 01/31/15: Resident #59's MAR indicated [REDACTED]. 8) February 2015 For the month of February 2015, Resident #59 received no doses of her PRN pain medication. Additionally, Resident #59 had not voiced any complaints of pain except on 02/09/15. On 02/09/15, Resident #59 complained of abdominal pain and nausea, but refused her PRN pain medications. There was no evidence the facility had a process in place to consistently assess the resident's pain and to ensure each nurse followed a process to reassess and treat the pain. Since July 2014, Resident #59 had multiple trips to the emergency room related to pain. There were occasions where Resident #59 complained of pain for multiple days in a row, at which time the facility failed to provide interventions and/or treatment to attempt to alleviate the resident's pain in a timely manner. On multiple occasions, Resident #59 suffered for days with pain because of the facility's failure to implement effective pain management. These findings were reviewed with the Director of Nursing and the Clinical Service

Based on observation, record review, and staff interview, the facility failed to provide services to prevent the development of an avoidable pressure ulcer for one (1) of three (3) residents reviewed for pressure ulcers. Assessments indicated the resident was at risk for the development of pressure ulcers; however, the resident's skin was not observed and monitored during the provision of ordered treatments. In addition, each treatment was not performed as ordered. This constituted actual harm to the resident. Resident identifier: #7. Facility census: 58. Findings include: a) Resident #7 On 03/05/14 at 12:30 p.m., upon request, Nurse Aides (NAs) #46 and #44 removed Resident #7's socks to enable a visual inspection of the resident's heels. The observation of the resident's left heel revealed a circular, non-blanching, reddened area, the size of a quarter. Within the quarter size reddened area, was a brown area the size of a nickel. On 03/05/15 at 1:40 p.m., a review of the nurses' notes for Resident #7 revealed the following entries: -- An entry on 02/04/15 at 16:27 by LPN #5, containing an addition by Registered Nurse (RN) #49. The addition by RN #49 identified the resident as having bilateral heels that were mushy, red, and blanchable, and for the heels to be floated off the bed with pillows under the lower legs. -- An entry on 02/27/15 at 13:15 by LPN #36, indicated a new physician's orders [REDACTED]. -- On 03/01/15 at 14:52 by RN #39, the MDS coordinator, completing the 14-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/24/15, noted, " ... Anti-pressure measures in place, no breakdown is noted at this time...." At 1:50 p.m. on 03/05/15, in response to an regarding the manner in which the weekly skin assessments were completed, as well as the protocol when wounds were identified, RN #47 responded, " If wounds were discovered by the NAs, they report to the nurse providing care for the resident on that day. If the wound was a pressure ulcer, it was reported to (RN #47) for monitoring and tracking. " She stated LPN #4 was responsible for performing the weekly skin assessment for Resident #7. A review of the Treatment Administration Record (TAR) with the DON and RN #49 on 03/05/15 at 2:15 p.m., revealed a treatment for [REDACTED].#7, twice daily. The treatment was initialed as applied twice daily on 03/01/15, 03/02/15, 03/03/15, and 03/04/15. The 8:00 a.m. application of Skin Prep on 03/04/15 was initialed as completed by LPN #4. As of 2:15 p.m. on 03/05/15, the 8:00 a.m., the application of Skin Prep for 03/05/15 was not initialed as completed. At 2:20 p.m. on 03/05/15, inquiry was made of LPN #4, in the presence of the DON and RN #49, as to the application of the skin prep on 03/04/15. In response to an inquiry as to whether she observed any areas of concern on the resident's heels during the application of the Skin Prep, she replied, "No." Her reply to further an inquiry as to whether she visualized the areas in which she applied the Skin Prep, was, "No, I didn't actually get down and look at them. I just sort of wiped the skin barrier on." She then did a demonstration of how she held up a leg with one (1) hand and applied the skin prep with the other, demonstrating the areas receiving the treatments were not in her line of vision. Therefore, LPN #4, the nurse responsible for completing the weekly skin assessments and for providing Resident #7's treatment on the morning of 03/04/15, neglected to visualize the area in which she was providing a treatment. This led to the facility failing to identify a pressure ulcer on Resident #7's left heel on the morning of 03/04/15. This failure caused a delay treatment to the area. The pressure ulcer was identified by the surveyor at 12:30 p.m. on 03/05/15. On 03/05/15 at 2:23 p.m., when asked if they thought the manner in which LPN #4 applied the treatment for [REDACTED].#49 both replied, "No." The DON agreed it would have been appropriate, as well as necessary, to visualize an area in which a treatment was being applied. At 2:25 p.m. on 03/05/15, The DON and RN #49 removed the socks from Resident #7, and observed her heels. Both agreed she had a pressure related area to her left heel. Both agreed the area was previously undetected by staff, and due to the coloring of the skin tissue, agreed it had most likely been there longer than 24 hours. They further agreed staff should have identified the area prior to surveyor intervention. A review of the weekly skin assessments for Resident #7, on 03/05/14 at 3:30 p.m., revealed no areas indicating pressure ulcers on the assessments dated 02/06/15, 02/13/15, and 02/17/15. The weekly skin assessment dated [DATE] indicated the resident had "boggy heels." The skin assessment dated [DATE] indicated the resident had a healing abdominal incision, boggy heels, groin redness, and the resident's buttocks were red and blanchable. There was no mention of the suspected deep tissue injury to the left heel. The skin assessments had been completed by LPN #4. LPN #4 had completed a Skin Assessment for Resident #7 on 03/05/15, prior to the surveyor's observation at 12:30 p.m.. Upon completing this assessment, she neglected to identify the pressure related area to the resident's right heel rendering the skin assessment process ineffective due to her failure to adequately visualize and inspect the resident's skin to ensure no pressure related areas were present. At 3:30 p.m. on 03/05/15, after this issue was brought to her attention, RN #49 completed the weekly wound assessment and progress review for Resident #7. RN #49 identified a wound on the resident's left heel. The type of wound was indicated as pressure, measuring 1.5 cm x 1.5 cm x 0 cm, staged as a deep tissue injury (DTI). The nurse identified 03/05/15 as the date the wound was first noted. The treatment section of the wound assessment indicated the application of Skin Prep twice daily, with a start date of 02/27/15. Wound specifications section described the wound as dark red, non-blanchable color with brown colored dots inside of redness. It further described the area as tender to palpation with no signs or symptoms of discomfort when the area was not being palpated. . .

Based on medical record review, staff interview, and resident interview, the facility failed to ensure one (1) of five (5) sampled residents maintained acceptable parameters of nutritional status. The resident had three (3) severe weight losses, between 02/11/15 and 03/01/15, which were not identified and addressed by the facility. These weight losses resulted in a cumulative weight loss of 15.69% of the resident's total body weight in fourteen (14) days, representing actual harm to the resident. Resident Identifier #7. Facility Census: 58 Findings Include: a) Resident #7 Medical record review revealed Resident #7 experienced the following weight losses: -- From 02/11/15 to 02/20/15, the resident lost 5.50% of her body weight, -- From 02/20/15 to 02/24/15, the resident lost 7.75 % of her body weight, and -- From 02/24/15 to 03/01/15, the resident lost 3.28 % of her body weight. These weight losses combined for a cumulative weight loss since readmission on 02/11/15 to the last available weight on 03/01/15 of 15.69 % of her body weight. A review of Resident #7's medical record at 9:46 a.m. on 03/03/15, revealed Resident #7 was admitted to the facility on [DATE]. She went back to the hospital on [DATE] and returned to the facility on [DATE], where she remained with no further discharges. Resident #7 had the following weights recorded in her medical record (all weights were obtained using a mechanical manual lift): -- 02/04/15 - 190.6 pounds (admission to the facility) -- 02/09/15 - 191.8 pounds (Resident #7 was in the hospital when the facility allegedly obtained this weight) -- 02/11/15 - 181.7 pounds (readmission to the facility). -- 02/20/15 - 171.7 pounds -- 02/24/15 - 158.4 pounds -- 03/01/15 - 153.2 pounds The resident's percentage of weight loss from 02/11/15 to 02/20/15, 02/20/15 to 02/24/15, from 02/24/15 to 03/01/15, and from 02/11/15 to 03/01/15 were calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) X 100. -- From 02/11/15 to 02/20/15, the resident lost 5.50% of her body weight -- From 02/20/15 to 02/24/15, the resident lost 7.75% of her body weight -- From 02/24/15 to 03/01/15, the resident lost 3.28% of her body weight -- Her cumulative weight loss since readmission on 02/11/15 to the last available weight on 03/01/15 is 15.69% of her body weight. Further review of the medical record found a Comprehensive Nutritional assessment dated [DATE] completed by Registered Dietitian (RD) #50. Review of the assessment revealed Resident #7 had the following disease/conditions: [MEDICAL CONDITION], Arthritis, Cardiovascular Disease, Diabetes, Gastrointestinal Problems, and Hypertension. RD #50 indicated in the assessment that Resident #7 had no significant [MEDICAL CONDITION]. RD #50 also indicated on the nutritional assessment Resident #7 had the following nutritional concerns: inadequate food/fluid intake and involuntary weight loss. RD #50 wrote the following narrative on the nutritional assessment (typed as written), "Readmission and recent new admission. 87 yof (year old female) dx (diagnosis): Upper GIB ([MEDICAL CONDITION]), PUD ([MEDICAL CONDITION] ulcer disease) w (with)/ hemorrhage, Dementia, UTI (urinary tract infection),[MEDICAL CONDITION] [MEDICAL CONDITION], DM2 (Diabetes Mellitus Type II), OA ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension). PO (by mouth) intake varies R (refused) X 2 (two) meals; 0 (zero) - 25% X 2 meals, 26 - 50 % X 5 meals, 51-75 % X 1 meal. Visited resident during evening meal and she states appetite "fine" and that there are no food she doesn't like. Poor PO intake observed. Wt. (weight) loss x 1 week and note further wt. changes may occur d/t (due to) generalized [MEDICAL CONDITION]. Therapeutic diet d/t dx. BMI (body mass index) indicates obesity; no interventions warranted d/t age and dx. skin: surgical wound abdomen. Rec. (recommendation) House Shake 2 p (p.m.) daily. Will fup (follow up) prn (as needed)." Review of Resident #7's physician orders [REDACTED]. Review of the documentation of the percentage of the supplement consumed found Resident #7 was offered her supplement 12 out of 14 times since it was ordered on [DATE]. Of the 12 times it was offered, she consumed 100% of the supplement six (6) times, consumed 75% once, consumed 50% three (3) times, and consumed 25% twice. RD #50 again assessed Resident #7 on 02/25/25. RD #50's note dated 02/25/15, contained the following text (typed as written): "PO (by mouth) intake varies R (refused) X 5 meals; 0 - 25 % X 8 meals; 26 - 50 % X 4 meals; 51 - 75 % x 2 meals. Visited resident during evening meal and resident states "eating good" no new food pref (preferences) but poor intake observed. Spoke to CNA (Nurse Aide) and they reported poor intake recently. Wt. (weight) history: 2/24 (2015) 158.4 # (pounds), 2/20 171.7#, 2/11 181.7#, 2/9 191.5#, 2/4 190.6# - sig (significant) wt. (weight) loss X 1, 3, & (and) 6 meals. Rec. (Recommend) house shakes bid (twice a day) @ (at) 10 a (a.m.) and 2 p (p.m.) Staff to feed resident prn (as needed) If poor intake continues consider appetite stimulant. Will fuo (follow up) prn (as needed)." Further review of the medical record on 03/03/15 found no evidence the physician was notified of RD #50's recommendation on 02/25/15. There was also no evidence this recommendation was ever implemented and/or addressed by the physician. An interview with the Director of Nursing (DON) at 2:28 p.m. on 03/03/15, revealed the nursing department had no knowledge of the dietary recommendation to increase the House Shake to twice daily. She stated the RD did not communicate this recommendation to nursing. The DON stated the RD should have sent a form with her recommendation on it to nursing so the physician could be notified and the recommendations could be implemented. She confirmed this process failed in this instance. When asked if Resident #7's physician had been notified of the resident's continued weight loss since his notification on 02/16/15, she confirmed she had no documentation to suggest Resident #7's physician had been notified since 02/16/15. She confirmed Resident #7 had three (3) additional weights in which she demonstrated a weight loss and the physician and/or Resident #7's Medical Power of Attorney (MPOA) were not notified. An additional interview with the DON, at 4:07 p.m. on 03/03/15, found that after the earlier conversation on 03/03/14 at 2:28 p.m., Licensed Practical Nurse (LPN) #5 telephoned Resident #7's physician to notify him of Resident #7's weight loss. She indicated, the physician agreed with the RD's recommendation to increase the House Shakes to two (2) times daily and to feed the resident at all meals. The DON indicated the information about Resident #7's weight loss was on the physician's board for him to address prior to our conversation, but the physician failed to address the weight loss, so they called him to make sure he had seen the information. Interview with LPN #5 at 5:00 p.m. on 03/03/15 found she had spoken with Resident #7's attending physician earlier about the resident's weight loss. She stated he agreed to increase the house shakes to two (2) times daily and to assist the resident with eating as needed. She stated she asked him about the appetite stimulant and he indicated he would wait until he was able to come to the facility and review her medication regimen, which would likely be 03/04/15. At 5:10 p.m. on 03/03/15, during the evening meal, Resident #7 was asked if she was going to eat her dinner. She stated, "I am going to eat what I can - I am not that hungry." When asked if she was served foods she liked, she stated, "I guess I am just not hungry." Resident #7 then pushed her food away. An interview with RD #50 at 4:26 p.m. on 03/4/15 revealed she had seen Resident #7 on 02/25/15 to address her continued weight loss. She stated, when she made a recommendation she would send an email to the Certified Dietary Manager (CDM) who would then share the recommendation with nursing. She indicated on 02/25/15 she tried to use a new form in the computer and had thought she had sent the recommendation to the CDM, but the message had failed to send and the recommendation was never implemented. She confirmed she saw the resident again today and recommended fortified foods for Resident #7 and if poor by mouth intakes continued, to consider an appetite stimulant if medically appropriate. An additional interview with RD #50 by telephone at 2:28 p.m. on 03/05/15, found RD #50 felt fortified foods were an appropriate intervention for Resident #7's weight loss. When asked how fortified foods would help a resident with such poor by mouth intake she stated, "It will increase the calories in what she does eat, even though she does not eat well." After the initial conversation with the DON at 2:28 p.m. on 03/03/15, the following physician orders [REDACTED].#7's medical record: -- Order dated 03/03/15 4:15 p.m. "4 oz (ounce) house shake BID (twice daily). D/C (discontinue) house shakes once daily. Feed all meals." -- Order dated 03/05/15 (no time specified) "Increase house shake to TID (three times daily) between meals. Add fortified foods to diet with meals." -- Order dated 03/05/15 (no time specified) "CBC (comprehensive blood count), comp metabolic (comprehensive metabolic panel)... weight loss...." Additionally, the following social service and nursing progress notes were entered into Resident #7's medical record after the initial conversation with the DON at 2:28 p.m. on 03/03/15 (all notes typed as written): -- Nursing progress note on 03/03/15 at 3:52 p.m., "Dr. (name of physician) has been informed about 30 lb (pound) weight loss. Agrees with dietician recommendation to increase 4 (four) ounce house shakes bid (two times daily) and order to provide feeding assistance prn (as needed)." -- Dietary progress note at 4:44 p.m. on 03/03/15, "Added 4 oz (ounce) shake to 10am snack for resident to address weight loss (resident currently receives 4 oz shake at 2pm). Recommend adding fortified foods to diet. Will follow." -- Nursing Progress note at 1:16 p.m on 03/05/15, "New order to increase house shake TID (three times a day) between meals and to add fortified foods to diet with meals..." -- Nursing Progress Note at 12:27 p.m. on 03/06/15, "(Name of physician) in for acute visit for resident losing weight, per labs her [MEDICATION NAME] is increasing and for now we will continue to monitor resident and her labs." Additionally, Resident #7's attending physician dictated the following physician's progress note on 03/05/15 and it was transcribed into the medical record on 03/06/15. The note contained the following text (typed as written), "Resident, who has undergone recent gastric surgery in early February related to GI (gastrointestinal) bleeding, was subsequently rehospitalized and again returned to the facility. Since her return less than a month ago the resident has demonstrated a significant weight change. Interestingly laboratory studies performed on 02/16/15 failed to reveal an obvious etiology for the resident's weight loss but where consistent with profound nutritional deficiency likely related to the resident's significant recent hospital stays and surgery." The attending physician identified his plan for Resident #7 as, "The resident has already had diet supplementation ordered between two and three weeks ago. Unfortunately the resident continues to manifest weight loss has had some recent nutritional modifications again and we will reassess lab work as it is now slightly more than two weeks old." After surveyor intervention on 03/03/15, the facility notified Resident #7's attending physician of her weight loss, and began to implement interventions to address Resident #7's weight loss as they had previously failed to do. '

Based on observation, water temperature measurements, staff interviews, review of facility procedures, and resident interview, the facility failed to ensure the resident's environment, over which the facility had control, was as free from accident hazards as possible for 34 of 64 facility residents. On 07/28/14, water temperatures obtained in resident areas on all hallways exceeded 110 degrees Fahrenheit (F). Three (3) resident rooms had water temperatures at sinks which exceeded 120 degrees F. The maintenance department became aware the facility's water temperatures exceeded 120 degrees F at 9:00 a.m. on 07/28/14. Maintenance did not promptly alert staff and enact a plan to ensure resident safety while they were adjusting the water temperatures. Interviews revealed nursing staff and administrative staff were not notified of any concerns regarding excessive hot water temperatures until 4:00 p.m. on 07/28/14. Staff interviews also confirmed that from 9:00 a.m., when the problem was identified, until 4:00 p.m., residents were provided showers as scheduled on the day shift, and showers continued to be provided into the evening shift until 4:00 p.m. At 4:00 p.m. on 07/28/14, a resident, who was receiving a shower, complained to staff the water temperatures were too hot. At that time all staff were advised to discontinue the showering of residents. Residents #20, #39, #36, #85, #52, #18, #31, #5, #13, #81, #50, #95, #15, #97, #49, #70, and #3 were all provided showers on 07/28/14 between 9:00 a.m. and 4:00 p.m. Between the hours of 9:00 a.m. and 4:00 p.m., all hand sinks were accessible to each resident who was able to independently wash his/her hands. Residents #53, #47, #19, #69, #46, #12, #37 , #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3 were all identified by facility staff as residents who were independently able to wash his/her own hands. A determination was made that an immediate jeopardy existed. The immediate jeopardy began at 9:00 a.m. on 07/28/14, when the maintenance department began using the hot water tank servicing the laundry department to service the resident care areas. On 07/28/14 at 6:00 p.m., the Chief Operating Officer, the nursing home administrator of the long term care unit, was notified of the existence of an immediate jeopardy. A plan of correction (POC) was provided by the facility at 6:15 p.m. on 07/28/14. The POC indicated the facility would do the following, "1. Water temperatures in the facility are being monitored by the maintenance department on an hourly basis until such time that the water temperatures are stabilized at or below 110 degrees. 2. All residents that received showers throughout the day of 07/28/14 are being assessed by the RN (Registered Nurse) nursing staff to determine that there was no harm such as redness, burning, or excoriation as a result of the water temperatures exceeding 110 degrees. 3. All of the residents have been informed by social services regarding the water temperatures and have been informed not to use the sinks to wash their hands until given clearance from social services. In the meantime, washcloths and hand sanitizer will be provided for cleansing of resident's hands. 4. Signs will be hung above the sinks to remind residents not to use the water. Also the hot water will be turned off to every sink. 5. All showers have been discontinued until such time that the water temperature can be maintained at or below 110 degrees. Bed baths will be used in place of showers." The items outlined in the POC were observed in place at the time the POC was provided on 07/28/14 at 6:15 p.m. The POC was accepted at 6:20 p.m. on 07/28/14; therefore, the immediacy of this deficient practice was abated at 6:20 p.m. on 07/28/14. A deficient practice in the area of accident hazards still remained, so the scope and severity was decreased from a "K" to an "E". In addition to the hot water, observation revealed used disposable shaving razors were not secured in a biohazard container, and were accessible to residents. Also, a bottle of sanitizer was stored in an unlocked shower room to which residents had access. Resident identifiers: #20, #39, #36, #85, #52, #18, #31, #5, #13, #50, #15, #97, #53, #47, #19, #69, #46, #12, #37, #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3. Facility Census: 64 Findings Include: a) Water Temperatures The following temperatures were obtained in resident hand sinks, by facility staff using the facility's thermometer: -- Room #3 at 2:57 p.m. on 07/28/14 120.2 degrees Fahrenheit (F) -- Room #4 at 3:00 p.m. on 07/28/14 113.5 degrees F. -- Room #0 at 3:03 p.m. on 07/28/14 113.4 degrees F. -- Room #18 at 3:05 p.m. on 07/28/14 112.6 degrees F. -- Room #23 at 3:25 p.m. on 07/28/14 120.6 degrees F. -- Room #22 at 3:27 p.m. on 07/28/14 118.6 degrees F. -- Room #0 at 3:30 p.m. on 07/28/14 118.6 degrees F. -- Room #36 at 4:45 p.m. on 07/28/14 122.0 degrees F. -- Room #3 at 5:01 p.m. on 07/28/14 121.8 degrees F. -- Room #36 at 5:05 p.m. on 07/28/14 109.6 degrees F. Interview with the Vice President (VP) of Environmental Services at 3:26 p.m. on 07/28/14, revealed the water tank that serviced the resident care area had ". . . went down . . ." and he had to switch to another tank which serviced the laundry department. He further indicated this hot water tank "gets a lot hotter" than the one previously servicing the resident areas. He stated the water from the tank which serviced laundry was at 160 degrees F and they had to adjust it down using the mixing valve so it would not be too hot going to resident areas. He stated, "We are working to get the water temperature down. We got it down to 140 degrees (F) this morning." He was then asked if the nursing department was notified of the situation and what was put into place to protect the residents while adjustments to the water temperatures were being made. He replied, "I don't know about that, we switched over the tanks and we have been taking temperatures trying to get the temperature down." He stated they switched to the tank servicing laundry at about 9:00 a.m. on 07/28/14 and he had no idea if nursing or any other department knew about the situation. He stated, "We were focused on getting the residents some hot water." An interview with the director of quality improvement Registered Nurse (RN) #96 and RN #133, at 3:57 p.m. on 07/28/14, revealed the residents received their showers as scheduled that day. RN #96 reported all female residents in the "A" bed would have received a shower on the day shift. She indicated they usually began giving showers at 9:00 a.m. She further stated evening shift would shower all the male residents in the "A" beds that night. Neither RN #96, nor RN #133 knew anything about the elevated water temperatures. RN #96 stated, "I think they are giving a resident a shower now." She went into the shower room and reported Resident #31 was getting a shower. RN stated the resident told her the water temperature was too hot. She then stated, "I am going to instruct the nurse aides (NA) to not give any more showers until this is fixed. No one told us anything about this. We did not know there was a problem." An interview with Licensed Practical Nurse (LPN) #116, at 4:11 p.m. on 07/28/14, revealed residents had been receiving their showers as scheduled. She stated she had not been informed about any issues with the water, and as far as she knew, the water was at a safe temperature for resident use. She stated no one had said anything to her about being careful with the water or about making sure residents did not use the water independently to wash their hands. RN #101, who was working as the charge nurse on 07/28/14, was interviewed at 4:30 p.m. on 07/28/14. She was asked if she had been made aware of any concerns about the hot water. She stated she was not aware of any concerns with the hot water. She said as far as she knew, the residents could use the water as needed and showers should be given as scheduled. Interview with the Chief Operating Officer (COO), at 11:10 a.m. on 08/05/14, revealed he was unaware of the unsafe water temperatures until after 4:00 p.m. on 07/28/14. He was asked if he could provide the water temperatures obtained by the maintenance department while they were attempting to regulate the hot water temperature between 9:00 a.m. and 4:15 p.m. on 07/28/14. He stated, "If they took any temperatures while they were regulating the water, I don't have a record of them." The COO was unable to provide any water temperatures for 07/28/14 prior to 4:15 p.m., seven (7) hours after the facility began using the hot water tank servicing laundry to service the resident care area. Those temperatures, when obtained by facility staff using their own thermometer at 4:15 p.m. were: -- Room #7 117 degrees F -- Room #25 119 degrees F -- Room #24 114 degrees F -- Room #31 118 degrees F -- Room #30 114 degrees F -- Room #33 113 degrees F . .b) Razors During the initial tour of the facility, on 07/28/14 at 11:53 a.m., an unlocked shower room was observed with a sharps disposal container (a container used to dispose of sharp objects) which was full. Two (2) personal disposable razors were sticking up out of the sharps disposal container. Another disposable razor was observed in a cabinet, with the door open, in the shower room. An interview with the director of quality improvement, Registered Nurse #96 on 07/28/14 at 11:55 a.m., confirmed the sharps disposal container was full. She stated the staff knew better than to leave razors sticking out of the container. She also agreed that the razor in the cabinet should not be there. She stated staff were to get razors out of the Omnicell (storage for healthcare items). Each razor removed from the Omnicell was to be used one (1) time, and then disposed of properly. A review of the facility policy and procedure, on 07/31/14 at 9:40 a.m., revealed each time a razor was needed, it should be obtained from the Omnicell. It noted razors were not to be stored in the shower room at any time, or for any reason. According to the policy, nursing staff was to notify the charge nurse when the sharps container was three-fourths (3/4) full to prevent overfilling and a possible injury to residents and staff. The charge nurse was then responsible for proper disposal and replacement with an empty container for disposal of razors. c) Chemical Observation, on 08/04/14 at 1:20 p.m., revealed the door was open to the shower room. A bottle of Santi-tyze (food contact surfaces sanitizer cleaner and sanitizer for institutional and industrial use) was found on the hand sink in the shower room. In an interview, on 08/04/14 at 1:30 p.m., with registered nurse/charge nurse (RN-CN) #101, the RN confirmed the Santi-tyze cleanser should not be on the hand sink in the shower room. She said nursing assistants (NAs) obtained the Santi-tyze from the housekeepers to clean the shower room. The NAs were supposed to return the Santi-tyze to the housekeepers so the cleanser could be locked up. The RN stated the nursing assistant must have forgotten to return the cleaner to the housekeeper. .

Based on observation, record review, staff interview, review of information from the National Pressure Ulcer Advisory Panel, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associated with the pressure ulcers on her heels, which was not addressed by the facility. Resident Identifiers: #23 and #19. Facility Census: 64. Findings Include: a) Resident #23 In an interview with Registered Nurse (RN) #101, on 07/29/14 at 11:30 a.m., the nurse reported Resident #23 did not have any pressure ulcers. A review of Resident #23's medical record, at 11:00 a.m. on 07/30/14, revealed Resident #23 was readmitted to the facility on [DATE] after a hospitalization due to a fractured femur. The admission nursing assessment indicated Resident #23 had no skin breakdown and/or pressure ulcers upon readmission to the facility. The resident had a Braden Scale for Pressure Sore Risk assessment, completed on 07/08/14, which indicated the resident was at high risk for development of pressure ulcers. A nurse surveyor observed incontinence care for the resident, provided by Nurse Aide (NA) #113, on 07/30/14 at 2:20 p.m. Resident #23 was observed with a pressure ulcer on the left buttock and another on the right buttock. NA #113 stated when she worked with the resident "a week ago" the resident had only a skin tear to his right buttock, which was caused by shearing. Registered Nurse (RN) #101 was requested to assess Resident #23's buttocks at 2:30 p.m. on 07/30/14. The assessment by RN #101 was observed by the nurse surveyor. The resident had a wound to the right buttock measuring five (5) centimeters (cm) in length and four (4) cm in width. The outer edges of the wound on the right buttock were bright red, and the inner part of the wound was pink/red with one (1) cm of yellow tissue in the center of the wound. Additionally, the resident had a wound to the left buttock that was five (5) cm in length and two (2) cm in width. The outer wound edges were bright red, and the inner part of the wound was white. RN #101 indicated both wounds would be considered Stage II pressure ulcers. (Note: According to the National Pressure Ulcer Advisory Panel (NPUAP) and the "Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0," a Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. The presence of the yellow tissue in the right buttock wound suggested the area was a Stage III ulcer rather than a Stage II.) At 2:48 p.m. on 07/30/14, RN #101 stated she was not aware Resident #23 had the pressure areas to his buttocks. She stated she assessed the right buttock on 07/22/14 and found shearing, which was not considered a pressure ulcer. She stated the physician ordered, on 07/22/14, "Hydrogel and border foam to shearing on right buttocks daily until healed." She indicated she had not reassessed the area because it was not a pressure ulcer. She said RNs only did weekly assessments on pressure ulcers. When asked if the wound to the right buttock looked worse today than it did on 07/22/14 she replied, "Yes it is a lot worse." When asked if the nurses providing the daily treatments had reported to her the wound had become worse, she stated, "The LPNs (Licensed Practical Nurses) have not reported the worsening of the wound to me." RN #101 said the LPNs were responsible for notifying the RN in charge of any worsening of an existing wound as well as the identification of any new areas of breakdown. This was supposed to occur on the day the areas were identified. She stated she was not made aware of the wound worsening or the development of the additional wound to the left buttock. RN #101 indicated if it had been reported to the RN as required, the wounds would have been assessed and treatment would have begun prior to this date. She stated it was likely the wound to left buttock started out as a reddened area and/or shearing like the wound to the right buttock, and then progressed to a Stage II pressure ulcer. RN #101 said it should have been identified prior to becoming a Stage II pressure ulcer. During this interview, RN #101 confirmed Resident #23 did not have any pressure ulcers to his buttocks upon readmission to the facility. She said he had a bruise to his right buttock; however, the pressure ulcer now noted was in a completely different part of the resident's buttock than the previously identified bruise. When asked what interventions were in place to prevent Resident #23 from developing pressure ulcers, she stated, "He has a Maxi float mattress, he is to be turned and repositioned every two (2) hours, and he is to have zinc applied to his buttocks every eight hours." When asked if the Stage II pressure ulcers should have been identified prior to the observation of incontinence care, during the survey on 07/30/14, RN #101 stated the pressure ulcers should have been identified during the daily treatment (a bandage to the right buttock) provided by the LPNs and NAs should have noticed them during the application of zinc cream to the resident's buttocks three (3) times a day. Interview with the Coordinator of Quality Improvement RN #96, at 9:04 a.m. on 07/31/14, revealed the the NAs were to immediately report, to a LPN or the RN in charge, if skin break down was noticed or a wound was worsening. If noticed or reported to the LPN, the LPN was to immediately report the information to the RN so the area could be assessed, measured, and staged if necessary. She stated if the LPN was providing the treatment daily (bandage) and the NAs were applying the zinc cream three (3) times a day, as well as providing incontinence care, the pressure ulcers to Resident #23's buttocks should have been identified and reported to the RN prior to the identification of the wounds while observing incontinence care during the survey. An additional interview with RN #101, at 10:14 a.m. on 07/31/14, revealed Resident #23's physician had evaluated the resident's wounds. As the result of the evaluation, the physician ordered a treatment of [REDACTED]. RN #101 stated the physician was in agreement with the staging and the measurements of the wounds on the right and left buttock. . . b) Resident #19 During a Stage 1 Quality Indicator Survey (QIS) interview with RN #101, at 4:33 p.m. on 07/28/14, she stated the resident was admitted with an unstageable DTI (deep tissue injury) to the right toe. Medical record review, during Stage 2 of the QIS, revealed the resident was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 05/28/14, indicated the resident was admitted with an unstageable pressure area and two (2) Stage I pressure areas. According to the MDS, the resident did not have any unstageable deep tissue injuries (DTI). Review of the admission nursing assessment, completed by the facility on 05/21/14 by a LPN, found the resident, "...has multi bruised areas and discoloration on b/l (bilateral) legs... a black in color scabbed area on the left big toe . . . and a small bruise in the right side of her lower back right above her hip area. . . ." There was no mention of any other skin issues. Documentation was added to the admission nursing assessment by a RN, on 05/22/14, indicating the resident had a left great toe nail which was raised, black, and thick. It also noted the tip of the right great toe had an unstageable necrotic area measuring 0.4 cm by 0.5 cm, with no drainage noted. In addition, the note indicated the left and right heels were soft and boggy. The RN coordinator of quality improvement, Employee #96, was interviewed on 07/30/14 at 8:16 a.m. regarding the admission nursing assessment. She agreed the LPN who admitted the resident did not mention any area to the right great toe or any problems with the resident's heels. She was asked how the facility determined the pressure area was present on admission, when the admission assessment, completed on 05/21/14, did not mention the areas. RN #96 said the admitting nurse should have captured those areas during her assessment. An interview with RN #101, at 3:32 p.m. on 07/29/14, found the facility had an order for [REDACTED]. Employee #101 stated she was not aware of any issues with the resident's heels. She said she could find no documentation regarding the heels on the weekly wound sheets completed on 06/05/14, 06/19/14, 07/04/19, 07/11/19, and 07/24/19. During an observation of the resident's bilateral feet with Employee #101, at 4:05 p.m. on 07/29/14, the resident stated her left heel was hurting. She said, "I have been telling you all that since I got here." Employee #101 examined the left heel and stated her heel appeared to be covered with dry callus skin and was soft and boggy. An examination of the right heel by Employee #101 yielded the same conclusion. The RN stated she would contact the medical director "today." According to the resident assessment instrument (RAI) manual, the definition of a Stage I pressure ulcer is, "An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues." At 5:00 p.m. on 07/29/14, Employee #101 reviewed the physician's progress notes dated 06/22/14, 06/24/14, 07/07/14 and 07/21/14. She was unable to find any documentation by the physician regarding the pressure areas on the resident's heels. An interview with Employee #101, at 11:00 a.m. on 07/30/14, found the physician examined the resident on 07/30/14 and ordered heel protectors while in bed and [MEDICATION NAME] external cream to be applied twice daily to the legs and feet for dryness. Employee #103, the MDS coordinator was interviewed, at 1:23 p.m. on 07/30/14, regarding the admission MDS. She was asked where the facility obtained the information for completion of the pressure ulcer information on the MDS. She said she did not complete the MDS and the employee who did was not at the facility. She said the employee who completed the MDS must have examined the resident and found the areas. She verified the weekly wound assessments did not mention the resident's heels. RN #103 provided a copy of the care area assessment (CAA) for pressure ulcers indicating the nurse who completed the admission MDS noted the resident was admitted with Stage I areas to the bilateral heels and an unstageable ulcer to the right great toe. She was unable to find any other documentation of the Stage I pressure areas to the bilateral heels. RN #103 concluded the facility had not addressed the Stage I pressure areas to the heels, and these areas were never described on any of the weekly wound sheets. She was unable to find any documentation to support the pressure areas to the heels were being monitored by the facility. An interview with the vice president of health services (VPHS), on 08/04/14 at 10:10 a.m., was conducted to discuss Resident #19's pressure areas and to determine how the facility addressed the resident's complaints of pain, which the resident expressed during observations of her feet on 07/29/14. The VPHS provided copies of pain assessments completed on 05/22/14, 06/03/14, 06/05/14, 06/22/14, and 07/24/14. These pain assessments indicated the resident did not have any pain and no interventions were necessary. The VPHS was again asked what the facility did regarding the resident's complaints of pain during the observation on 07/29/14. On the evening of 08/04/14, at approximately 4:00 p.m., the VPHS was once again asked what interventions the facility implemented regarding the resident's complaints of pain on 07/29/14. At 10:00 a.m. on 08/05/14, the VPHS was again asked about the provision of interventions for pain, related to the resident's complaints on 07/29/14. At the close of the survey, on 08/05/14 at 2:00 p.m., no information had been provided regarding interventions to address Resident #19's complaints of pain to the left heel, which she expressed on 07/29/14. .

Based on record review and staff interview, the facility failed to adequately assess / monitor and obtain timely medical intervention for one (1) of twenty-one (21) Stage II sample residents who was experiencing an acute change in condition. Resident #10, who was assessed upon admission on [DATE] as being continent of bowel, had twenty-seven (27) bowel movements (BMs) between her date of admission on [DATE] (with the first loose stool recorded on [DATE]) and until she expired on the early morning of [DATE]. Of those, twenty-one (21) BMs were described as "loose" and fourteen (14) of them were described as "incontinent". There was no evidence of any recognition by licensed nurses of the resident's frequent episodes of diarrhea until it was brought to their attention by therapy staff on [DATE], and no evidence of any assessment / monitoring of the resident's bowel elimination status (after it was identified by the therapy staff) until [DATE], when a nurse noted the resident had a recurrent fever and episodes of diarrhea and the physician gave orders for a stool culture and sensitivity. When the lab results came back positive for [MEDICAL CONDITION] (C diff) in her stool on [DATE], Resident #10 was placed in contact isolation and started on an antibiotic ([MEDICATION NAME]) to treat the infection. This lack of assessment / monitoring resulted in a delay in treatment for [REDACTED]. Findings include: a) Resident #10 Record review revealed this [AGE] year old female resident was admitted to the nursing facility [DATE] and expired [DATE]. Her [DIAGNOSES REDACTED]. The resident had been hospitalized for [REDACTED]. The antibiotic therapy continued at the nursing facility until [DATE]. According to her hospital history and physical examination [REDACTED]. There was no mention of any diarrhea or hyperactive bowel sounds in her hospital discharge summary dictated by the physician on [DATE]. According to the hospital discharge summary, her "(p)rognosis for further functional improvement is fair." -- Review of the admission nursing assessment dated [DATE] at 11:55 a.m., the nurse assessed Resident #10 as being continent of both bowel and bladder, and the nurse did not mark the assessment tool to indicate the resident was experiencing diarrhea. On a bowel incontinence assessment and progress notes form dated [DATE], a registered nurse (RN) wrote: "[DATE] Resident has been frequently incontinence of bowel through ARD (assessment reference date)." (Note the ARD referred to a seven-day period of time ending on [DATE].) Also on the form, the RN noted Resident #10 had been incontinent of bowel two (2) to three (3) times weekly, the stool was soft and brown, and section for recording the reason for the incontinence was marked through with a diagonal line. -- A review of care tracker reports for bowel and bladder detail showed Resident #10's first bowel movement (BM), following her admission to the facility on [DATE], was recorded at 10:44 p.m. on [DATE] and it was described as "loose". Of the twenty-seven (27) BMs recorded during her stay at the facility, twenty-one (21) of them were described as "loose" and fourteen (14) were described as being "incontinent". There were twenty-one (21) episodes of loose stool during a 16-day period from [DATE] to [DATE]. This was discussed with the vice president of health services (Employee #67), who provided the care tracker sheets, on the morning of [DATE]. -- Review of the medication administration record (MAR) for [DATE] found the resident was receiving [MEDICATION NAME] 17 grams in 8 ounces of water daily (in the morning) for constipation, as well as Power Pudding 1 ounce by mouth twice daily for constipation, both of which had been ordered on admission. The nurses' initials for all scheduled doses of the [MEDICATION NAME] from [DATE] to [DATE] were circled (to indicate they were not given). The nurses' initials for the Power Pudding were circled for the following scheduled doses: 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. and 10:00 p.m. on [DATE], and 10:00 a.m. on [DATE]. Documentation explaining why these doses of [MEDICATION NAME] and Power Pudding were not administered was absent from the reverse side of the MAR and the nursing notes except for the missed doses of [MEDICATION NAME] and Power Pudding due to have been administered at 10:00 a.m. [DATE]; the explanation written on the reverse side of the MAR for not administering these doses was (quoted as written): "held due to residents c/o loose stools." -- Review of the nursing notes in Resident #10's medical record revealed the following entries (quoted as written): - [DATE] at 1:10 a.m. - "VS (vital signs) - ,[DATE] (blood pressure), 99.8 (temperature), 64 (pulse), 20 (respirations). Resting in bed /c (with) eyes closed. Requires assist /c ADLs (activities of daily living), transfers & mobility. Therapy ordered." - [DATE] at 1:20 a.m. - "VS - ,[DATE], 99.6, 81, 17. Resting in bed /c eyes closed, Requires assist /c ADLs, transfers & mobility. Therapy ordered." - [DATE] at 2:50 a.m. - "Temp. re-(checkmark) still 99.6. Tylenol 650 po (by mouth) given per S.O. (standing orders)." - [DATE] at 6:00 a.m. - "Temp. re-(checkmark) 98.2." - [DATE] at 7:00 a.m. - "Wt. (weight) ,[DATE] - 94.0 (pounds). Wt. ,[DATE] - 87.1 (pounds). 6.9lb wt loss. No IBW (ideal body weight) available. Dietician notified. Will re wt (reweigh) tomorrow." - [DATE] at 8:10 a.m. - "Dr. (name) in facility. Made aware of 6.9lbs wt. loss since admission." - [DATE] at 10:10 a.m. - "Resident needs assistance /s ADLs, mobility and transfers. Works /c therapy as ordered. Therapy reports resident had loose, incontinent stools this morning." - [DATE] - "Notified Dr. (name) of Residents sporadic diarrhea episodes. No new orders received." - [DATE] at 6:00 p.m. - ",[DATE], 99.1 - 62 - 24. OOB (out of bed) to w/c (wheelchair). No C/Os (complaints) voiced needs assist /c ADLs, transfers & bed mobility. Call bell within reach." - [DATE] at 1:50 a.m. - "VS - ,[DATE], 100.6, 82, 22. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered." - [DATE] at 4:00 a.m. - "Temp. re-(checkmark) 100.1." - [DATE] at 7:00 a.m. - "Tem. re-(checkmark) 98.7." (Note these entries are out of chronological sequence, as the above entry was recorded on the bottom of a page of progress notes, while earlier entries beginning at 11:00 a.m. on [DATE] were recorded at the top of a new page of progress notes.) - [DATE] at 2:10 a.m. - "VS - ,[DATE], 100.2, 94, 18. Was given [MEDICATION NAME] @ 12:30 A. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered." - [DATE] at 5:00 a.m. - "Temp. re-(checkmark) 98.9." - [DATE] at 1:25 a.m. - "VS - ,[DATE], 100.2, 93, 24. [MEDICATION NAME] was given @ 12:30 A. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered." - [DATE] at 5:00 a.m. - "Temp. re-(checkmark) 98.6. " - [DATE] at 9:00 a.m. - "Resident has recurrent fever & diarrhea. Dr. (name) informed. New orders received. ..." - [DATE] at 11:05 a.m. - "Dr. (name) in to see residents mouth. See physicians orders for new orders." - [DATE] at 1:00 p.m. - "(name) from PCH lab called and reported to report positive [MEDICAL CONDITION] culture on recent stool specimen." - [DATE] at 3:30 p.m. - "New order received to move to room (#) and for contact isolation d/t (due to) (+) (positive) [MEDICAL CONDITION]. MPOA informed and Resident informed of room move & (+) [MEDICAL CONDITION] - verbalized understanding." - [DATE] at 6:30 p.m. - "See new orders." - [DATE] at 8:00 a.m. - "... [MEDICATION NAME] for [MEDICAL CONDITION]. Afebrile 97.9. Refused AM (morning) mouth care, refused breakfast. Remains in contact isolation." - [DATE] at 8:00 a.m. - "Dr. (name) informed that resident is refusing meds. New order for labs received." - [DATE] at 9:40 a.m. - "(Name) MPOA informed residents is refusing meds & of new orders. MPOA states she does not want resident sent to ER (emergency room ) @ this time. Resident also states she does not want to go to ER @ this time." - [DATE] at 5:50 p.m. - "Resident refusing meds. No C/O (complaints of) pain at this time. Resident also refused dinner. Call bell in reach." [DATE] at 12:25 a.m. - "Called to resident's room by CNA (certified nursing assistant). Noted to have no heartbeat, no VS X 2 nurses." There were no nursing notes between [DATE] and [DATE] addressing findings of loose stool or diarrheal episodes. There was no intervention until [DATE] when the physician ordered lab testing to rule out[DIAGNOSES REDACTED]. When the lab results came back positive for[DIAGNOSES REDACTED] on [DATE], the resident was placed in contact isolation and the physician started [MEDICATION NAME] (an antibiotic) to treat this infection. -- Review of the nutritional assessment completed by the registered dietician on [DATE] and dietary progress notes entered between [DATE] and [DATE], found no mention of the resident's frequent episodes of diarrhea and no recognition of the impact this diarrhea could have on the resident's nutrition and hydration needs. The assessment did, however, identify that constipation (not diarrhea) placed the resident at risk for dehydration. -- Review of Resident #10's physician orders [REDACTED]. - [DATE] - Tylenol 650 by mouth every four (4) hours as needed for elevated temperature - [DATE] - Discontinue [MEDICATION NAME] ,[DATE] mg every six (6) hours as needed for pain and administered [MEDICATION NAME] ,[DATE] mg every (6) hours for pain (scheduled doses instead of "as needed") - [DATE] - Check stool for CDT (C diff toxin) and culture and sensitivity - [DATE] - [MEDICATION NAME] oral suspension 5 cc four-times-daily swished for fourteen (14) days - [DATE] at 3:30 p.m. - Move to Room (#) due to positive[DIAGNOSES REDACTED]. Contact isolation due to[DIAGNOSES REDACTED]. - [DATE] at 6:15 p.m. - [MEDICATION NAME] 500 mg every eight (8) hours for fourteen (14) days for[DIAGNOSES REDACTED] - [DATE] - Move to Room (#) - [DATE] - CBC (complete blood count), CMP (comprehensive metabolic panel) - decreased po (oral) intake - on [DATE] - [DATE] - May release body to (Name) Funeral Home -- In an interview with the physician at 10:35 a.m. on [DATE], he had no further information about why intervention(s) were not started prior to [DATE] to address Resident #10's loose stools, given that the resident was known to have been receiving antibiotics for an extended period of time and that antibiotic use is a contributing factor to the development of[DIAGNOSES REDACTED] infections. -- The assessor encoded the re-entry minimum data set assessment (MDS) with an ARD of [DATE] to indicate the resident was frequently incontinent for bowel. An MDS with an ARD of [DATE] also indicated the resident was frequently incontinent of bowel. A care plan based on the MDS of [DATE] stated the resident had a [DIAGNOSES REDACTED]." Interventions included: "Observe, document and report s/s UTI i.e.: dysuria, polyuria, fever, increased confusion, lower flank pain, hematuria and etc. to notify MD prn (as needed)." On [DATE], the care plan was revised to reflect the positive culture for[DIAGNOSES REDACTED]. Interventions were to observe and report signs and symptoms such as diarrhea, abdominal cramping, and distinct bowel movement odor and to implement contact isolation per order. -- The above was discussed with the senior vice president (Employee #5) on the afternoon of [DATE], to allow the facility to obtain and present any additional information to the survey team. No additional information was provided as of the time of exit. .

Based on medical record review, review of facility protocol, staff interview, physician interview, and review of information published by the American Diabetic Association, the facility failed to provide clear and precise instructions to nursing staff concerning when to notify the physician of elevated blood glucose levels for residents with diabetes. This deficient practice resulted in repeated untreated episodes of [MEDICAL CONDITION] for two (2) of four (4) sampled residents, with one (1) of these residents requiring hospitalization . Residents #65 and #49 were both ordered Accu-checks four-times-a-day (qid); prior to meals and at bedtime. Both residents displayed pre-meal blood glucose levels greater than 200 mg/dl on multiple occasions with no evidence of physician notification. Resident #65's [MEDICATION NAME] was discontinued shortly after her admission in response to the pharmacist's recommendation. This antiglycemic medication was not replaced with an alternate form of treatment. The resident suffered harm when her blood glucose level reached 512 mg/dl and she required hospitalization . This resident's blood glucose level was recorded to be greater than 300 mg/dl on three (3) occasions immediately prior to her hospitalization . The facility could provide no evidence that clear and precise instructions were provided to nursing staff members to ensure the physician was notified of these increased blood glucose levels. Resident #49 experienced multiple episodes of [MEDICAL CONDITION] prior to the physician being notified. Resident identifiers: #65 and #49. Facility census: 64. Findings include: a) Resident #65 Resident #65 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her medical record found her admission physician orders [REDACTED]. She was also ordered Accu-checks qid to be administered prior to meals and at bedtime. Review of her documented glucose levels found she was admitted with a blood glucose of 118 mg/dl. Review of the medication regimen review, dated 01/19/11, found the pharmacist recommended the resident's [MEDICATION NAME] be discontinued due to laboratory results indicating decreased renal function. He further recommended adding [MEDICATION NAME] if needed. The recommendation was agreed to by the physician, and her [MEDICATION NAME] was discontinued on 01/21/11. The physician did not order [MEDICATION NAME] or any other antiglycemic medication. The medical record contained no orders, parameters, or instructions to nursing staff members to inform the physician of hyperglycemic episodes. Review of the American Diabetic Association 2011 guidelines found [MEDICAL CONDITION] was defined as a blood glucose level great than or equal to 200 mg/dl at any time. Further review of the diabetic monitoring documentation found the resident's blood glucose was recorded as follows: - 291 mg/dl at 11:45 a.m. on 01/29/11, - 285 mg/dl at 8:00 p.m. on 01/29/11, - 308 mg/dl at 11:45 a.m. on 01/30/11, - 324 mg/dl at 8:45 p.m. on 01/30/11, - 265 mg/dl at 6:45 a.m. on 01/31/11, and - 361 mg/dl at 4:45 p.m. on 01/31/11. The facility could provide no evidence that staff notified the physician concerning these hyperglycemic episodes. A nursing note, at 9:05 a.m. on 01/31/11, documented the resident's blood glucose reading to be 512 mg/dl. The resident was transported to the hospital where she was determined to be suffering from a urinary tract infection. She was returned to the facility with orders for insulin injections of [MEDICATION NAME] 5 mg to be administered at bedtime. In an interview on 03/09/11 at 1:00 p.m., the resident's physician agreed the facility did not have procedures in place to contact him when a resident's blood glucose level reached defined parameters. He stated a protocol would be developed for nursing staff to follow. -- b) Resident #49 Review of the medical record found this resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the diabetic monitoring record found the resident's blood glucose levels were greater than 200 mg/dl on 02/10/11, 02/11/11, 02/12/11, 02/13/11, and reached 296 mg/dl at 11:45 a.m. on 02/14/11. The physician was not notified of these episodes of [MEDICAL CONDITION] until 02/15/11. He ordered the resident's [MEDICATION NAME] to be increased to 10 mg bid on 02/15/11. Review of the resident's blood glucose levels following the increase in medication noted documentation of [MEDICAL CONDITION] with levels above 200 mg/dl on a daily basis from 02/15/11 until the physician was notified on 03/01/11. The resident's blood glucose was documented to be: - 315 mg/dl on 02/19/11 at 11:45 a.m., - 305 mg/dl on 02/19/11 at 4:45 p.m., - 322 mg/dl on the morning of 02/24/11, and - 398 mg/dl on 02/25/11 at 4:45 p.m. After notification on 03/01/11, the physician ordered Actos 15 mg to be added to her medication regimen. In an interview on 03/07/11 at 2:00 p.m., a registered nurse (RN - Employee #84) confirmed that nursing staff members were provided no orders or parameters instructing nursing staff to contact the physician for episodes of [MEDICAL CONDITION].