Every finding on record at Glisan Post Acute

Based on observation, interview and record review it was determined the facility failed to properly store food and failed to maintain sanitary conditions for 1 of 1 unit refrigerators and 1 of 1 unit freezers. This placed residents at risk for food borne illness and contaminated food. Findings include:The facility's 11/2022 Food Receiving and Storage Policy indicated:-All foods stored in the refrigerator or freezer are covered, labeled and dated; and;-Foods in the walk-ins are stored off the floor. On 3/9/26 at 9:03 AM, observation of the unit refrigerator and the unit freezer revealed the following items:-Two unlabeled, undated plastic bags of hot dogs;-One unlabeled, undated large container of sliced pepperonis;-One unlabeled, undated small container of lemon wedges;-One unlabeled, undated large container of shredded cheese;-One unlabeled plastic container of pulled pork;-One unlabeled medium container of corn dated 3/2;-One unlabeled medium container of chicken fried steak dated 2/17;-One unlabeled medium container of spaghetti sauce dated 12/3;-One box of opened ice cream bars stored on the floor of the freezer;-One box of opened bags of corn stored on the floor of the freezer;-Two unlabeled, undated plastic bags of premade egg patties stored on a shelf in the freezer. On 3/9/26 at 9:31 AM Staff 4 (Dietary Manager) acknowledged the unlabeled and undated food items and the food stored on the floor of the freezer and stated food items should be labeled, dated and stored off the floor.

Based on observation, interview and record review it was determined the facility failed to ensure appropriate use and disposal of personal protective equipment in accordance with CDC guidelines and failed to ensure the separation of soiled and clean linens for 1 of 1 facility. These failures placed residents at risk for infections and cross contamination. Finding include: The CDC's 2/11/25 Eye Protection for Infection Control website, https://www.cdc.gov/niosh/ppe/eye-safety/infection-control.html, specified to remove eye protection, such as face shields, by only handling the parts that secure it to the head (like plastic temples, elastic bands, or ties) and to avoid touching the front of face shields, as those surfaces are most likely contaminated by sprays or droplets. Non-disposable eye protection should be placed in a designated container for cleaning and disinfection. The facility's Droplet/Contact Precautions sign dated 5/2020 included the following: - Wear eye protection (face shield or goggles).- Remove mask and eye cover from earpiece or ties to discard - do not grab from front of mask.The facility's Laundry and Linen Policy dated 1/2014 included the following:- Separate soiled and clean linen at all times.- Consider all soiled linen to be potentially infectious and handle with standard precautions.1. rooms [ROOM NUMBERS] were identified as Transmission Based Precautions (TBP) rooms where COVID-19 positive residents resided.On 3/9/26 at 11:45 AM, Staff 24 (CMA) stated before going inside of rooms [ROOM NUMBERS], everyone was required to don PPE (Personal Protective Equipment), including a face shield due to the two rooms being on TBP Droplet Precautions. On 3/9/26 at 12:20 PM, Staff 35 (CNA) was observed exiting room [ROOM NUMBER] after delivering a meal. She was observed using her ungloved hand to remove the face shield from the front to remove it from her head and placed it behind the hand rails of the wall near room [ROOM NUMBER]. At 12:29 PM, Staff 35 was observed donning PPE, retrieving the face shield from behind the hand rails of the wall, and donning the face shield before entering room [ROOM NUMBER]. At 12:31 PM, Staff 35 was observed exiting room [ROOM NUMBER], removed the face shield by using her ungloved hand on front of face shield, and placing it behind the hand rails of the wall near room [ROOM NUMBER].Observations on 3/10/26 at 8:36 AM, 3/10/26 at 1:31 PM and 3/11/26 at 5:24 AM revealed a face shield was tucked behind the hand rails of the wall near room [ROOM NUMBER].On 3/10/26 at 8:40 AM, Staff 29 (CNA) was observed donning PPE and entered room [ROOM NUMBER] without a face shield.On 3/10/26 at 8:45 AM, Staff 35 was observed entering room [ROOM NUMBER] without a face shield.On 3/10/26 at 1:59 PM, Staff 29 was observed entering room [ROOM NUMBER] without a face shield. At 2:02 PM, Staff 29 stated she knew some staff wore the face shield and others did not. Staff 29 stated she did not wear a face shield, because she used two masks and had her own personal eyeglasses on. On 3/10/26 at 2:21 PM, Staff 36 (CNA) came out of room [ROOM NUMBER] with an N95 and face shield on. She was observed removing her face shield and placing it inside of the PPE cart. Staff 36 was observed still wearing the N95, entering the soiled linen room, then entering nurse's station where she was observed doffing her N95. On 3/11/26 at 5:56 AM, Staff 37 (CNA) was observed entering room [ROOM NUMBER] without donning PPE to deliver a pitcher of water and came out. At 6:08 AM, Staff 37 was observed entering room [ROOM NUMBER] without donning PPE to deliver briefs and came out. On 3/12/26 at 10:51 AM, Staff 38 (LPN/Infection Preventionist) stated she expected staff to follow the signage for TBP Droplet Precautions, including donning PPE and a face shield before staff enter a room. She stated all PPE must be removed before exiting the room, but the face shield could be reused if it was cleaned and disinfected. She stated she expected staff to not handle the face shield by the front, as the front of the face shield could potentially be contaminated. On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated if a resident room was identified on TBP for Droplet Precautions, staff were expected to don the required PPE before crossing through the doorway of the room. Staff 2 stated appropriate PPE included a gown, gloves, respirator and face shield which should be donned prior to entrance and doffed upon exit. Staff 2 stated face shields could be reused if cleaned and disinfected, but not stored in or on PPE carts or behind hand rails of the wall. 2. Observations on 3/11/26 at 6:14 AM revealed Staff 43 (CNA) placing clean linens onto a shelf inside of the [NAME] hall shower room. Observed inside of the shower room were a covered barrel with trash, a covered barrel with soiled linens, and folded wash cloths and bath towels on top of a shower chair. Staff 43 stated when residents were ready to shower, staff took out the barrels for residents to shower. Staff 43 acknowledged a clean linen room was directly across from the shower room and stated she replenished clean linens in both rooms.Observations on 3/12/26 at 8:24 AM revealed folded towels on top of a shower chair, clean linens on a shelf above two barrels, and staff placing a bag into the soiled linen barrel located inside of the [NAME] hall shower room. On 3/12/26 at 10:17 AM, Staff 44 (CNA) stated the garbage barrel and soiled linen barrel were stored inside of the [NAME] hall's shower room due to inadequate space. Staff 44 stated clean linens were not supposed to be stored in the shower room, as there was a clean linen storage across from the shower room. She stated clean linens were placed in the shower room when a resident was ready to shower immediately.On 3/12/26 at 10:51 AM, Staff 38 (LPN/Infection Preventionist) stated clean linens and soiled linens were expected to be kept and stored separately due to the risk of cross contamination. Staff 38 acknowledged the [NAME] hall had a garbage barrel and a soiled linens barrel inside of the shower room, as well as a clean linen storage room directly across from the shower room. Staff 38 stated she expected for staff to store clean linens in the clean linen storage room and not in the shower room. On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for clean linens to be stored separately from soiled linens to prevent cross contamination.

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 4 medication carts and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include: The facility's undated Storage of Medication Policy indicated only licensed nurses, pharmacy staff and those lawfully authorized to administer medications (such as medication aides) are allowed access to the medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. 1. On 3/11/26 from 5:08 AM to 5:22 AM, an unlocked and unattended treatment cart was observed in the east hall across from the nurse's station. Two boxes of enoxaparin (an injectable anticoagulant [blood thinner]) for Resident 15 were observed on top of the cart. CNA staff were in the area, one resident was observed to self-propel in her/his wheelchair near the cart, and the contents of the cart were accessible. On 3/11/26 at 5:22 AM, Staff 37 (LPN) acknowledged the treatment cart was unlocked and unattended and confirmed the cart contained insulins. Staff 37 stated the cart should be locked at all times when unattended and medications should not be stored on top of the cart. On 3/12/26 from 3:33 PM to 3:37 PM, an unlocked and unattended medication cart was observed on the south side of the facility. CNA staff were in the area, and the contents of the cart were accessible. On 3/12/26 at 3:37 PM, Staff 16 (CMA) acknowledged the medication cart was unlocked and unattended and confirmed the cart contained all of the day and evening shift medications for the residents in Rooms 131 through 138. Staff 16 stated the cart should be locked at all times when unattended. 2. On 3/11/26 at 11:17 AM a treatment cart was observed to be unlocked and unattended in the Intermediate Care Facility (ICF) hallway near the nurse's station. On 3/11/26 at 11:21 AM Staff 9 (RN) returned to the treatment cart and stated he left the cart unlocked and unattended. The cart contained residents' insulin, creams and other treatment supplies. On 3/11/26 at 11:25 AM Staff 2 (DNS) stated it was her expectation for the treatment carts to be locked when unattended. On 3/13/26 at 12:40 PM, Staff 2 (DNS) stated she expected medications to be stored inside a locked medication cart when not in use and the medication and treatment carts to be locked and secured at all times when unattended.

Based on observation, interview and record review it was determined the facility failed to ensure residents were comprehensively assessed to independently perform tracheostomy care and a person-centered care plan was developed for respiratory care for 1 of 1 sampled resident (#62) reviewed for respiratory care. This placed residents at risk for respiratory distress and unmet needs. Findings include:The facility's 8/2024 Respiratory Treatment Policy and Procedure indicated residents received respiratory treatments and monitoring according to their physician orders, standards of practice and care plan. Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing). Resident 62's 2/20/26 Nursing admission Assessment indicated the resident was cognitively intact, nonverbal and communicated her/his needs in writing. Resident 62's 2/20/26 Respiratory Care Plan indicated the following:-Provide respiratory treatments as ordered. -Tracheostomy care each shift and as needed. A 2/20/26 Progress Note written by Staff 12 (RN) revealed Resident 62 had a tracheostomy that was intact, and she/he was competent with self-directed suctioning with help with trach set ups. Resident 62's 2/24/26 Physician Orders directed the following:-The resident's laryngectomy tube insertion site was to be cleaned with soap and water or normal saline every day shift and as needed using a clean technique (a set of infection control practices that involve meticulous handwashing, maintaining a clean workspace and using clean, non-sterile gloves). -The resident's stoma was to be cleaned with a saline soaked cotton swab every day and as needed. -The resident's tracheostomy ties (a securement device used to hold a tracheostomy tube securely in place, preventing accidental dislodgement or movement) were to be changed on Mondays, Thursdays and as needed. -The resident's laryngectomy tube (a short, soft, flexible silicone tube inserted into the stoma after a total laryngectomy) could be removed and cleaned with normal saline every two hours as needed but should otherwise stay in place. Resident 62's 2/25/26 Self-Administration of Medication Observation Evaluation revealed the resident was determined to be appropriate to complete oral and laryngectomy tube suctioning (procedures used to remove mucus and secretions from the airway through a stoma) independently. A review of Resident 62's 3/2026 TAR revealed laryngectomy site care was completed and the resident's stoma was cleaned with a saline soaked cotton swab every day outside of 3/2/26 when the resident refused and on 3/4/26 when the resident was hospitalized . The TAR also revealed the resident's tracheostomy ties were changed on 3/2/26, 3/5/26 and 3/9/26, and the resident's laryngectomy tube was not removed and cleaned.No evidence was found in Resident 62's clinical record to indicate the type or size of the resident's laryngectomy tube. On 3/10/26 at 2:12 PM, Resident 62 was observed in her/his room in bed. Resident 62 used a pen and paper to communicate with the state surveyor. Resident 62 stated she/he completed all of her/his tracheostomy care independently. On 3/11/26 at 6:32 AM, Resident 62 stated in writing she/he was going to perform her/his tracheostomy care and offered for the state surveyor to observe. Without washing or sanitizing her/his hands or donning a pair of gloves, Resident 62 retrieved a partially opened package containing a laryngectomy tube and a wipe from an overbed table positioned on the left side of her/his bed and placed it on her/his stained sheets. A book was observed on top of a pink-stained wash cloth on an overbed table to the right of the resident's bed. The resident placed a free-standing mirror on top of the book and removed her/his tracheostomy tie and the laryngectomy tube. The resident placed the blood-tinged tube on the right side of the overbed table on top of the stained washcloth. The resident used the wipe located inside of the partially opened package that also contained a new laryngectomy tube and quickly wiped her/his stoma. Without performing any hand hygiene, the resident removed the new laryngectomy tube from the partially opened package, inserted it into her/his stoma, and attempted to secure the tracheostomy tie. From 6:39 AM to 6:51 AM, the resident attempted but was unable to re-thread her/his tracheostomy ties, and during this time period, placed the new laryngectomy tube both on her/his lap and on the stained washcloth. At 6:52 AM, the resident motioned for the state surveyor to assist her/him to thread the left side of the tracheostomy collar. The state surveyor indicated she was unable to assist with this process, and the resident declined the state surveyor's offer to obtain staff assistance. At 6:55 AM, the resident was able to secure the tracheostomy ties and placed gauze underneath the collar on either side of her/his stoma. On 3/11/26 at 10:36 AM, Staff 13 (RN) stated Resident 62 completed her/his tracheostomy care independently since her/his admission to the facility. Staff 13 stated he informed the resident how to perform tracheostomy care, but he had never observed the resident to complete the care. Staff 13 stated his documentation on the TAR for the resident's tracheostomy care indicated the resident had completed the task. Staff 13 stated he did not know the size or type of the resident's laryngectomy tube. Staff 13 further stated this information should be in the resident's physician orders and confirmed it was not. On 3/11/26 at 11:23 AM, Staff 14 (Respiratory Therapist) stated she verbally went over the procedure for tracheostomy care with Resident 62, including changing out the laryngectomy tube, but she had never observed the resident to do a return demonstration of the procedure. Staff 14 stated the resident seemed pretty capable and knew enough of herself/himself, I felt like he would be okay. Staff 14 stated she usually obtained the type and size of a resident's laryngectomy tube at admission and thought Resident 62's laryngectomy tube was a size ten. On 3/11/26 at 11:35 AM, Staff 15 (RN) stated Resident 62 completed all of her/his tracheostomy care independently, and her documentation in the resident's TAR indicated she confirmed with the resident she/he had completed the care. Staff 15 stated she provided the resident with education about hand hygiene during tracheostomy care but had not provided education on how to clean her/his laryngectomy tube nor had she observed the resident to clean the used tube. Staff 15 further stated she thought the resident's laryngectomy tube was a size eight but she needed to check the resident's physician orders to confirm the size. On 3/11/26 at 12:45 PM, Staff 9 (RN) stated Resident 62 completed tracheostomy care independently. Staff 9 stated he provided education to the resident about wearing gloves during tracheostomy care but the resident used her/his bare hands. Staff 9 further stated he did not know the size or type of laryngectomy tube the resident utilized but thought he could find this information in the resident's physician orders. On 3/11/26 at 1:01 PM, Staff 17 (LPN Resident Care Manager) stated licensed nurses were expected to observe tracheostomy care for a resident, even if the resident preferred to complete the care independently, unless a Self-Administration of Medication Observation Evaluation was completed. Staff 17 also stated information on the size and type of laryngectomy tubes should be in a resident's physician orders and care plan. Staff 17 stated Resident 62 had not been assessed to complete tracheostomy care independently and no information on the size and type of her/his laryngectomy tube was in either her/his physician orders or care plan. On 3/11/26 at 3:24 PM, Staff 12 stated Resident 62 informed him that she/he was able to perform all care related to her/his tracheostomy independently. Staff 12 stated he observed the resident to change out the gauze under her/his tracheostomy tie on 2/20/26, and the resident did not wear gloves or perform hand hygiene prior to completing this care task. Staff 12 stated he had never observed the resident to remove or insert the laryngectomy tube, clean the laryngectomy tube insertion site with soap and water or normal saline or use a cotton swab to clean her/his stoma. On 3/11/26 at 1:12 PM and 3:30 PM, Staff 2 (DNS) stated laryngectomy type and size information should be included in a resident's care plan and confirmed this information was not in Resident 62's care plan. Staff 2 stated a resident who wanted to complete tracheostomy care independently was required to complete a return demonstration of the care tasks to a licensed nurse prior to doing so independently. Staff 2 confirmed Resident 62 had not been comprehensive assessed to perform tracheostomy care independently and should have been.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 3 of 3 sampled residents (#s 10, 13 and 60) reviewed for self-administration. This placed residents at risk for unsafe medication administration. Findings include:The facility's Self Administration of Medication dated 8/2024 included the following:- No medications are stored at bedside nor self-administered until evaluation complete.- A physician order is obtained indicating the specific medications that resident is able to self-administer.- If the resident chooses to have the medications at the bedside, they are contained in a locked cupboard or drawer.- Medications are indicated on the MAR as self-administered. - The resident is reevaluated for continued ability to self-administer their medications annually and with significant change in condition.1. Resident 60 was admitted to the facility 7/2025 with diagnosis of metabolic encephalopathy (a syndrome of global brain dysfunction caused by underlying systemic illnesses). The Quarterly MDS with an ARD of 12/7/25 revealed Resident 60 had a BIMS score of 13, which indicated the resident was cognitively intact.Observations on 3/9/26 at 10:52 AM, 3/10/26 at 7:19 AM, and 3/12/26 at 8:29 AM revealed Resident 60 had Calcium Magnesium, Benadryl (over-the-counter antihistamine), Calamine lotion (over-the-counter topical medication), multivitamins, and Cetirizine Hydrochloride (over-the-counter antihistamine) on her/his nightstand and bedside table. A review of Resident 60's clinical record revealed no self-administration assessment for Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride.A review of Resident 60's Medication Administration Record for 3/2026 revealed no indication for medications to be self-administered.On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse.On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse.On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse.On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:43 AM, Staff 22 stated Resident 60 was known to purchase her/his own medications from outside of the facility and bring them back to her/his room. At 9:45 AM, Staff 22 entered Resident 60's room and confirmed she/he had Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride in her/his room.On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:47 AM, Staff 23 entered Resident 60's room and confirmed she/he had Calcium Magnesium, Benadryl, Calamine lotion, multivitamins, and Cetirizine Hydrochloride in her/his room.On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file.2. Resident 13 was admitted to the facility 5/2023 with diagnosis of calculus of kidney (solid mineral that forms in the kidneys). The Quarterly MDS with an ARD of 12/11/25 revealed Resident 13 had a BIMS score of 15, which indicated the resident was cognitively intact.Observations on 3/9/26 at 10:22AM, 3/11/26 at 11:23 AM and 3/12/26 at 9:49 AM revealed Resident 13's dresser had a bottle of Vitamin B12, a bottle of Caltrate bone vitamins (high-potency calcium and Vitamin D3) and a box of artificial tears. Resident 13's bedside table was also observed to have a bottle of phenol throat spray (over-the-counter antiseptic and anesthetic spray). A review of Resident 13's clinical record revealed she/he had a self-administration assessment from 10/11/24 for Vitamin B Complex. The clinical record revealed no self-administration assessment for the last 12 months for Vitamin B12, Caltrate bone vitamins, artificial tears, or phenol throat spray.A review of Resident 13's Medication Administration Record for 3/2026 revealed no indication for medications to be self-administered.On 3/9/26 at 10:22 AM, Resident 13 stated she/he thought it was okay to have the medications in her/his room and had been using the throat spray to relieve her/his throat.On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse.On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse.On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse. On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:49 AM, Staff 22 entered Resident 13's room and confirmed she/he had a bottle of Vitamin B12, a bottle of Caltrate bone vitamins, a box of artificial tears and a bottle of phenol throat spray in her/his room. Staff 22 stated Resident 13 was not authorized to self-administer the medications.On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:46 AM, Staff 23 entered Resident 13's room and confirmed there was a bottle of Vitamin B12, a bottle of Caltrate bone vitamins, a box of artificial tears and a bottle of phenol throat spray in her/his room. and confirmed she/he needed to have a self-administration assessment on file. On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected for staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file and self-administration assessments should be reviewed at least once a year.3. Resident 10 was admitted to the facility 1/2026 with diagnosis of cellulitis of right lower limb. The Admissions MDS with an ARD of 1/18/26 revealed Resident 10 had a BIMS score of 15, which indicated the resident was cognitively intact. Observations on 3/9/26 at 11:10 AM and 3/13/26 at 10:48 AM revealed Resident 10 had a bottle of nasal saline solution on her/his bedside table.A review of Resident 10's clinical record revealed no self-administration of medication assessment was completed to determine the resident's ability to safely self-administer nasal saline solution.On 3/9/26 at 11:10 AM, Resident 10 stated staff had given her/him the saline solution to use independently.On 3/12/26 at 8:49 AM, Staff 29 (CNA) stated she was unaware of any residents being authorized to self-administer medications. She stated if she saw medications at a resident's bedside, she would inform a nurse.On 3/12/26 at 9:33 AM, Staff 11 (CNA) stated residents were not supposed to have medications at their bedside. She stated if she saw medications at a resident's bedside, she would tell a nurse.On 3/12/26 at 9:35 AM, Staff 24 (CMA) stated she ensured residents completely swallowed oral medications safely prior to exiting the room and any medications at the bedside would be reported to a nurse. Staff 24 stated she thought it was okay for Resident 10 to have the saline nasal solution. On 3/12/26 at 9:41 AM, Staff 22 (LPN) stated he did not know of many residents who were authorized to have medications at the bedside. At 9:43 AM, Staff 22 entered Resident 10's room and confirmed the saline nasal spray was on Resident 10's bedside table. Staff 22 stated Resident 10 needed a self-administration assessment. On 3/13/26 at 10:34 AM, Staff 23 (LPN Resident Care Manager) stated the process for residents to have medications at the bedside included having a self-administration assessment completed for residents. Staff 23 stated he expected for staff to inform management if they observed residents to have medications at the bedside. At 10:48 AM, Staff 23 entered Resident 10's room and confirmed there was nasal saline solution on Resident 10's bedside and confirmed she/he needed to have a self-administration assessment on file. On 3/13/26 at 1:22 PM, Staff 2 (DNS) stated she expected staff to inform nurses if medications were observed to be in a resident's room. Staff 2 stated residents should not have medications, unless a self-administration assessment was on file.

Based on interview and record review it was determined the facility failed to obtain dental services for 1 of 2 sampled residents (#16) reviewed for dental. This placed residents at risk for difficulty with eating. Findings include:Resident 16 was admitted to the facility in 10/2020 with diagnoses including malnutrition.A 12/8/25 Quarterly MDS indicated Resident 16 had a BIMS score of 15 which indicated Resident 16 was cognitively intact. A 10/27/20 Care Plan indicated staff coordinated and made arrangements for dental care services and indicated Resident 16 had her/his own teeth. A 7/22/25 Dental Treatment Summary indicated Resident 16 had all her/his teeth extracted. On 3/9/26 at 2:38 PM, Resident 16 stated she/he had all her/his teeth extracted eight months earlier, had repeatedly asked staff about getting dentures without receiving a response, and was having trouble chewing and eating.On 3/12/26 at 11:35 AM, Staff 42 (CNA) stated Resident 16 had her/his own teeth and did not require assistance to complete dental hygiene. On 3/12/26 at 12:21 PM and 1:26 PM, Staff 19 (Social Services Director) stated Resident 16's mouth was swollen after her/his teeth were extracted and she had not scheduled an appointment to begin the denture process. Staff 19 stated the in-house dentist also had not scheduled an appointment, noted the denture process typically began eight weeks after extractions, and acknowledged Resident 16 had not started the process. On 3/12/26 at 12:38 PM, Staff 43 (Social Services Assistant) stated during a care conference Resident 16 mentioned she/he wanted dentures. On 3/12/26 at 2:38 PM, Staff 28 (RN) stated she was unsure Resident 16 had dentures. On 3/13/26 at 11:35 AM, Staff 17 (LPN Resident Care Manager) stated she expected staff initiate the process to receive dentures within eight weeks after the resident had their teeth extraction. On 3/13/26 at 12:04 PM, Staff 2 (DNS) stated dental services were not provided timely for Resident 16. Staff 2 stated she expected staff to ensure appropriate dental services were provided.

Based on observation, interview and record review it was determined the facility failed to ensure a comfortable and homelike environment for 1 of 1 sampled resident (#1) reviewed for environment. This placed residents at risk for lack of a homelike environment and loss of sleep. Findings include:The facility's 2/2021 Homelike Environment Policy indicated the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including comfortable sound levels. Resident 1 was readmitted to the facility in 3/2023 with diagnoses including insomnia. Resident 1's 2/5/26 Quarterly MDS revealed the resident was cognitively intact. On 3/10/26 at 9:50 AM, Resident 1 was observed in her/his room in bed. Resident 1 stated the backdoor, located just outside of her/his room, was broken and the alarm attached to the door would ring and ring and ring when the door was not shut properly. Resident 1 stated the sound of the alarm was constant, and at night, it prevented her/him from sleeping. Resident 1 stated the residents at the facility were expected to just have to deal with the constant sound of the alarm. The door to the resident's room was shut, and at 10:05 AM, the sound of the alarm was heard inside the resident's room.On 3/10/26 from 2:32 PM to 3:54 PM and from inside Resident 1's room with the door shut, the alarm to the backdoor was observed to loudly sound on five different occasions. On 3/11/26 from 5:21 AM to 5:26 AM, the alarm to the backdoor was observed to loudly sound. At 5:34 AM, Resident 1 stated the sound of the alarm was very intrusive and makes you nuts, and stated she/he had complained about the noise to everybody and anybody who would listen. At 5:47 AM, the alarm to the backdoor sounded again. On 3/11/26 at 5:59 AM, Staff 20 (CNA) stated residents were constantly going in-and-out of the backdoor, so the alarm sounded all of the time at night. Staff 20 stated the alarm sounded the loudest in Resident 1's room, and he would loose his mind if he were a resident and had a room by the backdoor because of the constant sound from the door alarm. On 3/11/26 at 6:08 AM, Staff 21 (CNA) stated Resident 1 complained she/he can't stand the noise from the backdoor's alarm.On 3/12/26 at 8:36 AM, Staff 11 (CNA) stated Resident 1 complained the noise from the backdoor's alarm was annoying. Staff 11 further stated the door alarm sounded at least ten times during her shift. On 3/12/26 at 9:12 AM, Staff 22 (LPN) stated Resident 1 slept during the day. At 9:16 AM, the alarm to the backdoor sounded and Staff 22 excused himself to turn it off. Upon his return, Staff 22 stated the noise from the alarm was bothersome to the residents, and it sounded at all times of the day, including during the middle of the night. On 3/12/2026 at 11:58 AM, Staff 1 (Administrator) stated she expected staff to notify her of complaints regarding sound levels at the facility so she could implement systems to address the complaints. Staff 1 further stated she was unaware of Resident 1's complaint about the noise from the backdoor alarm and did not consider the alarm sounding throughout the day and night to constitute a homelike environment.

Based on observation, interview and record review it was determined the facility failed to complete comprehensive assessments in the areas of cognition and mood for 1 of 1 sampled resident (#62) reviewed for respiratory care. This placed residents at risk for inaccurate assessments and unassessed needs. Findings include:Resident 62 was admitted to the facility in 2/2026 with diagnoses including acquired absence of larynx (the surgical removal of the voice box [laryngectomy]) and encounter for attention to tracheostomy (a surgically created opening [stoma] in the front of the neck leading directly into the trachea [windpipe] to create a new airway for breathing). Resident 62's 2/26/26 admission MDS revealed the resident had no speech but was able to communicate to and understand others without difficulty. The MDS further revealed the Brief Interview for Mental Status (BIMS) and Resident Mood Interview (PHQ-2 to 9) were not completed as the resident was rarely/never understood. On 3/9/26 at 11:51 AM, Resident 62 was observed in her/his room. The resident was nonverbal but able to appropriately communicate with the state surveyor through written communication. On 3/11/26 at 11:54 AM, Staff 19 (Social Services Director) stated she was responsible for completing the BIMS and PHQ-2 to 9 interviews. Staff 19 stated she did not attempt a BIMS interview with Resident 62 because the resident was unable to verbally communicate. Staff 19 stated she entered the resident's room on one occasion to attempt the mood interview but was unable to start the interview as the resident was busy with nursing staff. Staff 19 stated she did not reattempt to complete the mood interview with the resident. On 3/11/26 at 1:12 PM, Staff 2 (DNS) stated she expected the BIMS and PHQ-2 to 9 interviews to be attempted with all residents using the residents' preferred method of communication. Staff 2 further stated she expected the staff to reapproach and reattempt the interviews if initially refused.

Based on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for 2 of 2 sampled residents (#s 3 and 72) reviewed for ADLs. This placed residents at risk for poor grooming and loss of dignity. Findings include:1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes. On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room. Resident 3's fingernails were long and contained a thick, skin-colored debris beneath the nails. The ADL Function CAA dated 8/14/25 indicated Resident 3 required maximum assistance with all ADLs. A Physician Order dated 9/10/25 directed a licensed nurse to check Resident 3's fingernails and toenails weekly on bath days and trim as needed. A review of the 2/2026 and 3/2026 TAR indicated a licensed nurse was to check Resident 3's fingernails and toenails weekly on bath days and trim as needed. On 3/10/26 at 2:22 PM Staff 10 (CNA) stated a licensed nurse would have to trim Resident 3's fingernails due to Resident 3 being diabetic. Staff 10 observed Resident 3's nails and stated they were long and needed to be trimmed. On 3/10/26 at 2:30 PM Staff 11 (CNA) stated she would cut or trim residents' nails if they were not diabetic. Staff 11 observed Resident 3's nails and stated the fingernails were long. During this observation, Resident 3 stated her/his fingernails needed to be cut and they hurt from being so long. On 3/10/26 at 3:18 PM Staff 8 (LPN) stated Resident 3 had previously told her she/he bit her/his fingernails, so she did not need to trim them. On 3/10/26 at 3:30 PM Staff 7 (LPN Resident Care Manager) stated Resident 3 was care planned to have her/his nails trimmed by a licensed nurse. Staff 7 further stated the resident had requested to have her/his nails cut and the resident had been treated for a fungal infection on the fingernails and toenails. Staff 7 observed Resident 3's fingernails and stated they were long and needed to be filed. Staff 7 asked Resident 3 when the last time staff had soaked her/his nails and the resident replied it had been a long time ago. On 3/10/26 at 4:30 PM and on 3/12/26 at 3:47 PM Staff 2 (DNS) stated she was aware Resident 3's fingernails were long and the resident was scheduled for weekly nail care by a licensed nurse. Staff 2 acknowledged Resident 3's fingernails had not been trimmed since admission to the facility and stated it had not been reported to her the resident had experienced pain related to the length of her/his fingernails. 2. Resident 72 was admitted to the facility in 12/2024 with diagnoses including schizophrenia (mental disorder) (men. Resident 72's 12/11/25 Annual MDS revealed the resident was able to make herself/himself understood and understand others without difficulty, required substantial-to-maximal assistance from staff with personal hygiene tasks and she/he did not reject care. Resident 72's 12/24/25 ADL and Behavior Care Plans revealed the following:-The resident preferred to bathe on Wednesday and Sunday evenings and required assistance from one person. -The resident required set-up assistance and encouragement as needed with hygiene. -The resident's behaviors included talking to herself/himself, hallucinations and delusions. A review of Resident 72's Personal Hygiene Task Log from 2/12/26 to 3/12/26 revealed the resident refused personal hygiene care on 2/18/26 and 2/27/26 but was otherwise cooperative. On 3/10/26 at 2:03 PM, Resident 72 was observed in her/his room in bed. [NAME] hair that curled at the end of some of the strands, approximately one inch in length, was observed on both sides of her/his chin. Resident 72 stated she/he did not have the opportunity to look in the mirror much, so she/he was not always aware if she/he had any facial hair. Resident 72 felt the hair on her/his chin, bothered her/him and wanted the facial hair removed. Resident 72 stated staff did not offer to trim her/his facial hair, but if they had, she/he would accept the offer. On 3/13/26 at 8:22 AM, Resident 72 was observed in her/his wheelchair in the dining room. Long white facial hair was observed on either side of the resident's chin. Resident 72 stated she/he wanted her/his chin hair removed but staff had not offered. On 3/13/26 at 8:54 AM, Staff 30 (CNA) stated residents were offered facial hair grooming when they received a shower. Staff 30 stated she did not work on Resident 72's scheduled shower days, so she had never offered to assist the resident to shave her/his facial hair, but the resident did not refuse care. On 3/13/26 at 9:01 AM, Staff 31 (CNA) stated residents were offered facial hair grooming when they received a shower, and she provided facial hair grooming outside of a scheduled shower only if the resident requested it. Staff 31 stated Resident 72 was really cooperative with care. Staff 31 further stated she had never offered to assist the resident with facial hair grooming, and she was unaware of the resident's facial hair preference. On 3/13/26 at 9:12 AM, Staff 32 (CNA) stated Resident 72 never refused care, but she/he did require some cueing and encouragement to get out of bed. Staff 32 stated she had not offered facial hair grooming assistance to Resident 72. On 3/13/26 at 9:57 AM, Staff 28 (RN) stated facial hair grooming was offered by CNAs to residents during their scheduled showers and as needed. Staff 28 stated Resident 72 was cooperative with care, and she had not received any reports of the resident refusing care, including facial hair grooming. On 3/13/26 at 10:02 AM, Staff 33 (LPN) stated she was unsure of Resident 72's preferences for facial hair but stated this information was found in the resident's Kardex (a quick reference that provides an overview of patient care plans). On 3/13/26 at 10:17 AM, Staff 34 (CNA) stated Resident 72 was cooperative with care, including with trimming her/his facial hair. Staff 34 stated she assisted the resident with a shower on 3/11/26 and she did not offer to assist the resident to trim her/his facial hair. On 3/13/26 at 12:27 PM, Staff 7 (LPN Resident Care Manager) stated facial hair grooming was a sensitive subject for some residents, so it was provided per resident request. Staff 7 stated she had not considered residents with a limited access to a mirror or residents who were unable to request the assistance may still be interested in receiving assistance with facial hair grooming. Staff 7 further stated facial hair grooming should be completed according to resident preference, and she was unaware of Resident 72's preference for facial hair.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 1 of 2 sampled residents (s 3) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life. Findings include: An undated Facility Activity Programs Policy Statement indicated:-Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident.-The activities program is provided to support the well-being of residents and to encourage both independence and community interaction.-Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.-The activities program is ongoing and includes facility organized group activities, independent individual activities and assisted individual activities.-Activities are scheduled 7 (seven) days a week.-Our activity programs consist of individual, small group and large group activities designed to meet the needs and interests of each resident.-All activities are documented in the resident's medical record.1 Resident 3 was admitted to the facility in 9/2025 with diagnoses including quadriplegia and Type 2 diabetes.Resident 3's 8/8/25 Activity Care Plan revealed the following:-The resident enjoyed Bible study, cell phone, music, one on one visits, individual activities versus group activities, television and friends and family visits.-In room activities were to be offered, which included an activity calendar, music, books, newspapers and magazines.Resident 3's 8/14/25 admission MDS indicated the resident was cognitively intact.A review of Resident 3's Activity Task Records for the 30-day period from 2/9/26 through 3/9/26 revealed no documented in-room activities, no documented one-to-one activity visits, and no documented participation in any facility activity programming.On 3/9/26 at 11:10 AM Resident 3 was observed in her/his room in bed. The resident required total assistance due to quadriplegia and was unable to independently engage in activities without staff assistance. No books, magazines or newspapers were visible in the resident's room. Resident 3 stated she/he enjoyed watching television, Bible study, seeing pets and visiting with family over the phone. Resident 3 stated she/he preferred to stay in her/his room and not participate in group activities.Observations of Resident 3 conducted on 3/9/26 through 3/13/26 during various times of the day revealed the resident remained in bed in her/his room with the television on. The resident was not observed participating in any activities, being offered in-room activity materials, or receiving one-to-one visits from activity staff. The resident's room did not contain activity materials such as books, magazines, newspapers, puzzles, music devices or other items identified in the resident's care plan.On 3/10/26 at 2:22 PM, Staff 10 (CNA) stated Resident 3 spent her/his time in her/his room in bed watching television. Staff 10 stated the resident required staff assistance to use the phone and primarily spoke with family when staff helped dial the number. Staff 10 stated she/he had not observed activity staff offer the resident in-room activities or visit the resident for one-to-one engagement.On 3/10/26 at 2:39 PM, Staff 11 (CNA) stated Resident 3 spent most of the day in bed watching television or movies. Staff 11 stated she/he had not observed Resident 3 participate in group activities or receive one-to-one visits from activity staff. Staff 11 stated she/he had not observed the resident being offered music, reading materials, or other in-room activity options.On 3/10/26 at 3:18 PM, Staff 8 (LPN) stated she was unsure what type of activities the resident preferred other than watching television or movies. Staff 8 stated the activity department was responsible for assessing resident interests and providing appropriate individualized activities.On 3/10/26 at 3:30 PM, Staff 7 (LPN Resident Care Manager) stated she was unable to show documentation to support Resident 3's activity engagement other than the care plan noting the resident preferred to remain in her/his room. Staff 7 confirmed she could not locate documentation showing the resident had been offered individualized or one-to-one activities.On 3/10/26 at 4:02 PM, Staff 6 (Activity Director) stated she had spoken with Resident 3 informally but acknowledged she did not document these interactions. Staff 6 stated she had not provided in-room activity materials and had not offered individualized activities such as music, reading materials, or other engagement options to the resident. Staff 6 stated although a volunteer provided Bible study on Saturdays, she had not offered the volunteer to visit Resident 3 individually.On 3/10/26 at 4:30 PM, Staff 2 (DNS) stated residents who are unable or unwilling to attend group activities should receive individualized, one-to-one activity engagement based on their interests and care plan.

Based on observation and interview it was determined the facility failed to ensure kitchen equipment and food preparation areas were maintained in a clean and sanitary manner for 1 of 1 kitchen reviewed for sanitary kitchen practices. This placed residents at risk of illness and contaminated food. Finding include: The facility's Cleaning and Sanitation of Department: Food and Nutritional Services policy, dated 12/11/15, indicated the following: -The food and nutritional services manager would assure compliance of all cleaning and sanitation tasks needed in the department. Observation of the facility's kitchen on 7/8/25 between the hours of 9:30 AM and 2:30 PM, revealed the following: -A fan was blowing directly into the food preparation area with numerous spots of dust and debris clumps on the fan covering. -There was an orange/brown hard coating completely covering the inside of each oven door, and a black, hard substance covering the entire bottom of the oven and on the oven racks. -The grill had hard, burnt substances on the cooking surface, sticky grease-like splashes and food particles on the grill doors, grease build-up and food particles along the top of the grill doors and in the vents on the lower portion of the grill. -The floor to the left of the grill, between the grill and the food steamer, had an orange, greasy-like substance starting at the front of the grill and going the to the back of the grill. -There was a black substance on the flooring behind the steamer, around a pipe and along the wall edge. -The flooring under the steel prep counter next to the food steamer, which housed bulk food bins of oatmeal, flour and sugar, had a black substance under each bulk bin. The bulk bins had spills and food particles on the outside of the containers and on the lids. -Dried food particles and spills were on the facility's large commercial mixer and the mixer stand. -The food preparation steel counter used to cut and prep food and store clean cookware and cutting boards had numerous food particles and an approximate three inch round object of unknown substance in contact with clean pans and cutting boards. -The steam cart's lower shelf, which stored clean cooking items such as steam table pans and covers, had numerous food particles in contact with the clean items. -The clean dishware storage area had numerous food particles on the shelves where clean dishes were stored. -Stainless steel drawers contained cooking utensils which had a sticky substance spilled on the outside of the drawers and coffee spills inside the drawers. -The majority of the kitchen flooring had black debris build-up, spills and food particles where the floor and baseboards came together. -The wall along the entire food prep counter was coated with a sticky-orange substance which was not cleanable. -Walls throughout the kitchen had various sized spills and splashes which needed to be cleaned. On 7/8/25 at 12:46 PM, Staff 3 (Dietary Aid) stated each kitchen staff was responsible for cleaning their own area each shift. Staff 3 stated she was unaware of any routine cleaning protocols and was not required to document what cleaning she completed. Staff 3 reported everybody cleans their own stuff as they go. On 7/8/25 at 12:56 PM, Staff 4 (Dishwasher) stated she was unaware of any routine cleaning requirements but the cooks mopped the kitchen area floor and she mopped the dishwashing area floor each shift. On 7/8/25 at 2:05 PM, Staff 2 (Dietary Manager) stated she was new to the position and confirmed the kitchen did not meet her expectations of cleanliness and stated there was significant cleaning which needed to be completed. On 7/8/25 at 2:35 PM, Staff 1 (Administrator) acknowledged the kitchen equipment and food preparation areas were not clean and sanitary and stated the cleanliness of the kitchen needed to be brought up several levels.

Based on interview and record review it was determined the facility failed to reorder a medication in a timely manner resulting in missed medications for 1 of 3 residents (# 7) reviewed for medication administration. This placed residents at risk for increased pain. Findings include: Resident 7 was admitted to the facility in 5/2022 with diagnoses including chronic pain. An 11/14/24 Physician Order included 5 mg of oxycodone scheduled to be administered three times a day to assist with pain reduction. Review of 11/14/24 through 12/15/24 Narcotic Book records for oxycodone revealed Resident 7 did not receive her/his scheduled evening dose on 12/4/24 and scheduled morning dose on 12/5/24. A 12/2/24 Pharmacy fax stated the pharmacy was unable to dispense the medication because no refill was available and new orders were required to receive Resident 7's oxycodone medication. Physician orders were placed on 12/4/24 at 9:00 PM to continue Resident 7's oxycodone at 5 mg three times a day to assist with pain reduction. On 3/19/25 at 12:14 PM Resident 7 stated two doses of her/his scheduled oxycodone was not provided to her/him. Resident 7 stated she/he was told is was not available and the facility needed the provider to write new orders. On 3/19/25 at 12:47 PM Staff 7 (CMA) stated Resident 7 did not receive oxycodone as ordered on 12/4/24's evening dose as a refill was not available and new orders had not been signed. Staff 7 stated medications were requested to be refilled or reordered when ten doses remained. On 3/19/25 at 2:20 PM Staff 5 (Resident Care Manager/LPN) stated information was received from the pharmacy which stated no refill for oxycodone was available two days prior to Resident 7's last available dose. Staff 5 confirmed Resident 7 did not receive her/his oxycodone medication for the evening dose on 12/4/24 and the morning dose on 12/5/24 as new orders were not placed until Resident 7's supply of oxycodone pills was depleted.

Based on observation, interview and record review it was determined the facility failed to maintain sanitary equipment to prevent the unintended presence of potentially harmful substances, label and store food appropriately or handle and prepare food in a sanitary manner for 1 of 1 ice machine, 1 of 1 mobile ice carts and 1 of 1 kitchen reviewed for dining services. This placed residents at risk of illness and contaminated food. Finding include: In the dining room on [DATE] at 12:25 PM Staff 21 (CNA) was observed to scoop ice from the large ice machine into the mobile ice cart chest. Staff 21 used the ice scoop located to the left of the ice machine, mounted on the wall and contained in a black container. Staff 21 was then observed to use an ice scoop, stored in a white mesh bag on the mobile ice cart, to place ice into a cup. The white mesh bag had a black substance on the bottom of the bag about the size of a playing card. On [DATE] at 12:28 PM Staff 21 stated they did not know if the white mesh bag to hold the scoop was clean or not, but it appeared to have mold growth on the bag. On [DATE] at 12:32 PM Staff 2 (DNS) stated they would expect the ice scoop to be contained in a clean environment. Staff 2 and surveyor approached Staff 21 with the mobile ice cart. Staff 21 stated the white mesh bag for the mobile ice cart scoop was thrown away. On [DATE] at 12:36 PM Staff 11 (Maintenance Director) confirmed the white mesh bag for the mobile ice cart scoop was thrown away because it was nasty. On [DATE] at 12:37 PM the surveyor used a white paper towel to wipe the bottom inside of the black ice machine scoop holder mounted on the wall left of the ice machine. The paper towel came out with a black [NAME] debris which felt slimy. On [DATE] at 12:40 PM Staff 14 (Housekeeping Supervisor) stated the housekeeping department was responsible to clean the ice scoop and its container to the left of the ice machine. Staff 14 placed a cloth rag into the container and wiped the bottom. Staff 14 confirmed the container was not clean and they were unsure exactly how often it was cleaned. On [DATE] at 1:45 PM Staff 1 (Administrator) acknowledged this finding and confirmed they expected both ice scoop containers to be clean. 47000 2. The facility's ,d+[DATE] Food Preparation and Service Policy and Procedure directed the following: -Gloves were to be worn when handling food directly and changed between tasks. -Refrigerators and/or freezers were to be maintained in good working condition. -Frozen foods were to be maintained at a temperature to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. -All food was to be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) were to be marked on cases and on individual items removed from cases for storage. Use by dates were to be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food were to be observed and use by dates were to indicate once food was opened. -Supervisors were responsible for ensuring food items in the pantry, refrigerators and freezers were not past the use by or expiration dates. Supervisors were to contact vendors or manufacturers when expiration dates were in question or to decipher codes on packaging. On [DATE] at 9:46 AM during the initial tour of the facility's kitchen, the following was observed in the dry storage area: -an opened bag of French onions, undated; -an opened container of vinegar, undated; -an opened bag of Sloppy [NAME] seasoning, undated; -an opened bag of biscuit gravy mix, undated; -an opened bag of mashed potato mix, undated; -an opened bag of chicken gravy mix, undated; -an unopened container of horseradish, expired on [DATE]; -an unopened container of mayonnaise, expired on [DATE]; -four unopened coleslaw dressings, expiration date unable to be determined; -two unopened containers of ranch dressing, expiration date unable to be determined; and -three unopened containers of mayonnaise, expiration date unable to be determined. On [DATE] at 10:00 AM during the initial tour of the facility's kitchen, the following were observed in the facility's walk-in freezer: -a large chunk of ice attached to a pipe in the back of the freezer hung down and was positioned above an open box of corn. The box contained many chunks of ice that appeared to have broken off from the ice chunk that hung above; -a bag of freezer burned asparagus; and -an open bag of bratwurst. On [DATE] at 9:52 AM Staff 15 (Dietary Director) stated all of the opened and undated, expired and freezer burned food items should be thrown out. On [DATE] at 11:12 AM Staff 15 stated the items with an expiration date that was unable to be determined needed to be removed from the shelf in the dry storage. On [DATE] between 11:55 AM and 12:30 PM during a return visit to the kitchen the following was observed during the lunch tray line service: -At 11:55 AM Staff 25 (Cook) was observed to plate resident meal trays and wore gloves. At 11:57 AM Staff 25 opened a drawer in the kitchen, removed two utensils and resumed plating resident meal trays. Staff 25 did not change his gloves after he touched the kitchen drawer. -At 12:06 PM Staff 25 wore the same pair of gloves and opened the door to the facility's freezer, retrieved a salad and a sandwich, removed the sandwich from the bag, placed the sandwich on a plate and resumed plating resident meal trays. Staff 25 did not change his gloves after he touched the door handle to the freezer. -At 12:10 PM Staff 25 wore the same pair of gloves and opened the door to the facility's freezer and retrieved another sandwich. The state surveyor asked Staff 25 at this time about when he was expected to change his gloves to which Staff 25 stated he changed his gloves when he touched the doors. Staff 25 did not change his gloves and continued to plate resident meal trays. On [DATE] at 12:36 PM Staff 15 stated staff were expected to change their gloves between tasks.

Based on interview and record review it was determined the facility failed to initiate a grievance process for 1 of 2 sampled residents (#169) reviewed for personal property. This placed residents at risk for unaddressed concerns. Findings include: Resident 169 admitted to the facility in 10/2024 with diagnoses of displaced intertrochanteric fracture of left femur and schizophrenia. On 11/18/24 at 12:27 PM Resident 169 stated after he/she arrived staff took her/his clothes to the laundry and did not return them. Resident 169 stated to several staff members that her/his clothing items were missing. Resident 169's 10/31/24 inventory sheet revealed Resident 169 admitted with a shirt, underpants and jeans. On 11/21/24 at 9:54 AM Staff 14 (Housekeeping Supervisor) stated if a resident reported a missing item staff looked for the item. If the item was not found, staff would assist the resident to fill out a grievance form. Staff 14 indicated she/he was not aware Resident 169 was missing clothing. On 11/21/24 at 12:34 PM Staff 22 (CNA) stated resident 169 mentioned her/his clothing was missing, but she did not report it to anyone. On 11/21/24 at 12:58 PM Staff 2 (Director of Nursing) stated if a resident voiced concern regarding missing clothing, staff were to check the inventory sheet and look for the missing items. If items were not found CNAs were to start a grievance and the resident would be reimbursed.

Based on observation, interview and record review it was determined the facility failed to provide adequate bathing for 1 of 3 sampled residents (#37) reviewed for ADLs. This placed residents at risk for unmet hygiene needs. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment indicated the resident was cognitively intact and dependent upon staff assistance for showers/bathing. Resident 37's 9/23/24 ADL Care Plan revealed the resident was to receive showers on Monday and Friday evenings. Resident 37's 10/25/24 through 11/18/24 Bathing Task sheet revealed the following: -10/25/24, Friday: not applicable. -11/4/24, Monday: resident refused. No documentation was found to indicate the resident was reoffered a shower during the shift, the resident's refusal was reported to the nurse or the resident was reoffered a shower on an alternative shift. -11/8/24, Friday: not applicable. -11/11/24, Monday: resident refused. No documentation was found to indicate the resident was reoffered a shower during the shift, the resident's refusal was reported to the nurse or the resident was reoffered a shower on an alternative shift. -11/18/24, Monday: not applicable. On 11/18/24 at 12:33 PM Resident 37 was observed in her/his room and sat in her/his wheelchair. Resident 37 stated she/he was lucky if [she/he] got a shower once every two weeks. Resident 37 stated staff were always too busy to assist her/him with a shower on her/his scheduled days and they don't have time on my off days. Resident 37 stated she/he preferred showers in the afternoons, and on shower days, staff would frequently enter her/his room and say you can have one right now, right now, without any warning. Resident 37 stated she/he needed time to prepare, and if she/he refused, she/he would not be offered a shower at a different time during the shift. Resident 37 further stated she/he was occasionally told she/he could not shower because the shower was broken. On 11/20/24 at 4:07 PM Resident 37 stated she/hetold two people today [she/he] wanted a shower and they said they hope I get one. The resident's room was observed to smell of urine and a plastic bag was observed on the floor in the corner of the room. Resident 37 stated the bag was filled with a draw sheet and wash cloths from last night. Resident 37 stated she/he used the wash cloths to wipe her/his groin area as she/he often felt moist and sticky and the wash cloths would be covered in urine and blood. On 11/21/24 at 8:15 AM Resident 37 was observed in her/his room and sat in her/his wheelchair. Resident 37 stated she/he did not receive a shower yesterday despite her/his request and stated she/he asked this morning for a shower and was told we will have to see. On 11/21/24 at 8:21 AM Staff 23 (CNA) stated CNAs were supposed to offer a resident a shower more than once if the resident refused, and if the resident continued to refuse, CNAs were to report the refusals to the nurse, document the refusals and let the next shift know so they could reoffer a shower. Staff 23 stated Resident 37 would wait to the last hour of her shift before agreeing to take a shower and then I have to tell [her/him] I don't have time. On 11/21/24 at 9:03 AM Staff 26 (CNA) stated residents were supposed to be reoffered showers two to three times, and if they still refused, CNAs were to inform the nurse. CNAs were responsible for documenting refusals, and if a CNA documented not applicable, that would indicate the shower was not offered. Staff 26 stated Resident 37 never refused showers when she worked with her/him. Staff 26 further stated other CNAs did not offer Resident 37 a shower until 8:30 PM or 9:00 PM at night because they knew the resident would refuse at those times. Staff 26 stated other CNAs did not offer showers on alternative days so residents had to wait until their next scheduled day to receive a shower. On 11/21/24 at 9:30 AM Staff 27 (RN) stated Resident 37 preferred to take her/his showers around 4:00 PM to 4:30 PM and showers were very important for the resident because she/he had a lot of folds and could be incontinent in the bed at night. On 11/21/24 at 12:44 PM Staff 2 (DNS) stated CNAs were expected to reoffer a resident a shower three times during their shift, the nurse was expected to document any continued refusals and the next shift was to do a PRN shower. Staff 2 reviewed Resident 37's clinical record, stated she did not know if the resident was offered a shower on 10/25/24, 11/8/24 or 11/18/24 and confirmed there was no documentation to indicate the resident was reoffered a shower on 11/4/24 or 11/11/24.

Based on observation, interview and record review it was determined the facility failed to implement interventions to prevent pressure ulcers and skin breakdown for 1 of 1 sampled resident (#37) reviewed for skin conditions. This placed residents at risk for the development of pressure ulcers and skin breakdown. Findings include: Resident 37 was admitted to the facility in 11/2023 with diagnoses including neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). Resident 37's 8/25/24 Quarterly MDS Assessment revealed the resident was cognitively intact, at risk to develop pressure ulcers/injuries and to have a pressure reducing device for her/his chair. Resident 37's 11/2024 Physician Orders directed the resident to receive wound care to her/his right and left thigh rear skin tears twice daily. On 11/18/24 at 12:33 PM Resident 37 was observed in her/his room and sat on a folded towel in her/his wheelchair. Resident 37 stated she/he experienced skin irritation and breakdown on her/his bottom area and she/he did not have a cushion for her/his wheelchair so she/he had to sit on a folded towel instead. Resident 37 stated the wheelchair was uncomfortable and she/he had asked for a cushion many times and but still did not have one. Random observations of Resident 37 from 11/19/24 to 11/21/24 between 8:15 AM through 4:07 PM revealed the resident to be in bed or in her/his wheelchair. When the resident was observed in her/his wheelchair, she/he sat on a folded towel. On 11/21/24 at 8:15 AM Resident 37 stated the facility offered her/him a cushion for her/his wheelchair about four months ago but it was too thick, caused her/him to sit up too high in her/his wheelchair and was uncomfortable. Resident 37 stated she/he asked again about receiving a cushion for her/his wheelchair a few weeks ago and staff brought back the same one with a stain. Resident 37 further stated she/he asked about trying a different cushion and was told they did not know. On 11/21/24 at 8:21 AM Staff 23 (CNA) stated Resident 37 was supposed to have a cushion when up in her/his wheelchair, and the resident had regular complaints about [her/his] bottom hurting. Staff 23 further stated there were days when the resident was up in the wheelchair a majority of the day. On 11/21/24 at 9:03 AM Staff 26 (CNA) stated Resident 37 usually spent one to three hours up in her/his wheelchair during each day shift. Staff 26 stated she had never seen a cushion in the resident's wheelchair but had seen the resident sit on bath blankets instead. On 11/21/24 at 9:30 AM Staff 27 (RN) stated Resident 37 should sit on a cushion every time [she/he] was in the wheelchair. On 11/21/24 at 12:44 PM Staff 2 (DNS) reviewed Resident 37's clinical record, confirmed she/he was at risk for the development of pressure ulcers/injuries and stated the resident should have a cushion for her/his wheelchair.

Based on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#16) reviewed for pain. This placed residents at risk for ongoing pain or over sedation. Findings include: Resident 16 was admitted to the facility in 10/2024 with diagnoses including chronic pain and opioid dependency (a chronic brain disease that causes a person to compulsively seek out opioid pain medications). a. An 11/2/24 Physician Order indicated Resident 16 was prescribed oxycodone (an opioid medication used for pain management) 10 mg every 4 hours as needed for severe pain of 7 to 10 out of a pain scale of 10. A review of Resident 16's 11/2024 MAR revealed the resident was administered 10 mg of oxycodone outside of the physician's parameters on the following days: -11/10/24: pain was documented as 5; -11/13/24: pain was documented as 6; -11/16/24: pain was documented as 5 and -11/20/24: pain was documented as 6. On 11/22/24 at 8:19 AM Staff 2 (DNS) reviewed Resident 16's 11/2024 MAR and acknowledged on 11/10/24, 11/13/24, 11/16/24 and 11/20/24, the resident received 10 mg of oxycodone when she/he should have received 5 mg, and confirmed Resident 16's oxycodone was administered outside of the physician ordered parameters. b. An 11/2/24 Physician Order indicated Resident 16 was prescribed oxycodone (an opioid medication used for pain management) 5 mg every 4 hours as needed for moderate pain of 4 to 6 out of a pain scale of 10. A review of Resident 16's 11/2024 MAR revealed the resident was administered 5 mg of oxycodone outside of the physician's parameters on the following days: -11/11/24: pain was documented as 7 and -11/12/14: pain was documented as 7. On 11/22/24 at 8:19 AM Staff 2 (DNS) reviewed Resident 16's 11/2024 MAR and acknowledged on 11/11/24 and 11/12/24, the resident received 5 mg of oxycodone when she/he should have received 10 mg, and confirmed Resident 16 was administered oxycodone outside of the physician ordered parameters.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 2 of 4 sampled dependent residents (#s 9 and 36) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Evaluation policy, dated 2/2023 and Activities Attendance policy, dated 6/2018 indicated the following: -The activity evaluation was used to develop an individualized activity care plan that allowed the resident to participate in activities of her/his choice and interest. -Each resident's activities care plan related to her/his comprehensive assessment and was reflective of the resident's individual needs. -Attendance and participation was recorded for every resident in group and individual activities on a daily basis. 1. Resident 36 was admitted to the facility in 5/2024 with diagnoses including cardiomyopathy (a disease of the heart muscle), dementia, restlessness and anxiety disorder. Resident 36's 6/11/24 Activities Initial Evaluation revealed the following: -Resident 36 wished to participate in activities while in the facility including group and independent activities such as reading and doing puzzles. -Resident 36 wished to go on outings. Resident 36's 9/5/24 Significant Change MDS revealed the resident had moderate cognitive impairments and Resident 36 considered it somewhat to very important to do the following activities: listen to music, be around animals, keep up with the news, have books, newspapers or magazines to read, do things with groups of people, do favorite activities and go outside when the weather permitted. Resident 36's 9/19/24 Activities Care Plan revealed the following: -Resident 36 had a need for activities that were consistent with her/his abilities and interests. Enjoyable and meaningful activities for Resident 36 included but were not limited to: -Bingo; -Board games; -Using her/his cell phone; -Group activities; -Hair appointments; -Movies; -Nail care; -Smoke breaks; -Special events; -Television (Resident 36 liked watching the History Channel, news, science fiction, space shows and anything related to airplanes) and -Visiting with friends and family. The facility's Activity Calendar revealed the following scheduled activities: -11/18/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/19/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Resident Council Meeting 2:30 PM: Resident shopping -11/20/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Bingo -11/21/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/22/24 11:00 AM: Ball Toss 2:30 PM: Bingo 3:30 PM: Movie and popcorn A review of Resident 36's 10/20/24 through 11/20/24 Independent, One to One and Group Activity Logs indicated the resident participated in no activities of any kind in the past 30 days. Random observations of Resident 36 conducted from 11/18/24 through 11/20/24 between the hours of 8:00 AM and 4:00 PM revealed the resident was typically in her/his bed with the blinds drawn. The resident was either asleep or fidgeting in her/his bed. The resident had no TV on, no music playing, and no books, newspapers or magazines in the room. The resident was seen one time up in her/his wheelchair but not engaged in any group activities and no one to one activities occurred in Resident 36's room. On 11/20/24 at 8:08 AM Staff 21 (CNA) reported she had never seen Resident 36 out of her/his bed until, yesterday, 11/19/24. Staff 21 stated she had not seen Resident 36 in any group or one to one activities and she did not notice music playing in the resident's room nor her/his TV turned on. Staff 21 reported the only activity she observed occurring with Resident 36 was sometimes her/his family visited. On 11/20/23 at 8:23 AM Staff 23 (CNA) reported she had not seen Resident 36 engaged in any group or one to one activities. She stated the resident typically was in her/his bed and occasionally the TV was on or the resident's daughter visited. Staff 23 stated Resident 36 had no other real activities. On 11/20/24 at 2:20 PM and 11/21/24 at 11:44 AM Staff 9 (Activities Director) and Staff 10 (Activities Assistant) both acknowledged they did not know Resident 36, were unaware of her/his activity preferences and the resident had not been involved in any group or one to one activities. Staff 9 and Staff 10 stated the last activity director left around the third week in 9/2024 and Staff 9 started as the Activity Director on 11/4/24, thus minimal activities occurred since 9/2024. Staff 10 stated she assisted with activities on a very part-time basis up until the last few weeks. Staff 10 stated when she assisted with activities, her primary focus was on the residents she was familiar with. 47000 2. Resident 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke affecting the left non-dominant side. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, the resident's preferred language was Vietnamese and she/he wanted an interpreter to communicate with health care staff. The MDS also indicated listening to music she/he enjoyed, having books, newspapers and magazines to read, being around pets, doing things with groups of people, going outside when the weather was good and participating in religious practices were important activities to the resident. Resident 9's 10/2/24 Activity Care Plan revealed the following: -Activity preferences included to self-propel around the facility, interact with staff and residents, traditional Vietnamese music and food and exercise class. -The resident enjoyed to get her/his nails done, play games and meet with her/his spouse and friends for worship. -The resident wanted to garden when the weather was nicer. -The resident liked to do ball toss for exercise class. Ball toss was one of her/his favorite activities. A review of Resident 9's 10/21/24 through 11/19/24 Activity Tasks which documented activity participation revealed the resident did not participate in a group, one to one or self-directed/independent activity. The facility's 11/2024 Activity Calendar revealed the following scheduled activities: -11/18/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/19/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Resident Council Meeting 2:30 PM: Resident shopping -11/20/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Bingo -11/21/24 9:00 AM to 10:00 AM: One to one activities 11:00 AM: Ball Toss 2:30 PM: Crafts -11/22/24 11:00 AM: Ball Toss 2:30 PM: Bingo 3:30 PM: Movie and popcorn On 11/19/24 at 3:49 PM Resident 9 was observed in her/his room in bed. With the use of the state's translation service, an interview was conducted with the resident in Vietnamese. Resident 9 stated she/he could only speak and understand a little English, the folks here spoke English and the activities were all in English. Resident 9 stated she/he enjoyed listening to Vietnamese music on a music box she/he had a long time ago, but it was broken so they threw it away. Resident 9 stated she/he really liked exercise but had only been invited to the exercise group once. Resident 9 stated she/he did not get invited to the group ball toss today, but if she/he had been invited, she/he would have participated. Resident 9 stated she/he enjoyed reading the newspaper but all of the newspapers at the facility were in English. Resident 9 further stated she/he could only read large print and the newspapers were all written in small print. On 11/20/24 at 9:41 AM Staff 23 (CNA) stated Resident 9 hung out and did [her/his] own thing. Staff 23 stated she had never seen the resident read, listen to music, receive a pet visit or garden. On 11/20/24 at 9:52 AM Staff 28 (CNA) stated Resident 9 just hung out. Staff 28 stated she did not know if the resident liked pets or to read and was unsure of what type of music the resident enjoyed. Staff 28 stated the resident loved to garden but she had never seen indoor gardening offered at the facility. On 11/20/24 at 10:32 AM Staff 21 (CNA) stated Resident 9 liked group activities and wanted to be in there and participate. On 11/20/24 at 2:20 PM Staff 9 (Activities Director) stated she started to work at the facility on 11/4/24 and she had seen Resident 9 in the hallway briefly but had not had a chance to speak with [the resident] yet. On 11/20/24 at 2:29 PM and 11/21/24 at 11:43 AM Staff 10 (Activities Assistant) stated activity preference information from a resident's MDS assessment should go in the care plan. Staff 10 stated her interactions with Resident 9 over the past few weeks consisted of just saying hi. Staff 10 stated the resident enjoyed to get her/his nails done but she/he had not been getting them done because she did not have a key to the nail supplies. Staff 10 stated the resident enjoyed to garden but she had never tried indoor gardening, all of her interactions with Resident 9 were in English and all of the reading material she provided the resident was in English. On 11/20/24 at 3:27 PM Staff 1 (Administrator) acknowledged the findings and did not provide any additional information.

Based on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services in the area of communication for 1 of 2 sampled residents (#9) reviewed for communication. This placed residents at risk for diminished quality of life and potential decline in their ability to carry out activities of daily living. Findings include: Resident 9 was admitted to the facility in 10/2019 with diagnoses including hemiparesis (partial weakness on one side of the body) and hemiplegia (complete paralysis on one side of the body) following a stroke affecting the left non-dominant side. Resident 9's 9/11/24 Annual MDS Assessment indicated the resident was moderately cognitively impaired, experienced moderate difficulty hearing, the resident's preferred language was Vietnamese and she/he wanted an interpreter to communicate with health care staff. The Communication CAA indicated staff who communicated with the resident needed to elevate their voice, face the resident and minimize background noise due to her/his hearing impairment. Resident 9's 10/2/24 Communication Care Plan revealed the following: -Language: Vietnamese. -The resident was mostly non-English speaking. She/he could say certain simple words. -Telephone interpreter: (503) [PHONE NUMBER]. -The resident could communicate her/his needs. Use interpreter as needed for medical needs. -The resident was to have access to cue cards for communication assistance. On 11/18/24 at 11:32 AM Resident 9 was observed to sit in her/his wheelchair in her/his room. No communication cue cards were observed in the resident's room. The state surveyor communicated with the resident in English, and the resident was able to nod her/his head in response to some basic yes or no questions but was unable to answer specific questions about how long she/he had lived at the facility, the care she/he received at the facility or her/his daily routine. On 11/18/24 at 11:43 AM, 11/18/24 at 2:42 PM and 11/19/24 at 8:55 AM the state surveyor called the phone number listed in Resident 9's Care Plan for an interpreter. On each occasion, the phone did not ring and the screen on the phone read user busy. On 11/19/24 at 3:49 PM Resident 9 was observed in her/his room in bed. No communication cue cards were observed in the resident's room. With the use of the state's translation service, an interview was conducted with the resident in Vietnamese. Resident 9 stated she/he could only speak and understand a little English and the folks here spoke English. Resident 9 stated there was only one staff person she/he was able to communicate with as this staff person spoke Vietnamese. Resident 9 stated she/he was hard of hearing and needed staff to speak slowly and elevate their voice. Resident 9 stated she/he sometimes could not hear or understand the people who take care of me but I pretend to. Resident 9 did not know what a communication cue card was or if she/he had one. On 11/20/24 at 9:41 AM Staff 23 (CNA) stated Resident 9 primarily spoke Vietnamese, she did not necessarily use a translation service when communicating with the resident and she had never seen cue cards for the resident. On 11/20/24 at 9:52 AM Staff 28 stated Resident 9 did not really speak English. Staff 28 stated she never used a translator when communicating with the resident and did not know if the facility had a translation service available. Staff 28 stated she had never seen a cue board used with Resident 9. Staff 28 further stated she thought the resident's hearing was good and she just spoke loud when [the resident] couldn't understand. On 11/20/24 at 11:09 AM Staff 21 (CNA) stated Resident 9 had trouble hearing people with a quieter voice. Staff 21 stated she found information about a resident's hearing impairment and related interventions in the resident's care plan. On 11/20/24 at 2:38 PM and 3:19 PM Staff 6 (RNCM) stated she put a picture board in Resident 9's room about a month ago to help with communication but thought the resident's roommate took it shortly after it was provided and it was never replaced. Staff 6 stated the resident experienced difficulty hearing and interventions including repeating questions, face to face, eliminating loud noises and elevate voice should be in her/his care plan but were not. On 11/20/24 at 2:53 PM Staff 2 (DNS) confirmed the phone number for the translation service listed in Resident 9's care plan did not work, the resident's care plan was missing necessary interventions related to her/his hearing impairment and communication cue cards were not available to the resident and should have been.

Based on observation and interview it was determined the facility failed to ensure shower rooms were clean and in good repair for 1 of 3 shower rooms and to accommodate residents with wheelchair arm rests in proper cleanable order for 2 of 7 sampled residents (#28 and 40) reviewed for environment. This placed residents at risk for lack of a clean and homelike environment and with personal equipment in disrepair. Findings include: 1. Multiple random observations from 11/18/24 through 11/20/24 between the hours of 8:00 AM and 4:00 PM revealed the shower on the TCU (Transitional Care Unit) had a black colored substance along the entire metal floor board edging, the left front corner of the shower's flooring had several deep cracks with black substance in the cracks, the overhead fan had a layer of dirt/dust in all vents and made a loud grinding noise. On 11/20/24 at 9:03 AM Staff 14 (Housekeeping Supervisor) confirmed the TCU shower floor board edging was rusted and could not be cleaned, the left corner flooring was cracked and not cleanable and the fan was dirty. Staff 14 acknowledged the TCU shower was not clean or home like. 38140 2. On 11/18/24 at 10:46 AM Resident 28's left wheelchair arm rest was observed with the black covering torn and about three inches of foam exposed. The surface was in disrepair and uncleanable. Resident 40's left wheelchair arm rest was observed with black tape peeled back from the arm rest. The surface was not cleanable under the peel back tape. On 11/20/24 at 10:27 AM Staff 12 (Maintenance Assistant) acknowledged the residents' wheelchairs which need to be fixed were reported the maintenance department to fix. Staff 12 confirmed Resident 28's and Resident 40's wheelchair arm rests were in poor condition. On 11/20/24 at 11:01 AM Staff 2 (DNS) confirmed Resident 28's and Resident 40's wheelchair arm rests were in poor condition and not cleanable.

Based on interview and record review it was determined the facility failed to ensure cognitively impaired residents did not have access to excessively hot liquids for 1 of 3 sampled residents (#2) reviewed accidents and hazards. This failure resulted in Resident 1 sustaining a second-degree burn (partial thickness involving the first two layers of skin) to her/his thigh. Findings include: Resident 2 was admitted to the facility in 9/2022 with diagnoses including diabetes. A 11/13/23 progress note indicated Staff 9 (Agency CNA) notified Staff 2 (LPN) that Resident 2 spilled hot coffee on her/his lap. A 11/13/23 facility investigation revealed nursing staff took the coffee cart out of the kitchen prior to the coffee cooling to a safe temperature. Resident 2 was provided with coffee that was too hot (above 155 degrees). The resident was found by Staff 9 after she/he spilled the coffee in her/his lap. A 11/23/23 progress note indicated Resident 2 was assessed to have a second degree burn described as a large area of reddened skin noted to the right lateral thigh with several ruptured blisters with clear fluid drainage. The resident reported pain. On 7/22/24 at 11:02 AM and 7/24/24 at 12:36 PM Staff 7 (Dietary Aide) and Staff 8 (Cook) confirmed the coffee was brewed too hot to serve and was supposed to cool before it was served to residents. On 7/22/24 at 11:28 AM Staff 1 (Administrator) stated staff went into the kitchen and took the coffee cart out prior to the coffee cooling to a safe temperature on 11/13/23 which resulted in Resident 2 receiving a second-degree burn. Staff 1 stated there were no other incidents related to hot coffee temperatures since the 11/13/23 incident. Staff 1 stated the facility had already completed their own corrections. On 7/23/24 at 11:35 AM and 12:15 PM Staff 3 (CNA) and Staff 2 (LPN Resident Care Manager) stated coffee temperatures were not checked prior to Resident 2's incident. The deficient practice was determined to be past non-compliance as the facility self-identified this problem (on 11/13/23) and initiated a plan of correction that included: - Policy/procedure change related to coffee preparation. - audit for other potentially effected residents. - All staff education related to hot liquid safety. - audits of new process for distributing hot beverages to ensure completion. - coffee machine brew temperature lowered. These corrections were completed 11/16/23.

Based on interview and record review it was determined the facility failed to follow the resident's plan of care for 1 of 1 sampled resident (#1) reviewed for falls. As a result, Resident 1 fell and suffered a subarachnoid hemorrhage (brain bleed), and placed all residents at risk for significant injury. Findings include: Resident 1 admitted to the facility in 11/2011 with diagnoses including heart failure and osteoporosis. The 1/7/24 Annual MDS revealed Resident 1 had moderate cognitive impairment. The 1/15/24 ADL Care Plan revealed Resident 1 required two person extensive assistance for bed mobility and two or more person assistance to transfer with the mechanical lift. The 3/19/24 Progress Notes revealed at 5:30 AM, Resident 1 fell out of bed, hit her/his head on the floor and assessed to have a bruise on her/his scalp. The floor mats were not in place at the time of the fall as they were removed in preparation for the upcoming mechanical lift transfer. At approximately 11:00 AM, the resident complained of increased neck and upper back pain, the provider was notified and the resident was transferred to the hospital for further evaluation. The resident returned to the facility around 10:00 PM. Staff 2's (CNA) 3/19/24 Written Statement indicated he placed the (lift) sling under the resident and rolled the resident to one side, he then began to walk to the other side of the bed to finish when the resident rolled over (out of bed) and hit her/his head on the floor. The 3/19/24 Facility Investigation revealed Staff 2 did not follow Resident 1's care plan. Staff 2 placed the mechanical lift sling under the resident independently, the resident rolled, fell out of the bed onto the floor and hit her/his head. Staff 2 did not utilize a second person for bed mobility in preparation for the resident's transfer out of bed. The 3/19/24 Hospital Records indicated Resident 1 sustained a minimal left parietal subarachnoid hemorrhage (small bleed to the left side of the brain) and a subcutaneous hematoma (bruise) over the left side of the skull. Additionally, the records revealed Resident 1 had left parietal chronic encephalomalacia of the left parietal lobe (long-term bone softening to the left side of the skull). Resident 1 was evaluated by the initial hospital and then transferred to a second hospital where she/he was observed in the intensive care unit. When the resident's code status was determined to be comfort measures only and Resident 1 was assessed to be stable, Resident 1 returned to the facility. The 3/22/24 facility records revealed the facility identified the deficient practice and instituted the following corrections: *Staff 2 was terminated from the facility. *All residents were evaluated by nursing and therapy staff to determine the need for two person assistance with bed mobility and transfers. *All clinical staff were educated on following the residents plan of care with emphasis on bed mobility and transfers. *The DNS initiated both visual and documentation audits related to following residents' care plans for bed mobility and transfers. Audits would review two to three residents, three times a week for one week and then once a week for four weeks. *Quality Assurance Team involved with correction of the identified deficiencies. *Corporate Office involved with audits and discussion of increase in night shift staffing. On 3/27/24 at 9:38 AM, Resident 1 stated a male CNA transferred her/him alone and she fell and hit her/his head. Resident 1 was unable to remember the details of the fall. On 3/27/24 at 10:15 AM, Staff 1 (Administrator) stated Staff 2 did not follow Resident 1's Care Plan for bed mobility and independently assisted Resident 1 with her/his bed mobility while he set up the sling for transfer. Staff 1 stated all aspects for past non-compliance were in place by 3/22/24. On 3/27/24 at 10:20 AM, Staff 1 was notified the incident on 3/19/24 was determined to qualify for the designation as past non-compliance as the facility identified the deficient practice and instituted corrections. Through staff interviews and record review, survey determined past non-compliance was corrected on 3/22/24 when the facility identified deficient practice, initiated corrections and completed staff education.

Based on interview and record review it was determined the facility failed to ensure fall risk interventions were followed for 1 of 1 sampled resident (#13) reviewed for accidents. This resulted in Resident 13 sustaining wrist and leg fractures which placed residents at risk for falls and injuries. Findings include: Resident 13 was admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (difficulty breathing), stroke and diabetes. Resident 13's Annual MDS dated [DATE] indicated the resident was moderately impaired in cognition and needed extensive assistance with ADLs. Resident 13's Care Plan dated 6/21/23 identified the resident was at risk for falls due to gait/balance problems. Interventions on the care plan included: extensive two-person assistance for bed mobility, staff were to anticipate the resident's needs, keep the call light and personal items within reach, the resident was to wear non-skid footwear and promptly respond to all requests for assistance. A FRI dated 6/29/23 indicated Resident 13 was provided care by Staff 6 (CNA) on 6/28/23 when a fall occurred. Staff 6 turned Resident 13 on her/his side for care and the resident rolled off the bed, onto her/his right side, onto the floor. Staff 6 stated she saw the resident roll off of the bed onto her/his right side onto the floor. Staff 6 indicated Resident 13 cut her/his lip open and complained of right wrist pain. Staff 5 (LPN) assessed the resident and the resident stated she/he did not want to go to the hospital. A 6/30/23 Alert Note indicated Resident 13 agreed to go to the hospital on 6/29/23. A hospital Inpatient Progress Note dated 7/3/23 revealed Resident 13 sustained a lip laceration, right wrist fracture and had a nondisplaced tibia (shinbone) fracture that was confirmed on a medical imaging scan. On 8/9/23 at 1:38 PM Staff 6 stated she recalled the incident on 6/28/23 when she was assisting Resident 13 with care. Staff 6 stated the incident happened very quickly and she provided care to Resident 13 alone many times. Staff 6 stated the resident had a visible injury to her bottom lip and her right arm was swollen. Staff 6 acknowledged Resident 13 required two-person extensive assistance with bed mobility at the time of the accident and the care plan was not followed. On 8/9/23 at 1:42 PM Staff 5 (LPN) stated Staff 6 did not follow Resident 13's 6/28/23 bed mobility care plan, which resulted in Resident 13's fall. On 8/10/23 at 12:14 PM Staff 3 (RNCM) stated Resident 13 required two-person extensive assistance for bed mobility at the time of the fall. Staff 3 stated the care plan was not followed and Staff 6 should have had a second person helping her. Staff 3 stated it was her expectation the care plans were always followed.

Based on interview and record review it was determined the facility failed to administer prescribed medications to residents for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to follow Resident 7's physician orders and obtain medications which likely resulted in Resident 7's severe change of condition and hospitalization . Findings include: The National Institutes of Health indicated the following: -Depakote [name brand for divalproex sodium], revised 2/2023. Do not stop taking without consulting a healthcare provider. Stopping suddenly can cause serious problems. Stopping a seizure medicine suddenly .can cause seizures. - Clobazam, revised 2/2023. Do not suddenly stop taking Clobazam. Stopping suddenly can cause serious and life-threatening side effects, including, unusual movements, responses, or expressions, seizures, sudden and severe mental or nervous system changes, depression, seeing or hearing things that others do not see or hear, an extreme increase in activity or talking, losing touch with reality, and suicidal thoughts or actions. Call your healthcare provider or go to the nearest hospital emergency room right away if you get any of these symptoms. Resident 7 admitted to the facility on [DATE] with diagnosis including convulsions (sudden, violent, irregular movement of limb or body) and type 2 diabetes. Resident 7's 12/30/22 Physician Order directed staff to administer medications which included the following: -clobazam (sedative to treat convulsions), 10 mg tablet, two times a day for convulsions. -divalproex sodium extended release of 24 hours (anticonvulsant), 750 mg, two times a day for convulsions. -Levocarnitine (helps body use certain chemicals), 330 mg tablet, two times a day related to carnitine levels. -Novolog injection solution (insulin), 100 unit, sliding scale for diabetes. -Novolog Flex pen injector (insulin), inject 15 units with meals for held nutritional insulin and per sliding scale. Record review of the 12/30/22 through 1/2/23 MARs revealed the MAR chart codes indicated a medication marked as NA meant the medication was not available. Resident 7's MARs revealed the chart code of NA for the following medications: -12/30/22: clobazam in PM; Levocarnitine in PM; Novolog injection solution at 11:30 AM and 4:30 PM; Novolog Flex pen injector at 12:00 PM. -12/31/22: clobazam in AM/PM; Levocarnitine in AM/PM; and divalproex sodium in AM/PM. -1/1/23: clobazam in AM/PM. Record review of Resident 7's progress notes between 12/30/22 to 1/2/23 indicated staff contacted the pharmacy about the missing medications which were not delivered. Hospital Records dated 1/2/23 revealed Resident 7 was found unresponsive at the facility. Emergency Medical Services (EMS) reported the resident was asystole (heart stopped beating) when they arrived at the facility. EMS intubated the resident and brought her/him to the emergency department (ED). Multiple ED notes indicated Resident 7 received treatments and tests to rule out the cardiac failure. [There were no notes indicating the hospital was aware the resident missed several doses of seizure medications.] On 1/9/23 an investigation by Staff 1 (Administrator) concluded Resident 7 missed five doses of clobazam and two doses of divalproex sodium between 12/30/22 to 1/1/23. On 4/9/23 at 4:09 PM Staff 5 (RN) confirmed he wrote a statement for the investigation about medications. He confirmed he attempted to get the clobazam and divalproex sodium medications from the pharmacy for Resident 7 who had missed multiple doses. For the doses given of divalproex sodium, he used other means to obtain the divalproex sodium medication for Resident 7 other than it being delivered from the pharmacy for Resident 7. Staff 5 reported, although the current pharmacy delivery of resident's medications had improved, there are times when medications were not delivered timely as ordered by physician. On 4/9/23 at 4:37 PM Staff 6 (LPN) confirmed Resident 7 missed doses of clobazam and divalproex sodium due to the pharmacy not delivering the medications. Staff 6 stated the late delivery of medications was still an issue for residents. On 4/10/23 at 9:45 AM Staff 10 (CMA) confirmed the pharmacy continued to not send prescribed medications upon admission. On 4/10/23 at 12:40 PM Staff 4 (LPN/Resident Care Manager) confirmed she was aware Resident 7 missed medications due the pharmacy not sending the medications. On 4/10/23 at 12:52 PM Staff 1 confirmed her investigation with Resident 7 missed medications due to pharmacy not delivering the medications. Staff 1 believed the issue was resolved. On 4/10/23 at 4:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and a plan of care was requested. On 4/10/23 at 6:08 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: -Resident 7 no longer in the facility. -Review new admissions in the last week by 4/10/23 to ensure pharmacy needs were met. -Educate nurse to order medications, to ensure every effort to ensure medications were available, pull medication from the storage unit for medications and how to pull from emergency kit. -Educate to notify DNS or Administrator if medications were not available in the medication storage unit. -Audit two to three new admissions weekly for three weeks and monthly for three weeks. -Audit narcotics to ensure the facility had enough medications to last the weekend. -A facility Performance Improvement Plan in place to address the issue. -Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team for further review. On 4/11/23 staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On 4/11/23 at 10:21 AM it was determined the IJ immediacy was removed.

1. Based on interview and record review it was determined the facility failed to monitor and assess Resident 7 after a fall and failed to recognize and treat a change of condition for 1 of 3 sampled residents (#7) reviewed for medications. This failure was determined to be an immediate jeopardy situation because the facility failed to recognize a change of condition which likely resulted in Resident 7's severe health status change and hospitalization . Findings include: The facility's Accident/Incident Policy and Procedure, revised ,d+[DATE], directed staff to complete an incident investigation was to be completed for the following reasons but not limited to: falls with or with out injury, witnessed or unwitnessed; medication errors - if there was a negative effect on the resident or potential risk of harm. Incident reports were to be completed by the charge nurse at the time of the incident. Resident 7 admitted to the facility on [DATE] with diagnosis including convulsions (sudden, violent, irregular movement of limb or body). Resident 7's [DATE] Physician Order directed staff to administer medications, which included the following: -clobazam (sedative to treat convulsions), 10 mg tablet, two times a day for convulsions. -divalproex sodium extended release of 24 hours (anticonvulsant), 750 mg, two times a day for convulsions. Record review of the [DATE] through [DATE] MARs revealed Resident 7 was not administered her/his clobazam five times and divalproex sodium two times. Resident 7's [DATE] Admission Nursing Database Assessment indicated she/he was alert, orient to person, place and time and confused. Resident 7 had clear speech with the ability to express ideas and wants. A progress note on [DATE] at 1:47 AM by Staff 6 (LPN) revealed on [DATE] at 6:20 PM during the nurse hand over shift meeting, he received communication from Staff 5 (RN) that Resident 7 experienced an unwitnessed fall at 4:45 PM. Resident 7 was non-responsive for about 20 minutes. The resident later woke up and started to talk. Neuro checks (neurological and motor skill assessments) were in place. As the night unfolded, she/he was alert, oriented to self and situation, hand grips were moderately strong, pupils reactive, and vital signs taken. Her/his lungs were clear, and no shortness of breath observed. Resident 7 was able to communicate her/his needs. On [DATE] at 12:30 AM the CNA assigned to Resident 7's room yelled for help. Staff 6 rushed to the room and found Resident 7 lying on the bed non-responsive as foam came out of her/his mouth. Staff extended her/his neck to open the airway, started CPR, Staff 6 asked one of the CNAs to call 911 and a second nurse to bring the crash cart (emergency life sustaining equipment). Staff suctioned the resident while two people continued CPR. Ten minutes later a team six (emergency) medical personnel arrived and took over Resident 7's care. CPR continued for another fifteen minutes as the IV medication ran and then transferred Resident 7 to the hospital. On [DATE] at 5:02 AM Staff 5 initiated an incident fall form for Resident 7 for the fall on [DATE] at 4:45 PM. The 5:07 AM progress notes was linked to the report which stated the CNA went to room to help roommate, Resident 7 self-transferred to the bathroom and the CNA heard the fall. The CNA alerted this nurse and assisted Resident 7 back to bed. Neuro checks initiated, PERRLA (pupils equal, round, reactive to light and accommodation), grips equal (hand grips), and feet push and pull were equal. On [DATE] an investigation by Staff 1 (Administrator) concluded Resident 7 missed five doses of clobazam and two doses of divalproex sodium between [DATE] through [DATE]. The investigation indicated Resident 7 had an unwitnessed fall on [DATE] at 6:20 PM and on [DATE] at 12:30 AM. Included was a witness statement from Staff 5 completed on [DATE]. The investigation was focused on the missed medication and not the fall which occurred on [DATE] at 4:45 PM. Record review of the [NAME] check form indicated neuro checks were initiated on [DATE] at 4:45 PM. The form directed staff to complete assessments every 15 minutes for four times, then every 30 minutes for four times, then every hour for four times, then every four hours for four times and then every shift for 72 hours. The Neuro check form indicated several blood pressure measurements out of range, as high as ,d+[DATE] (normal range for Resident 7 should have been close to ,d+[DATE]) at 6:00 PM. The form ended with neuro check information at 8:30 PM. No further neuro checks were documented as completed. Record review did not have any additional assessments of Resident 7 or attempts to notify the medical provider for altered mental status after the fall on [DATE] at 4:45 PM. The incident report was initiated the following day, after Resident 7 discharged . Review of Resident 7's medical record revealed no evidence of comprehensive nursing assessments, identification of potential harm or risks related to the significant medication errors at the time of the incidents. Hospital Records dated [DATE] revealed Resident 7 was found unresponsive at the facility. Emergency Medical Services (EMS) reported the resident was asystole (heart stopped beating) when they arrived at the facility. EMS intubated the resident and brought her/him to the emergency department (ED). Multiple ED notes indicated Resident 7 received ongoing treatments and tests to rule out the cardiac failure. [There were no notes indicating the hospital was aware the resident missed several doses of seizure medications.] On [DATE] at 4:09 PM Staff 5 confirmed he wrote a statement on [DATE] for the investigation about missed medications and the fall which occurred on [DATE] at 4:45 PM. He stated and confirmed Resident 7 was out of it, mostly non-responsive, for ,d+[DATE] minutes but started to talk and came back after the time passed. Staff 5 stated he called the on-call doctor and did not get a return call. He stated he was unsure if he had notified the doctor Resident 7 missed doses of the medications prescribed for convulsions. Staff 5 was unsure if the resident hit her/his head during the unwitnessed fall. Staff 5 acknowledged he could send a resident to the hospital if it was urgent, without a doctors order. On [DATE] at 4:37 PM Staff 6 confirmed Resident 7 missed doses of clobazam and divalproex sodium. Staff 6 confirmed his progress note on [DATE] and the statement that Resident 7 was unresponsive for 20 minutes after the fall and stated the resident was out of it mentally. No contact with the physician was made during his shift and no additional assessments were completed. Staff 6 acknowledged he was not required to have physician permission to send a resident to the hospital if it was urgent. On [DATE] at 5:33 AM Staff 7 (CNA) stated he was aware Resident 7 fell on the evening shift on [DATE]. Staff 7 stated there was no documentation of the fall, he knew Resident 7 was a fall risk and she/he was a bit off her/his base line and slept quit a bit during his shift. Staff 7 checked on Resident 7 repeatedly until he found her/him lying in bed with legs hung off the side of the bed, foam came out of the resident's mouth and was she/he was unresponsive. Staff 7 proceeded to alert the LPN and initiate CPR. On [DATE] at 12:03 PM Staff 8 (CNA) stated she was in Resident 7's room when she heard a thud in the bathroom. Staff 8 went to check and found Resident 7 lying face down on the bathroom floor and it looked like she/he hit her/his head. Staff 8 received help from the charge nurse (Staff 5) to assist Resident 7 back to bed. Staff 8 stated Resident 7 had an altered mental status post fall. Staff 8 stated the resident did gain some alertness after 20 minutes but never returned to her/his pre-fall baseline. Staff 8 took Resident 7's vitals through out her shift, stated the vitals were high and she reported them to the charge nurse. Staff 8 stated she had spoken with the resident earlier about many things and the resident was very detail oriented in her/his stories. Resident 7 ate dinner and did talk a little more after dinner but was not back to her/his normal. Staff 8 stated she reported her observations of the resident's changes to the charge nurse through out her shift until 10:00 PM. Staff 8 stated the charge nurse replied to her that he did not know the resident and her/his baseline. On [DATE] at 1:06 PM Staff 2 (DNS) stated she expected if a resident had an unwitnessed fall or if it was known the resident hit their head, then neuro checks would be initiated, and completed as it states on the form for the timelines. Staff 2 expected alert charting every shift after a fall and if the resident experienced a change of mental status, call the doctor to report the change and send the resident out to the hospital if they were unable to get direction from the doctor about the change of condition. On [DATE] at 4:20 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On [DATE] at 6:08 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: -Resident 7 no longer in the facility. -Review residents in the last week by [DATE] with a change of condition for appropriate assessment/monitoring/notification. -Educate nurses on Change of Condition monitoring to include comprehensive assessment, monitoring and notification of medical provider. If there is no response from on call physician, the Medical Director will be contacted directly. -Audit resident within system for change of condition for assessment, monitoring and notification daily for one week, weekly for three weeks and monthly for three months. -Results of the audits would be reviewed by the QAPI (Quality Assurance and Performance Improvement) team for further review. On [DATE] staff interviews verified re-education per the immediacy removal plan was competed. A review of facility documentation revealed all aspects of the immediacy removal plan was implemented. On [DATE] at 10:21 AM it was determined the IJ immediacy was removed. 33179 2. Based on interview and record review it was determined the facility failed to provide wound care monitoring and treatment for 1 of 2 sampled residents (#18) reviewed for wound VAC's (Vacuum Assisted Closure of a wound). This placed residents at risk of worsening of wounds. Findings include: Resident 18 admitted to the facility on [DATE] with diagnoses including right toe cellulitis (skin infection), cutaneous (skin) abscess of right foot and diabetes. The [DATE] Admission Database (nursing assessment) revealed Resident 18 had a wound VAC to the right lower extremity. The [DATE] Admission orders did not include wound VAC care, monitoring and treatment orders. The [DATE] Hospital Records revealed Resident 18 had a surgical right foot wound debridement to the bone and used negative pressure wound therapy. The wound VAC was maintained at 125 mmHg (mm of mercury). The [DATE] Skin Wound Evaluation indicated it was the first assessment of the wound. The [DATE] TARs revealed no wound VAC care, monitoring or treatment was in place until [DATE]. The [DATE] Facility Investigation indicated the nurses neglected to ensure the wound VAC functioned properly the first two days of admission to the facility. The [DATE] facility documentation revealed the resident was admitted on Friday evening ([DATE]) with orders for a wound VAC. The dressing was observed by the admitting RN who assumed the dressing was attached to the VAC. The documentation further revealed no nurse checked to ensure the VAC was set up correctly and functioned properly until day shift on the following Monday ([DATE]). On [DATE] at 9:05 AM Staff 1 (Administrator) verifed Resident 18 did not have wound VAC orders on admission and the wound VAC was not properly monitored or cared for until [DATE].

Based on observation, interview and record review, it was determined the facility failed to ensure residents received pain medication as ordered for 1 of 3 sampled residents (#10) reviewed for medication. As a result, Resident 10 experienced severe, unrelenting pain for several hours on 10/29/22 and 12/10/22. Findings include: The facility's Pain Management policy and procedure form, revised 10/2022, revealed the resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the Preliminary Plan of Care and/or physician order. This data is collected on the MAR, in the interdisciplinary progress notes and through the MACC (Managing Acute Condition Change) process. Resident 10 admitted to the facility on [DATE] with diagnoses including fractures of the left femur (upper thigh bone), left tibia (lower large leg bone), left fibula (lower small leg bone) and traumatic compartment syndrome (a painful medical condition with muscle pressure reaching dangerous levels) of the lower left leg. Resident 10's care plan, dated 10/29/22 revealed she/he was care planned for pain management. Interventions implemented were to administer medication as ordered, anticipate the resident's need for pain relief and respond immediately to any complaints of pain and to monitor/record/report to the nurse any complaints of pain or requests for pain treatment. Resident 10's most recent comprehensive MDS, dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Physician Orders for 10/29/22 revealed orders to administer up to 8 mg of Hydromorphone (Dilaudid) every three hours PRN for pain. The facility completed a pain assessment with Resident 10 during the admission process on 10/29/22. The highest acceptable pain level given by the resident was 5 on a 1-10 scale, with 1 being no pain and 10 being severe pain. The 10/2022 MAR revealed on 10/29/22, Resident 10 was not administered pain medication until 10:00 PM. The time of the administration order was 3:30 PM. Nursing/progress notes reviewed for 10/29/22 revealed Resident 10 was admitted to the facility at 1:40 PM and Dilaudid was first administered at 10:00 PM. The facility's Weights and Vitals Summary revealed three pain assessments for Resident 10 on 10/29/22 with the first pain level recorded as 0 at 3:34 PM, the second pain level recorded as 10 at 9:55 PM and the third pain level recorded as 9 at 10:00 PM. In an interview with Resident 10 on 12/8/22 at 2:39 PM, she/he stated she/he arrived at the facility on 10/29/22 around 2:00 PM. She/he stated initially there was no pain in her/his left leg as she/he was given Dilaudid before discharging from the hospital. Resident 10 recalled as the afternoon went on, the surgical wounds on her/his lower left leg started to hurt to the point she/he felt her/his leg was shattered. She/he requested pain medication from staff multiple times and was told the medication was not available. Resident 10 stated she/he was unable to eat dinner due to the pain, she/he felt it was the worst pain she/he had ever experienced and rated it as a definite 10 on a 1-10 scale, with 1 being no pain to 10 being severe, unmanageable pain. Resident 10 stated facility staff told her/him no available pain medication was a common issue in facilities and the medication would be delivered on the night delivery. Resident 10 recalled a nurse telling her/him about some type of safe the medication was in, but I don't know if they had the code. Resident 10 stated she/he called the hospital she/he had discharged from requesting re-admission but was told to stay at the facility since the medication was en route from the pharmacy. In a phone interview with Resident 10 on 12/12/22 at 9:00 AM, Resident 10 stated the facility ran out of her/his pain medication on 12/10/22, which caused in her/him to experience severe pain for several hours. A nursing note written by Staff 16 (RN) on 12/10/22 at 5:12 PM revealed this nurse notified by medication aide that she was giving last dose of Hydromorphone (Dilaudid) at 2:00 PM. Pharmacy contacted to ensure order was current and able to pull from Cubex. A nursing note written by Staff 3 (RCM) on 12/11/22 at 12:42 AM revealed this RCM called pharmacy related to Dilaudid out. Pharmacy informed this RCM it is too soon and insurance would not cover. RCM gave permission to bill facility and stat Dilaudid medication. A nursing note written by Staff 23 (LPN) on 12/11/22 at 1:08 AM revealed CNA notified this LN that resident is requesting pain medication .this LN went into resident's room and explained to resident that pharmacy already notified and will deliver STAT which is between 2 -4 hours from the time the other LN made the call around midnight. Resident started cussing and yelling 'I want my pain meds now.' We will reapproach resident once she/he's calm. The facility's Weights and Vitals Summary did not reflect any pain levels recorded on 12/10/22 after 5:41 PM. Pain levels were recorded on 12/11/22 at 2:25 AM as 8. A nursing note written by Staff 23 revealed the Dilaudid was administered to Resident 10 at 2:25 AM. In an interview with Staff 22 (Director of Pharmacy Services) on 12/14/22 at 12:47 PM he stated the facility had two regularly scheduled pharmacy deliveries daily which were 2:00 PM and 9:00 PM. He stated the resident's pain medication delivery had been ordered for the night delivery on 10/29/22 at 4:50 PM. Staff 22 stated it was common for nursing facilities to have pain medications such as Dilaudid, morphine and hydrocodone in the Cubex (emergency medication kit used to dispense commonly used medications) for situations like new admissions that required medications prior to pharmacy delivery or if a scheduled narcotic prescription ran out. Staff 22 confirmed the facility had Dilaudid in the Cubex at the time of Resident 10's admission and noted there was a physician's order to administer one dose of the Dilaudid on 10/29/22 at 3:30 PM. Staff 22 stated pharmacy records indicated the Dilaudid was delivered as a stat delivery to the facility on [DATE] at 10:34 PM and was signed as delivered to by Staff 18 (LPN). He further stated on 12/10/22, the pharmacy was contacted by the facility, a new prescription was requested as well as a new code to dispense an emergency dose of Dilaudid. Staff 22 stated the pharmacy could not approve a new code for an emergency dose due to federal guidelines and the the pharmacy required a new physician's order, which could have been a verbal or faxed order. The pharmacy did not receive any orders from the facility's provider. In an interview with Staff 18 on 12/14/22 at 2:43 PM, she stated she worked at the facility on 10/29/22 from 6:30 PM to 6:30 AM. At the begining of her shift, Staff 16 (RN) told her Resident 10 was getting the medication through the Cubex. Throughout Staff 18's shift she recalled Resident 10 told Staff 18 she/he was very painful. Staff 18 stated she contacted the pharmacy but was on hold three hours. Staff 18 stated she was unable to pull the pain medication from the Cubex because she was agency/pool staff, did not have the codes required to pull the medication and only full time facility staff had the codes. Staff 18 confirmed the pain medication was not delivered to the facility until after 10:00 PM and she immediately administered the maximum ordered dose to the resident. Staff 18 stated she did not contact the facility's provider to request a new order. In an interview with Staff 3 (RCM) on 12/14/22 at 3:08 PM, she confirmed the facility had an emergency kit on site when Resident 10 was admitted to the facility. Staff 3 confirmed that agency or pool nurses were not given the codes to the emergency kit and the expectation was that a full time staff would have to access the emergency kit. She confirmed the facility ran out of the Dilaudid prescription on 12/10/22 at 2:00 PM. Staff 3 stated she was not aware a new order could have been called in to the pharmacy by the provider to dispense an emergency dose from the emergency kit. In an interview with Staff 2 (DNS) on 12/15/22 at 2:30 PM, she confirmed Resident 10 had not received her/his pain medication timely on 10/29/22 or 12/10/22. Staff 1 (Administrator) was notified of the findings of this investigation on 12/16/22 at 1:00 PM and provided no further information.

1. Based on observations, interview and record review it was determined the facility failed to provide care and services to manage diabetic care for 1 of 4 sampled residents (#107) reviewed for diabetic care. This failure resulted in the resident receiving more insulin than the physician ordered because the nurse administered the physician-ordered dose without being aware that Resident 107 had already self-administered insulin from her/his personal supply. This placed the resident at risk for serious harm related to [DIAGNOSES REDACTED] (low blood sugar) and was determined to be an immediate jeopardy situation. Findings include: Resident 107 admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. A progress note dated 8/6/17 at 4:00 am indicated Witness 1 (Resident 107's significant other) approached the nurse at 6:30 pm because Resident 107 had not received her/his CBG and insulin prior to the supper meal. The note also indicated Witness 1 informed the nurse that she/he was going to get Resident 107's insulin from home and administration staff was notified. The note stated at 1910 the resident's CBG was taken by the nurse and Witness 1 and the resident informed the nurse that they had just taken the resident's CBG and the resident had self-administered 10 units of insulin. The note stated that the ordered [MEDICATION NAME] was given, but the fast acting [MEDICATION NAME]was held. The August 2017 MAR indicated [REDACTED]. There was no further documentation regarding the incident, including an assessment of Resident 107's ability to self-administer medications, or care plan to coordinate care with staff in regards to the resident safely self-administering insulin. The Admission MDS assessment with assessment reference date 8/12/17 indicated the resident had a BIMS score of 13 out of 15 (indicating the resident was cognitively intact) and received insulin injections 7 out of the last 7 days. The resident's diabetic care plan, dated 8/19/17, did not reference the incident or have interventions in place regarding self-administration of insulin. In an interview on 8/24/17 at 8:17pm, Witness 1 (Resident 107's significant other) reported earlier that evening the resident felt her/his blood sugar was elevated and self-administerd 8 units of insulin from her/his personal supply that was in her/his room. Witness 1 reported a similar incident had occurred shortly after the resident admitted to the facility and she/he had brought in the resident's insulin from home and the resident had self administered insulin. Witness 1 reported the insulin supplies had remained in Resident 107's room since then and that administrative staff were aware. Witness 1 showed she/he had text messages from Resident 107 which indicated the resident had been waiting for her/his CBG to be checked and insulin to be administered. In interviews on 8/24/17 at 9:25 pm and 10:01 pm, Resident 107 reported she/he had checked her/his CBG around 7:30 pm and gotten a reading of high which indicated her/his blood sugar level was over 500, a critically high value, so she/he had self-administered 8 units of insulin in order to take the edge off. Resident 107 stated she/he did not self-administer her/his [MEDICATION NAME] (long-acting) insulin, only the Novilin (fast-acting) insulin. Resident 107 stated she/he was not instructed to notify staff after self-administration of insulin. Resident 107 stated that she/he knew her/his own body and how to manage the diabetes because she/he had been a brittle diabetic for over [AGE] years, and administrative staff was aware the insulin was still in her/his room. Resident 107 reported she/he kept the supplies in a black camera bag at her/his bedside. The bag was observed to contain a vial of Novilin insulin, a vial of [MEDICATION NAME], needles for administration, and CBG testing supplies. Resident 107 showed the CBG machine indicated the last taken CBG was at 7:34 pm with a reading of high. In an interview on 8/24/17 at 9:27 pm, Staff 11 (agency LPN) reported she had difficulty locating the resident in order to check her/his blood sugar and she took it around 8-8:10 pm, approximately an hour after Resident 107's initial request. She reported the CBG reading was high so she called the physician, obtained insulin orders, and she administered the [MEDICATION NAME] and [MEDICATION NAME] insulins to the resident. She reported she was unaware the resident had already self-administered 8 units of insulin until the surveyors notified her. A progress note dated 8/24/17 at 10:11 pm stated a physician order [REDACTED]. In an interview on 8/25/17 at 9:49 am Resident 107 stated facility staff had never asked her/him about having medications in her/his room, and had never instructed her/him to take the medications home. On 8/25/17 at 10:29 am Staff 3 (RNCM) stated she had gone into Resident 107's room in the morning of 8/24/17 to check her/his blood sugar, and the resident informed her she/he would be discharging in a couple days. Staff 3 said she inquired about what testing and administration equipment she/he used at home so that diabetic teaching could be started, and later that day the resident showed her the glucometer supplies and syringe she/he used to administer insulin at home. She stated she did not see or ask if the resident had any insulin with her/him, and she left the syringe with the resident because they were going to start diabetic teaching. She stated she did not see when or how the resident received the syringe. In an interview on 8/25/17 at 10:34 am, Staff 7 (Social Services assistant) recalled attending a meeting with the resident, Witness 1, the administrator, and DNS. She did not recall discussing the resident's self-administration of insulin or anything to do with her/his diabetes management. In an interview on 8/25/17 at 11:05 am, Staff 1 (Administrator) was aware of the incident involving the resident self-administering insulin and recalled having a meeting with Witness 1, the DNS, social services and the resident after the first incident. Staff 1 could not recall what was discussed in regards to the resident's insulin administration, could not recall if the resident was instructed to take the insulin home, and was unable to provide information as to what follow-up actions were taken after the first incident to ensure the resident's diabetes was managed and insulin was administered safely. She stated she was aware the resident was going to be doing diabetic training with the RNCM, but did not expect the RNCM would ask the resident to bring in supplies from home. Staff 1 stated she was unaware the resident had insulin in her/his room. In interviews on 8/25/17 at 11:05 am and 11:33 am, Staff 2 (DNS) reported she was notified after the resident self-administered insulin the first time, but had not initiated an investigation into the incident because she did not think it was warranted. Staff 2 confirmed a meeting was held after the first incident, and stated she had instructed Witness 1 and the resident to take the medications home, but could produce no documentation to confirm the medications were removed from the facility. When asked about the process for residents to self-administer medications, Staff 2 stated that if a resident wanted to take their own medications they would have to have an assessment and a physician order [REDACTED]. When asked if an assessment or plan had been put in place to prevent another incident from occurring, Staff 2 said there was no written plan and that it should have been put in the care plan. In an interview on 8/25/17 at 12:13 pm, Resident 107 again stated she/he had never been told to take the medications home, and reported she/he was a brittle diabetic who experienced challenges maintaining stable blood sugars. In phone interviews on 8/25/17 at 11:43 am and 8/30/17 at 5:05 pm, Resident 107 and Witness 1 maintained that Witness 1 had brought in the black camera bag with the insulin to the facility, told Staff 10 insulin was in the bag, and Staff 10 (CNA) told her he would add it to the resident's inventory list as camera bag. Resident 107 and Witness 1 reported it had remained with the resident throughout her/his stay at the facility except for a time when she/he forgot it in their car after an appointment. Resident 107 and Witness 1 also maintained they were never instructed by the facility to remove the insulin and were never asked about it again until after the second incident. Witness 1 stated the facility was aware of what was going on and didn't do anything about it. A copy of Resident 107's inventory list was provided on 8/25/17 at 11:50 am and had the item camera bag listed The item was not crossed off, which indicated it was not removed from the facility and thus remained accessible to the resident since being checked in by staff on 8/5/17. The form was signed by Staff 10 (CNA). In an interview on 8/25/17 at 3:10 pm, Staff 10 recalled adding the camera bag to the resident's inventory list, but did not recall what was in the bag. He reported he had not held or looked inside the bag. Summary: - The facility was aware of Resident 107 self-administering insulin after the first incident on 8/5/17. - There was no documentation to show measures were taken to address the incident, assess the resident for self-administration, create a plan in regards to the resident's self-administration of insulin, or confirm the insulin had been removed from the facility. - The resident then self-administered insulin a second time on 8/24/17 without nurse knowledge, who then administered additional insulin. Refer to F176. 2. Based on interview and record review, it was determined the facility failed to monitor skin conditions for 1 of 2 sampled residents (#32) reviewed for pressure ulcers. This put residents at risk for worsening wounds. Findings include: The facility's Policy and Procedure for Skin at Risk/Skin Breakdown dated 6/2017 stated that upon discovery of a newly identified skin impairment document findings on the Skin Grid for Pressure, Venous, Arterial, and Diabetic Ulcers or Skin Grid for Non-Pressure Related Skin Impairment . Resident 32 admitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. A progress note dated 3/29/17 indicated Resident 32 had both scabbed and intact blisters on her/his right foot. The note also indicated the resident reported she/he had obtained them from trauma at home because she/he did not wear shoes at home. The March and April 2017 TARs directed for the resident to have skin prep applied to scabbed/blistered areas on all toes daily, and these were signed as administered appropriately. The skin impairment care plan started on 4/11/17 directed for weekly skin at risk assessments. There was no further documentation, progress note or skin grid to indicate the skin conditions were monitored in Resident 32's clinical record. In an interview on 8/30/17 at 10:33 am, Staff 3 (RNCM) reported she believed the blisters that were present in March would not be monitored on a skin grid because they were not pressure wounds, and that they were probably being monitored in the progress notes when the skin prep was applied. She could not supply any documentation to support the wounds were being monitored. On 8/30/17 at 2:21 pm, Staff 2 (DNS) confirmed the blisters were considered skin conditions that should have been monitored on a tracking sheet. She was unable to provide any documentation to show the resident's blisters were monitored. Refer to F 176.

Based on interview and record review it was determined the facility failed to assess and develop a plan for self-administration of insulin for 1 of 1 sampled residents (#107) who was discovered to self-administer insulin. This failure, determined to be an immediate jeopardy situation, resulted in the resident self-administering insulin from her/his personal supply. Findings include: Resident 107 admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. A progress note dated 8/6/17 at 4:00 am indicated Resident 107 self-administered 10 units of insulin from her/his personal supply. The August 2017 MAR indicated [REDACTED]. There was no further documentation regarding the incident, including an assessment of Resident 107's ability to self-administer medications, or care plan to coordinate care with staff in regards to the resident safely self-administering insulin. The Admission MDS assessment with reference date of 8/12/17 indicated the resident had a BIMS score of 13 out of 15 (indicating the resident was cognitively intact) and received insulin injections 7 out of the last 7 days. The resident's diabetic care plan, dated 8/19/17, did not reference the incident or have interventions in place regarding self-administration of insulin. In interviews on 8/24/17 at 8:17 pm with Witness 1 (Resident 107's significant other) and at 9:25 pm and 10:01 pm with Resident 107 it was reported that Resident 107 had self-administered 8 units of insulin from her/his personal supply and had not informed the nurse. A progress note dated 8/24/17 at 10:11 pm stated a physician order [REDACTED]. In an interview on 8/25/17 at 9:49 am Resident 107 stated facility staff had never asked her/him about having medications in her/his room, and had never instructed her/him to take the medications home. On 8/25/17 at 10:19 am Staff 8 (LPN) reported no residents in the facility self administered their medications. He reported that in order for a resident to be allowed to self-administer medications she/he would have to be evaluated and an order would be obtained from the physician. In an interview on 8/25/17 at 11:05 am, Staff 1 (Administrator) was aware of the incident involving the resident self-administering insulin and was unable to provide information as to what follow-up actions were taken after the first incident to ensure the resident's diabetes was managed and insulin was administered safely. In interviews on 8/25/17 at 11:05 am and 11:33 am, Staff 2 (DNS) reported she was notified after the resident self-administered insulin the first time, and stated that if a resident wanted to take their own medications they would have to have an assessment and a physician order [REDACTED]. On 8/25/17 at 4:41 pm Staff 1 (Administrator) provided a Safety Plan as part of the immediate jeopardy abatement, which indicated the facility had interviewed each resident to find out their desire to self-administer insulin so that assessments/plans could be put in place. Summary: - The facility was aware of Resident 107 self-administering insulin after the first incident on 8/5/17. - There was no documentation to show measures were taken to address the incident, assess the resident for self-administration, or create a plan in regards to the resident's self-administration of insulin. - The resident then self-administered insulin a second time on 8/24/17 without nurse knowledge. Refer to F309

Based on interview and record review it was determined the facility staff failed to follow professional nursing standards for 1 of 2 sampled residents (#1) reviewed for pressure ulcers and weight loss. Resident 1's pressure ulcer worsened to a Stage 4 (Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures), the resident lost 9 pounds or 9 percent of her/his body weight and the resident was hospitalized for [REDACTED]. Oregon State Board of Nursing Division 45 standards of practice OAR [PHONE NUMBER] indicated Scope of Practice Standards for All Licensed Nurses .(1) .(b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering . Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/14/15 local hospital Wound, Ostomy and Skin Department Progress Note documented the resident had a Stage 3 pressure ulcer (Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) on her/his right and left buttock. The 4/15/15 local hospital physician's orders indicated Wound care instructions (Defined in Comments) Sacral decubitus ulcers: Cleanse the ulcers. Apply [MEDICATION NAME] to each ulcer and then [MEDICATION NAME] border. There was no documentation of wound care instructions in the comments area of the physician's orders. There were no physician's orders for the frequency of the wound care. There was no documentation the physician was contacted for clarification of the physician's orders when the resident was admitted to the facility. The 4/15/15 local hospital physician's orders indicated the resident was to be provided a Geomatt chair cushion (Therapeutic seat cushion which provides pressure reduction and comfort) and an air mattress . There was no facility documentation the resident was provided with a Geomatt chair cushion and an air mattress when admitted to the facility. The 4/15/15 weight record indicated the resident weighed 94 pounds and the physician ordered a low salt low fat diet. The 4/16/15 Skin Grid for Pressure, Venous, Arterial and Diabetic Ulcers documented the Coccyx pressure ulcers were identified on 4/16/15. The Skin Grid contained a diagram of the resident's body and identified one Stage 2 pressure ulcer (Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) on the resident's left buttock. The ulcer was labeled as #1 and measured 4 cm by 3.1 cm with a depth of 0.1 cm. Documentation in the box labeled Appearance of wound described the wound with 40-60% slough (slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy.) The Skin Grid documentation also included an ulcer located on the right buttock of the resident and labeled #2. The ulcer was assessed to be a Stage 2 ulcer which measured 1.5 cm by 2 cm with a depth of 0.1 cm. The appearance of the ulcer was described as 75% slough. The 4/16/15 Preliminary Care Plan indicated the resident had actual skin breakdown and indicated the interventions were included in the In Room Care Plan for ADL plan. The 4/16/15 In Room Care Plan identified the resident as mild risk for skin breakdown and was to have frequent turning. There was no documentation the resident had pressure ulcers and the interventions the CNAs were to provide. The In Room Care Plan indicated the resident ate in her/his room and required supervision. The 4/16/15 Physical Therapy Treatment Encounter Notes indicated the resident was extensively ed (educated) on importance of repositioning every 2 hours d/t (due/to) sacral ulcers .Alerted charge nurse of PT recommendations and concerns given skin issues .also suggested air bed as pt (patient) carry over seems poor .pt ed on recommendation for seating clinic as current w/c is worn and for appropriate cushion d/t sacral wounds There was no further documentation by the nursing staff regarding the need for an air bed and a seating clinic referral. The 4/22/15 CAA Summary Report indicated the resident was admitted with Stage 2 pressure ulcer on sacrum .encourage adequate nutritional intakes to promote wound healing The April 2015 TAR contained documentation of treatment for [REDACTED]. There was no directive as to when to provide the treatment other than during the day shift. The TAR documented the treatments were done on 4/17/15, 4/20/15, 4/21/15 and 4/26/15. The resident's intake record from 4/15/15 through 4/27/15 revealed the resident ate 50 percent or less for 19 out of 39 meals. There was no documentation the resident was offered a supplement. On 4/19/15 and 4/21/15 the resident refused the dinner meals and there was no documentation of a supplement offered. The 4/27/15 Wound Care Physician notes indicated the resident had a left medial sacral pressure ulcer. The notes indicated While in the hospital .developed a small pressure ulcer over the left side of the sacrum/coccyx, which has progressed to a larger unstageable ulcer being treated with SSD (silver [MEDICATION NAME]) at present .buttock pressure ulcer has extensive slough/necrotic tissue over the entire surface and requires debridement. Have been using SSD in hospital which seems to be helping promote autolytic debridement of the necrotic tissue, though it remains slow .Will try to speed the process using Santyl and reassess next week The Wound Care Physician ordered the facility to cleanse wound with cleanser, protect periwound with skin prep, apply Santyl to wound bed .Change daily and PRN loss of dressing Additional orders were for the resident have more protein to help with wound healing, was to have pressure redistribution mattress, wheelchair pressure redistribution cushion Will need ROHO or equivalent given new deep pressure ulcers .Continue with silver [MEDICATION NAME] until Santyl available .Hold off on any seated therapies given unstageable pressure ulcer over the sacrum. Limit time in seated position to under 30 mins (minutes) at a time The 4/27/15 Physical Therapy Treatment Encounter notes indicated (Wound Care Physician) talked with PTA (Physical Therapy Assistant) about getting a pressure mapping of (her/his) back side to get a better seat cushion ordered for (her/him). (Physician) said he was going to put in an order for [REDACTED]. The 4/28/15 Medical Nutrition Therapy Admission Assessment indicated Res (Resident) w/(with) poor to fair intakes of (her/his) NAS (No added salt), low fat, reg (regular) text (texture) diet. Res received healthshakes btwn (between) meals w/ (with) varied acceptance per staff. Res w/ increased needs AEB (as evidenced by) sacral wound The resident was assessed to have an unplanned significant weight loss. The Registered Dietitian's (RD) interventions/recommendations were to Liberalize diet to Gen (general), NEMS (nutritionally enhanced meals), regular texture, small portions; Add Juven (therapeutic nutrition drink to support tissue building) 1 pkt (packet)/day and Vit C (Vitamin) BID; Trial 2 Cal (high calorie liquid food to increase protein and calories) 60 mls QID w/med passes. Obtain MD order if accepts; wkly (weekly) weights; Add to NAR (Nutrition at Risk) for next wk (week); Check CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count) for baseline There was no documentation the resident had been provided with health shakes between meals prior to 4/28/15. There was a 4/28/15 fax to the physician to add NEMs to diet and health shakes 4 oz TID between meals and HS (hour of sleep). There was no documentation the physician was informed of the recommendations for Juven, Vitamin C, 2 Cal QID with med pass, weekly weights, inclusion on NAR and CMP and CBC tests. The April 2015 TAR contained documentation of the physician's order for the use of [REDACTED]. The April 2015 TAR documented on 4/29/15 the resident received both the [MEDICATION NAME] and Santyl treatments for the sacral wound. The TAR also contained documentation the resident had an air overlay mattress on her/his bed on 4/29/15. The April 2015 TAR contained no documentation the resident received a sacral wound treatment on 4/30/15. There was no documentation in the progress notes regarding the provision of a sacral wound treatment on 4/30/15. The May 2015 TAR contained documentation the resident received Santyl as treatment of [REDACTED]. There was no documentation the resident received a treatment on 5/3/15. There was no documentation in the progress notes regarding the resident's dressing change on 5/3/15. The 5/11/15 wound care physician's notes indicated the resident's left medial sacral ulcer is an acute Stage 4 pressure ulcer and has received a status of not healed .debrided sacral wound last week and still have a little slough present. Have some difficulty with the pharmacy and insurance company ensuring availability of the Santyl for unclear reasons. Submitted Prior Authorization form this week and contact (insurance company) customer service re: pharmacy's assertion that the medication is not covered under (her/his) pharmacy benefit. Will continue the Santyl for another week or so The May 2015 TAR documented Santyl was used as a treatment for [REDACTED]. There was no documentation of the sacral ulcer on 5/15/15 and 5/16/15. The TAR revealed the resident received the Santyl treatment on 5/17/15. The resident's meal intakes were reviewed from 5/1/15 through 5/18/15. There were 19 out of 54 meals when the resident ate 50 percent or less and two occasions the resident refused a meal. There was no documentation the resident was provided with a supplement. The 5/18/15 wound physician's note documented Left medial sacral ulcer is an acute Stage 4 pressure ulcer .debrided the sacral wound 2 weeks ago and have had some difficulty securing the Santyl from (her/his) insurance company. Wound appears a little worse this week with stringy necrotic tissue over the bed and now advancing necrotic skin. As it is unlikely to be able to obtain the Santyl via a DME (Durable Medical Equipment) company in a timely fashion now, will transition to SSD pacing BID to try and better promote autolytic debridement of the remaining necrotic tissue while providing more antimicrobial coverage .(insurance company) denied Santyl as a DME benefit rather than prescription benefit without providing information on DME providers who might carry the medication. Unclear what staff have been using in the interim The 5/18/15 Nutritional Risk Review meeting minutes indicated the addition to the plan was request weekly weights. The diet orders were for NAS, NEMS, regular texture, health shakes three times a day between meals. There was no discussion regarding recommendations made during the initial Nutritional assessment. The May 2015 TAR contained the change in the physician's order on 5/18/15 to treat the resident's sacral ulcer twice a day with [MEDICATION NAME]. The documentation on 5/19/15 for the 2nd shift indicated the dressing change had not been done as there was a circle around the nurse's initials. There was no documentation the resident's ulcer treatments were done during the second shift on 5/22/15 through 5/24/15. There was documentation in the 5/24/15 progress notes to indicate the resident stated she/he was too painful for the dressing change to be done. There was no documentation why the resident's wound treatment was not provided on 5/22/15. The 5/25/15 wound care physician's notes indicated the pressure ulcer Stage 4 .exposing more viable connective tissues over the sacrum .ligament exposure .unclear what dressing has been on there the most this past week .Will continue the SSD for another week or so and submit referral to (local hospital) wound clinic for ongoing follow up .No dressing order changes this week The May 2015 TAR contained the change in the physician's order on 5/18/15 to treat the resident's sacral ulcer twice a day with [MEDICATION NAME]. There was no documentation the resident's ulcer treatments were done during the second shift on 5/25/15, 5/26/15 and 5/30/15. The TARs were blank on those dates. On the second shift of 5/27/15 and 5/28/15 there was a circle around the nurse's initials. On the first shift there were blanks where the documentation for the provision of treatments were to be provided for dates 5/28/15 and 5/30/15. There was no documentation in the progress notes to indicate why the resident's wound treatments were not provided. The resident intake records were reviewed from 5/19/15 through 6/5/15 and there were 18 out of 54 meals when the resident ate 50 percent or less and one occasion when the resident refused a meal. There was no documentation the resident was offered a replacement or a supplement. On 6/2/15 the resident weighed 85 pounds, a weight loss of 4 pounds in 31 days and a total of 9 pounds or 9 percent of her/his body weight since admission on 4/15/15, a period of 48 days. This constituted a severe weight loss. The June 2015 TAR contained blanks to indicate the dressing changes had not been done on the second shift of 6/1/15, 6/2/15 and 6/4/15. There was no documentation on the TAR or in the progress notes to indicate why the dressing changes were not done. The 6/5/15 progress notes written at 11:28 pm indicated the patient conversing with people that staff cannot see. Increased confusion. Received lab results of WBC was 24.2 (reference range was between 4.5 and 10.0. Higher than normal WBC indicated the potential for infection or inflammation). The physician was contacted and orders obtained to transport the resident to the local hospital emergency department. The 6/6/15 local hospital history and physical indicated the resident's coccyx pressure ulcer was reaching the bone. The facility noted new onset agitation, confusion. Large, deep malodorous coccygeal ulcer noted; bone may be visible .sepsis; agree with concern for infected coccygeal ulcer .uti could cause current sx (symptoms) .Patients (sic) care facility noted that patient is often mildly confused at baseline but they were concerned with worsening confusion during the day yesterday (6/5/15) prompting lab studies which demonstrated WBC 24K-patient was thus brought to the ED. Nursing staff at the facility was unable to describe whether there were changes to patients (sic) sacral wound aside from stating that the wound is 'just not healing' .noted to be oriented to self only upon exam On 8/20/15 at 11:50 am Staff 2 (DNS) stated she was on medical leave when the resident resided in the facility. Staff 2 stated the resident's RNCM no longer worked at the facility. Staff 2 stated the initial assessments of the resident's pressure ulcers were not accurate and the resident was inaccurately assessed to be a mild risk of skin breakdown. Staff 2 stated the resident's In Room Care Plan failed to contain interventions regarding the pressure ulcers. There was no documentation regarding the need for pressure relief. Staff 2 stated the local hospital physician's orders regarding wound care were not specific and should have been clarified by the nurses when the resident was admitted . Staff 2 reviewed the April 2015 TARs and confirmed the treatments were not provided and it was difficult to know when the treatments were to be provided. Staff 2 stated the wound care physician who examined and treated the resident was no longer associated with the facility. Staff 2 was asked if Santyl had been available for the resident. Staff 2 was asked to provide documentation from the pharmacy of the provision of Santyl for the resident. No additional information was provided. On 8/20/15 at 1:30 pm copies of the facility's OT and PT notes were provided and indicated the need for a seating clinic. On 8/20/15 at 1:40 pm Staff 1 (Administrator) was asked about the seating clinic and pressure relief used in the resident's wheelchair. Staff 1 stated Resident 1 used the facility's wheelchair so the therapy department assessed the pressure relief provided. On 8/20/15 at 1:50 pm Staff 3 (Physical Therapy Assistant) stated she thought the resident had her/his own wheelchair because the wheelchair was in such poor condition. Staff 3 was asked about the documentation regarding the need for a seating clinic. Staff 3 stated the procedure was for the physician to write an order for [REDACTED]. Staff 3 stated she remembered the wheelchair the resident used was well worn or well used. Staff 3 remembered the resident requested two cushions in the wheelchair, one on top of the other. Staff 3 was unable to provide documentation regarding the cushions and the resident's request. On 8/20/15 at 2:15 pm Staff 5 (RN) reviewed the resident's record and stated the first time she saw Resident 1's sacral ulcer was on 4/21/15. Staff 5 stated it did not appear to be a Stage 2 pressure ulcer as it had been identified by the nursing staff on 4/16/15. Staff 5 stated the ulcer had a lot of slough which Staff 5 stated would indicate the ulcer was unstageable. Staff 5 stated she thought the resident had a pressure cushion in her/his wheelchair though could not remember when the air overlay mattress was put in place. Staff 5 thought the facility staff followed physician's orders regarding wound treatments. Staff 5 acknowledged there was no documentation the wound treatments were provided as ordered. On 8/25/15 at 1:48 pm and 2:05 pm Staff 12 and 13 (CNAs) stated when a resident ate 50 percent or less the CNAs were to offer a supplement and document the amount the resident consumed on the meal intakes. On 8/25/15 at 2:45 pm Staff 2 (DNS) stated the facility was unable to know if the resident was seen at the local hospital seating clinic though there was no follow up by the facility. Staff 2 stated the facility would have provided a wheelchair cushion upon admission. Staff 2 stated there was no documentation a seating clinic or assessment of the wheelchair cushion was done. Staff 2 stated the RD's recommendations were usually sent to the resident's physician to determine what the physician wanted done. Staff 2 stated there was no documentation the recommendations were sent to the resident's physician. Staff 2 was asked to provide any additional information regarding treatments not provided as ordered. Staff 2 was asked to provide any additional information regarding supplements provided when the resident ate 50 percent or less. Staff 2 was also asked about the documentation Juven and [MEDICATION NAME] were not consistently provided to the resident. No additional information was provided. On 8/31/15 at 4:11 pm Staff 16 (RN) stated she conducted a skin assessment of Resident 1 when she/he was admitted . Staff 16 stated she worked at the local hospital emergency department prior to being hired at the facility. Staff 16 stated she learned she inaccurately assessed the resident's sacral ulcer. Staff 16 stated she should have assessed the resident's ulcer as a Stage 3 pressure ulcer due to presence of slough in the ulcer. Staff 16 was asked about the physician's orders when the resident was admitted . Staff 16 stated the physician's order was not specific as to when the treatments were to be completed. Staff 16 stated the standard procedure was to contact the physician by fax for specific instructions. On 8/31/15 at 4:38 pm Staff 9 (CNA) stated the resident did not have an air mattress on her/his bed when she/he was admitted to the facility. Staff 9 stated the air mattress was not in place until the resident was at the facility for 2-3 weeks. Staff 9 was asked if the resident had pressure relief when seated in a wheelchair. Staff 9 stated when the resident was first admitted there was a thick black cushion in the wheelchair. Staff 9 stated then the staff placed an egg crate mattress in the wheelchair. Staff 9 stated she also observed the use of both the thick black cushion and the egg crate cushion in the wheelchair. Staff 9 was unable to recall if Resident 1 had a seating evaluation performed. Refer to F-314 and F-325.

Based on interviews and record review, it was determined the facility failed to provide care and services for 1 of 2 sampled residents (#1) reviewed for weight loss. Resident 1 had a Stage 4 pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures) and lost 9 pound or 9 percent of her/his body weight. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/14/15 local hospital Wound, Ostomy and Skin Department Progress Note documented the resident had a Stage 3 pressure ulcer (Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) on her/his right buttock and a Stage 3 pressure ulcer on her/his left buttock. The 4/15/15 weight record indicated the resident weighed 94 pounds and the physician ordered a low salt low fat diet. The 4/17/15 Occupational Therapy (OT) Treatment Encounter Notes indicated the resident's SLUMS (Saint Louis University Mental Status) score was 4/30 on 4/17/15. A score of 4 was indicative of dementia. The 4/16/15 In Room Care Plan indicated the resident ate in her/his room and required supervision. The 4/22/15 CAA Summary Report indicated the resident was currently eating a therapeutic diet of NAS (No added salt) heart healthy, regular texture, thin liquid .(her/his) intakes are inadequate to meet nutritional needs (breakfast and lunch avg. intake of 26-50% and dinner 1-25% with occasional meals not taken/refused, will request for routine supplements TID in between meals and add NEMs to diet as well as offer supplement replacement if eats less than 50% of meals .Will also refer (her/him) to RD .(She/he) does have two open wounds upon admit; one Stage 2 pressure ulcer on coccyx The 4/27/15 Wound Care Physician notes indicated the resident had a left medial sacral pressure ulcer. The notes indicated While in the hospital .developed a small pressure ulcer over the left side of the sacrum/coccyx, which has progressed to a larger unstageable ulcer .more protein to help with wound healing The 4/27/15 weight record documented the resident's weight to be 89.5 pounds. This represented a five pound weight loss or a 5 percent loss of body weight in twelve days. The resident's intake record from 4/15/15 through 4/27/15 revealed the resident ate 50 percent or less for 19 out of 39 meals. There was no documentation the resident was offered a supplement. On 4/19/15 and 4/21/15 the resident refused the dinner meals and there was no documentation of a supplement offered. The 4/28/15 Medical Nutrition Therapy Admission Assessment indicated Res (Resident) w/(with) poor to fair intakes of (her/his) NAS (No added salt), low fat, reg (regular) text (texture) diet. Res received health shakes btwn (between) meals w/ (with) varied acceptance per staff. Res w/ increased needs AEB (as evidenced by) sacral wound The resident was assessed to have an unplanned significant weight loss. The Registered Dietitian's (RD) interventions/recommendations were to Liberalize diet to Gen (general), NEMS (nutritionally enhanced meals), regular texture, small portions; Add Juven (therapeutic nutrition drink to support tissue building) 1 pkt (packet)/day and Vit C (Vitamin) BID; Trial 2 Cal (high calorie liquid food to increase protein and calories) 60 mls QID w/med passes. Obtain MD order if accepts; wkly (weekly) weights; Add to NAR (Nutrition at Risk) for next wk (week); Check CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count) for baseline There was no documentation the resident had been provided with health shakes between meals prior to 4/28/15. There was a 4/28/15 fax to the physician to add NEMs to diet and health shakes 4 oz. TID between meals and HS (hour of sleep). There was no documentation the physician was informed of the recommendations for Juven, Vitamin C, 2 Cal QID with med pass, weekly weights, inclusion on NAR and CMP and CBC tests. The April 2015 MAR indicated [REDACTED]. On 5/6/15 the resident's recorded weight was 87 pounds, a weight loss of an additional two pounds. On 5/12/15 the resident's recorded weight was 89 pounds, a weight gain of two pounds. The resident's meal intakes were reviewed from 5/1/15 through 5/18/15. There were 19 out of 54 meals when the resident ate 50 percent or less and two occasions the resident refused a meal. There was no documentation the resident was provided with a supplement. The 5/18/15 wound physician's note documented Left medial sacral ulcer is an acute Stage 4 pressure ulcer The 5/18/15 Nutritional Risk Review meeting minutes indicated the addition to the plan was request weekly weights. The diet orders were for NAS, NEMS, regular texture, health shakes three times a day between meals. There was no discussion regarding recommendations made during the initial Nutritional assessment. The 5/20/15 fax to the physician requested the use of Juven everyday for wound healing and [MEDICATION NAME] everyday as an appetite stimulant. The May 2015 MAR indicated [REDACTED]. The documentation indicated there were circles around initials to indicate Juven was not given on 5/24/15 and 5/30/15 and [MEDICATION NAME] was not given on 5/27/15 and 5/29/15. The 5/25/15 wound care physician's notes indicated the pressure ulcer base is non-granulating slough/necrotic .Stage 4 .ligament exposure . The 5/24/15 progress notes indicated resident is crying out at 0700 (7:00 am) .refusing to eat and get out of bed .Refusing dressing change to buttocks 'it hurst (sic) to (sic) bad ' The 5/28/15 progress notes indicated resident doesn't want to eat. The 5/29/15 progress notes at 1:30 pm and 3:47 pm indicated resident's dressing change was not able to be done because of complaints of pain. (Resident 1) did not eat breakfast and spit out milk, shakes and any other drinks. The 6/1/15 progress notes indicated resident had a poor appetite for breakfast and unable to tolerate morning medications whole pills needed to be crushed with water. There was no documentation the facility recorded the resident's weight from 5/12/15 until 6/2/15, a period of 31 days. On 6/2/15 the resident weighed 85 pounds, a weight loss of 4 pounds in 31 days and a total of 9 pounds or 9 percent of her/his body weight since admission on 4/15/15, a period of 48 days. This constituted a severe weight loss. The resident intake records were reviewed from 5/19/15 through 6/5/15 and there were 18 out of 54 meals when the resident ate 50 percent or less and one occasion when the resident refused a meal. There was no documentation the resident was offered a replacement or a supplement. The resident's In Room Care Plan had not been updated since 4/16/15. The 6/5/15 progress notes written at 1:28 pm indicated the patient conversing with people that staff cannot see. Increased confusion The physician was contacted and orders obtained to transport the resident to the local hospital emergency department. The 6/6/15 local hospital history and physical indicated the resident had a Large, deep malodorous coccygeal ulcer noted; bone may be visible .sepsis; agree with concern for infected coccygeal ulcer On 8/25/15 at 1:48 pm and 2:05 pm Staff 12 and 13 (CNAs) stated when a resident ate 50 percent or less the CNAs were to offer a supplement and document the amount the resident consumed on the meal intakes. On 8/25/15 at 2:45 pm Staff 2 (DNS) stated it was the practice of the facility to send the RD's recommendations to the resident's physician. Staff 2 stated there was no documentation the RD recommendations were sent to the resident's physician. Staff 2 was asked to provide any additional information regarding supplements provided when the resident ate 50 percent or less. Staff 2 was also asked about the documentation Juven and [MEDICATION NAME] were not consistently provided to the resident. No additional information was provided. On 8/31/15 at 4:38 pm Staff 9 (CNA) stated when the resident was first admitted to the facility she/he ate meals in her/his room. Staff 9 stated when the resident's ulcer was painful and Resident 1 was more confused she/he needed assistance with eating her/his meals and ate in the dining room. Staff 9 stated prior to the resident's hospitalization (6/6/15) it was too painful for the resident to sit up for meals and she/he ate in her/his room with assistance. Staff 9 stated the resident had a very poor appetite and would often refuse to eat her/his meals. Staff 9 stated when the resident ate 50 percent or less the CNAs were to offer a supplement and document the amount consumed in the resident's intake record.

Based on interviews and record review, it was determined the facility failed to provide care and services for 1 of 2 sampled residents (#1) reviewed for pressure ulcers. Resident 1's pressure ulcer worsened to a Stage 4 (Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures) and the resident was hospitalized for [REDACTED]. The facility's 1/15 Skin at Risk/Skin Breakdown Policy and Procedure indicated a resident having pressure sores receives necessary treatment and services to promote healing .Upon admission .residents will be reviewed using the 'Braden Scale' to determine risk for development of pressure ulcers. Within 8 hours of admission, a Licensed Nurse will examine the resident's entire body to determine if skin impairment is present. Findings of the examination will be documented in the Summary Section of the Admission Nursing Database and on the Individual Skin Grids .Upon admission .any actual skin impairment will be identified on the Preliminary Care Plan with interventions based on risk level identified .Weekly Wound Rounds are to be completed by a team consisting of the Director of Nursing Services (DNS)/Designee and Resident Care Manager's (RNCM) .Pressure .Wounds are to be assessed, measured and documented on the Skin Grid The 1/15 Braden Scale Care Plan Interventions Policy and Procedure indicated Complete the Braden Scale to determine the Skin at Risk Score .If actual skin breakdown present increase to the next risk level and review for appropriate interventions Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/14/15 local hospital Wound, Ostomy and Skin Department Progress Note documented the resident had a Stage 3 pressure ulcer (Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) on her/his right buttock measuring 1.5 cm by 1 cm and a Stage 3 pressure ulcer on her/his left buttock measuring 3 cm by 2.5 cm. The local hospital placed the resident on a low air surface mattress in bed and the resident needed to be prompted to turn in bed. The 4/14/15 local hospital Occupational Therapy (OT) indicated referral to wheelchair seating clinic is recommended for follow up for appropriate w/c (wheelchair) cushion and potentially new wheelchair. The 4/15/15 local hospital Physical Therapy (PT) indicated Pt. (Patient) unable to provide specific history .but does think that (she/he) went to seating clinic in the past. Pt would greatly benefit from seating clinic evaluation for more appropriate seating system and pressure relieving cushion There was no documentation the resident was seen at the seating clinic when she/he was at the local hospital. The 4/15/15 local hospital physician's orders indicated Wound care instructions (Defined in Comments) Sacral decubitus ulcers: Cleanse the ulcers. Apply [MEDICATION NAME] to each ulcer and then [MEDICATION NAME] border. There was no documentation of wound care instructions in the comments area of the physician's orders. There were no physician's orders of the frequency of the wound care. There was no documentation the physician was contacted for clarification of the physician's orders when the resident was admitted to the facility. The 4/15/15 local hospital physician's orders indicated the resident was to be provided a Geomatt chair cushion (Therapeutic seat cushion which provides pressure reduction and comfort) and an air mattress . There was no facility documentation the resident was provided with a Geomatt chair cushion and an air mattress. The 4/15/15 facility Progress Note written at 7:43 pm indicated the resident had pressure ulcers to buttocks. Resident needs wound care for both buttocks .Resident to be seen by (Wound Care Physician). Next shift to do admit assessment The 4/16/15 Skin Grid for Pressure, Venous, Arterial and Diabetic Ulcers documented the Coccyx pressure ulcers were identified on 4/16/15. The Skin Grid contained a diagram of the resident's body and identified one Stage 2 pressure ulcer (Partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) on the resident's left buttock. The ulcer was labeled as #1 and measured 4 cm by 3.1 cm with a depth of 0.1 cm. Documentation in the box labeled Appearance of wound described the wound with 40-60% slough (slough is necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist and stringy.) The Skin Grid documentation also included an ulcer located on the right buttock of the resident and labeled #2. The ulcer was assessed to be a Stage 2 ulcer which measured 1.5 cm by 2 cm with a depth of 0.1 cm. The appearance of the ulcer was described as 75% slough. The 4/16/15 Preliminary Care Plan indicated the resident had actual skin breakdown and indicated the interventions were included in the In Room Care Plan for ADL plan. The 4/16/15 In Room Care Plan identified the resident as mild risk for skin breakdown and was to have frequent turning. There was no documentation the resident had pressure ulcers and the interventions the CNAs were to provide. The 4/16/15 Physical Therapy Treatment Encounter Notes indicated the resident was extensively ed (educated) on importance of repositioning every 2 hours d/t (due/to) sacral ulcers .Alerted charge nurse of PT recommendations and concerns given skin issues .also suggested air bed as pt (patient) carry over seems poor .pt ed on recommendation for seating clinic as current w/c is worn and for appropriate cushion d/t sacral wounds There was no further documentation by the nursing staff regarding the need for an air bed and a seating clinic referral. The 4/17/15 Primary Care Physician's notes written by Witness 2 (Physician) indicated the resident was assessed at the facility. There was no documentation the physician assessed the resident's sacrum pressure ulcers. There was no discussion in the notes of the resident's wound care treatment. The 4/17/15 Occupational Therapy (OT) Treatment Encounter Notes indicated the resident's SLUMS (Saint Louis University Mental Status) score was 4/30 on 4/17/15. A score of 4 was indicative of dementia. The 4/18/15 OT Treatment Encounter Notes indicated the resident was instructed in pressure relief and weight shifting/positioning in bed and w/c to improve skin integrity The 4/19/15 Progress Notes documented the resident's sacrum wound healing well-no drainage noted-black eschar tissue noted-dry no change in size-no [DIAGNOSES REDACTED]-pink dry tissue-shallow surface. Right side sacrum-small wound-pink tissues no drainage no [DIAGNOSES REDACTED]-OTA (open to air) -use barrier cream-this healing nicely at present There was no documentation the resident's skin was assessed, using the Skin Grid completed by the facility staff on 4/22/15, a week after the resident was admitted to the facility. The 4/22/15 Admission MDS indicated the resident had pressure reducing device in bed and chair, was to be on a turning/repositioning program and was to receive pressure ulcer care. The 4/22/15 CAA Summary Report indicated the resident was admitted with Stage 2 pressure ulcer on sacrum .and has been referred to wound care consultant (Wound Care Physician) for treatment and management .Staffs (sic) will continue to assist with turning and repositioning, prompt incontinent care, wound care per MD order and ongoing assessment and monitoring for s/sx (signs and symptoms) of infection, encourage adequate nutritional intakes to promote wound healing The 4/22/15 Physician's notes indicated the physician Witness 2 (Physician) visited the resident at the facility. There was no documentation the physician assessed the resident's sacrum pressure ulcers. There was no discussion in the notes of the resident's wound care treatment. The notes indicated No concerns from staff The resident had a 4/23/15 clinic appointment to assess the resident's bilateral above the knee amputation wounds. There was no documentation the physician assessed the resident's sacrum pressure ulcers. There was no discussion of the resident's wound care treatment. The 4/23/15 physician's orders indicated continue with wound care to .and sacrum The 4/24/15 Progress Notes documented the resident's buttock wound slough noted and yellowish drainage to old dressing with odor-periwound no redness or swelling-this wound treat with [MEDICATION NAME] .will cont. (continue) to turn/reposition q (every) 2 hours The April 2015 TAR contained documentation of treatment for [REDACTED]. There was no directive as to when to provide the treatment other than during the day shift. The TAR documented the treatments were done on 4/17/15, 4/20/15, 4/21/15 and 4/26/15. The 4/27/15 Wound Care Physician notes indicated the resident had a left medial sacral pressure ulcer. The notes indicated While in the hospital .developed a small pressure ulcer over the left side of the sacrum/coccyx, which has progressed to a larger unstageable ulcer being treated with SSD (silver [MEDICATION NAME]) at present .buttock pressure ulcer has extensive slough/necrotic tissue over the entire surface and requires debridement. Have been using SSD in hospital which seems to be helping promote autolytic debridement of the necrotic tissue, though it remains slow. Discussed alternative debridement options such as enzymatic and sharp, which (she/he) was open to considering but did not want to have sharp debridement at the bedside for unclear reasons. Will try to speed the process using Santyl and reassess next week The Wound Care Physician ordered the facility to cleanse wound with cleanser, protect periwound with skin prep, apply Santyl to wound bed-measure a 6 cm ribbon from 30 gm tube, spread to nickel thickness over the wound bed, cover with 4 x 4 gauze, secure with clear film dressing. Change daily and PRN loss of dressing Additional orders were for the resident have more protein to help with wound healing, was to have pressure redistribution mattress, wheelchair pressure redistribution cushion Will need ROHO or equivalent given new deep pressure ulcers .Continue with silver [MEDICATION NAME] until Santyl available .Hold off on any seated therapies given unstageable pressure ulcer over the sacrum. Limit time in seated position to under 30 mins (minutes) at a time The 4/27/15 Physical Therapy Treatment Encounter notes indicated (Wound Care Physician) talked with PTA (Physical Therapy Assistant) about getting a pressure mapping of (her/his) back side to get a better seat cushion ordered for (her/him). (Physician) said he was going to put in an order for [REDACTED]. The 4/28/15 Medical Nutrition Therapy Admission Assessment indicated Res (Resident) w/(with) poor to fair intakes of (her/his) NAS (No added salt), low fat, reg (regular) text (texture) diet. Res received healthshakes btwn (between) meals w/ (with) varied acceptance per staff. Res w/ increased needs AEB (as evidenced by) sacral wound The resident was assessed to have an unplanned significant weight loss. The Registered Dietitian's (RD) interventions/recommendations were to Liberalize diet to Gen (general), NEMS (nutritionally enhanced meals), regular texture, small portions; Add Juven (therapeutic nutrition drink to support tissue building) 1 pkt (packet)/day and Vit C (Vitamin) BID; Trial 2 Cal (high calorie liquid food to increase protein and calories) 60 mls QID w/med passes. Obtain MD order if accepts; wkly (weekly) weights; Add to NAR (Nutrition at Risk) for next wk (week); Check CMP (Comprehensive Metabolic Panel), CBC (Complete Blood Count) for baseline There was no documentation the resident had been provided with health shakes between meals prior to 4/28/15. There was a 4/28/15 fax to the physician to add NEMs to diet and health shakes 4 oz TID between meals and HS (hour of sleep). There was no documentation the physician was informed of the recommendations for Juven, Vitamin C, 2 Cal QID with med pass, weekly weights, inclusion on NAR and CMP and CBC tests. The April 2015 MAR indicated [REDACTED]. The April 2015 TAR contained documentation of the physician's order for the use of [REDACTED]. The 4/28/15 Skin Grid form contained one ulcer measurement. There was no documentation where the ulcer was located on the resident's body. The facility staff assessed the ulcer as a Stage 3 with measurements of 3 cm by 4 cm with a depth of 0.3 cm. The ulcer had brown, yellow drainage and was described as 75% slough. The April 2015 TAR documented on 4/29/15 the resident received both the [MEDICATION NAME] and Santyl treatments for the sacral wound. The TAR also contained documentation the resident had an air overlay mattress on her/his bed on 4/29/15. On 8/20/15 at 1:20 pm Staff 1 (Administrator) provided a rental invoice for Resident 1's air overlay mattress. The start date of the rental of the air overlay mattress was 4/29/15. On 4/29/15 there was a fax to the resident's physician Dear (physician), We have patient (Resident 1) here and we have a very good wound care MD .who comes in every Monday and would like to follow (Resident 1) for (her/his) wounds. Would this be OK? . The 4/29/15 progress notes documented the resident's coccyx wound has a lot of drainage and is some malodorous after cleansing The 4/29/15 OT Treatment Encounter Notes indicated the resident was found in room and willing to participate in therapy. Attempted follow-up Slums, but pt was so disoriented that (she/he) could not come up with (her/his) age after over a minute. Pt presented as much groggier than in previous sessions Pt agitated and unfocused .COTA (Certified Occupational Therapy Assistant) spoke w/ (with) nursing re: (regarding) change in status The April 2015 TAR contained no documentation the resident received a sacral wound treatment on 4/30/15. There was no documentation in the progress notes regarding the provision of a sacral wound treatment on 4/30/15. The May 2015 TAR contained documentation the resident received Santyl as treatment of [REDACTED]. There was no documentation the resident received a treatment on 5/3/15. There was no documentation in the progress notes regarding the resident's dressing change on 5/3/15. The 5/4/15 wound care physician's notes indicated the resident's left medial sacral ulcer is an acute necrotic tissue (unstageable) pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 5 cm length by 3 cm width by 0.6 cm depth, with an area of 15 sq cm and a volume of 9 cubic cm The May 2015 TAR contained documentation the resident received Santyl as treatment of [REDACTED]. The 5/11/15 wound care physician's notes indicated the resident's left medial sacral ulcer is an acute Stage 4 pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.8 cm length by 2.1 cm width x 0.4 cm depth with an area of 7.98 sq cm and a volume of 3.192 cubic cm .Undermining has been noted at 11:00 (o'clock) and ends at 1:00 (o'clock) with a maximum distance of 1 cm debrided sacral wound last week and still have a little slough present. Have some difficulty with the pharmacy and insurance company ensuring availability of the Santyl for unclear reasons. Submitted Prior Authorization form this week and contact (insurance company) customer service re: pharmacy's assertion that the medication is not covered under (her/his) pharmacy benefit. Will continue the Santyl for another week or so to get the remaining slough out of the wound bed with the intention of then likely going to either wound vac or alternate dressings The May 2015 TAR documented Santyl was used as a treatment for [REDACTED]. There was no documentation of the sacral ulcer on 5/15/15 and 5/16/15. The TAR revealed the resident received the Santyl treatment on 5/17/15. The 5/18/15 wound physician's note documented Left medial sacral ulcer is an acute Stage 4 pressure ulcer .measured 3.4 cm length x 1.9 cm width x 0.5 cm depth .Undermining has been noted at 10:00 and ends at 5:00 (o'clock) .debrided the sacral wound 2 weeks ago and have had some difficulty securing the Santyl from (her/his) insurance company. Wound appears a little worse this week with stringy necrotic tissue over the bed and now advancing necrotic skin. As it is unlikely to be able to obtain the Santyl via a DME (Durable Medical Equipment) company in a timely fashion now, will transition to SSD pacing BID to try and better promote autolytic debridement of the remaining necrotic tissue while providing more antimicrobial coverage .(insurance company) denied Santyl as a DME benefit rather than prescription benefit without providing information on DME providers who might carry the medication. Unclear what staff have been using in the interim The May 2015 TAR contained the change in the physician's order on 5/18/15 to treat the resident's sacral ulcer twice a day with [MEDICATION NAME]. The documentation on 5/19/15 for the 2nd shift indicated the dressing change had not been done as there was a circle around the nurse's initials. There was no documentation the resident's ulcer treatments were done during the second shift on 5/22/15 through 5/24/15. There was documentation in the 5/24/15 progress notes to indicate the resident stated she/he was too painful for the dressing change to be done. There was no documentation why the resident's wound treatment was not provided on 5/22/15. The 5/25/15 wound care physician's notes indicated the pressure ulcer base is non-granulating slough/necrotic. There was an Excisional debridement .post debridement measurements: 3.3 cm length x 2 cm width x 0.5 cm depth .Stage 4 .exposing more viable connective tissues over the sacrum .ligament exposure .unclear what dressing has been on there the most this past week .would consider a wound vac, though suspect (her/his) level of arterial compromise extends to this region and it might further complicate (her/his) wound healing. Will continue the SSD for another week or so and submit referral to (local hospital) wound clinic for ongoing follow up .No dressing order changes this week The May 2015 TAR contained the change in the physician's order on 5/18/15 to treat the resident's sacral ulcer twice a day with [MEDICATION NAME]. There was no documentation the resident's ulcer treatments were done during the second shift on 5/25/15, 5/26/15 and 5/30/15. The TARs were blank on those dates. On the second shift of 5/27/15 and 5/28/15 there was a circle around the nurse's initials. On the first shift there were blanks where the documentation for the provision of treatments were to be provided for dates 5/28/15 and 5/30/15. There was no documentation in the progress notes to indicate why the resident's wound treatments were not provided. The 5/24/15 progress notes indicated resident is crying out at 0700 (7:00 am) .refusing to eat and get out of bed .Refusing dressing change to buttocks 'it hurst (sic) to (sic) bad ' The 5/29/15 progress notes at 1:30 pm and 3:47 pm indicated resident's dressing change was not able to be done because of complaints of pain. Resident did not eat breakfast and spit out milk, shakes and any other drinks. On 6/2/15 the resident weighed 85 pounds, a weight loss of 4 pounds in 31 days and a total of 9 pounds or 9 percent of her/his body weight since admission on 4/15/15, a period of 48 days. This constituted a severe weight loss. The June 2015 TAR contained blanks to indicate the dressing changes had not been done on the second shift of 6/1/15, 6/2/15 and 6/4/15. There was no documentation on the TAR or in the progress notes to indicate why the dressing changes were not done. The 6/3/15 progress notes indicated the physician ordered urinalysis (UA) with culture and sensitivity and referral to wound clinic. The resident was described as more confused than usual Progress notes written at 6:25 pm indicated laboratory tests were drawn, UA obtained and the facility was awaiting results. The 6/4/15 progress notes written at 5:51 pm indicated the UA appeared positive and WBC (white blood count) was high as well as KCL (potassium chloride). The 6:25 pm progress notes indicated the physician ordered an antibiotic and the lab tests were to be repeated. The 6/5/15 progress notes written at 8:50 am indicated noted abnormal labs increase in WBC r/o (rule out) UTI, UA sent to lab. Waiting for results. Antibiotic ordered and started. Continue to monitor The 11:28 pm progress notes indicated the patient conversing with people that staff cannot see. Increased confusion. Received lab results of WBC was 24.2 (reference range was between 4.5 and 10.0. Higher than normal WBC indicated the potential for infection or inflammation). The physician was contacted and orders obtained to transport the resident to the local hospital emergency department. The 6/6/15 local hospital history and physical indicated the resident's coccyx pressure ulcer was reaching the bone. The facility noted new onset agitation, confusion. Large, deep malodorous coccygeal ulcer noted; bone may be visible .sepsis; agree with concern for infected coccygeal ulcer .uti could cause current sx (symptoms) .Patients (sic) care facility noted that patient is often mildly confused at baseline but they were concerned with worsening confusion during the day yesterday (6/5/15) prompting lab studies which demonstrated WBC 24K-patient was thus brought to the ED. Nursing staff at the facility was unable to describe whether there were changes to patients (sic) sacral wound aside from stating that the wound is 'just not healing' .noted to be oriented to self only upon exam On 8/20/15 at 11:50 am Staff 2 (DNS) stated she was on medical leave when the resident resided in the facility. Staff 2 stated the resident's RNCM no longer worked at the facility. Staff 2 stated the local hospital physician's orders regarding wound care were not specific and should have been clarified by the nurses when the resident was admitted . Staff 2 reviewed the April 2015 TARs and confirmed the treatments were not provided and it was difficult to know when the treatments were to be provided. Staff 2 stated the initial assessments of the resident's pressure ulcers were not accurate and the resident was inaccurately assessed to be a mild risk of skin breakdown. Staff 2 stated the resident's In Room Care Plan failed to contain interventions regarding the pressure ulcers. There was no documentation regarding the need for pressure relief. Staff 2 stated the wound care physician who examined and treated the resident was no longer associated with the facility. Staff 2 was asked if Santyl had been available for the resident. Staff 2 was asked to provide documentation from the pharmacy of the provision of Santyl for the resident. On 8/20/15 at 12:05 pm Staff 14 (LPN) stated she admitted the resident on 4/15/15 though did not complete the admission assessment. Staff 14 stated the assessment was conducted by night shift. Staff 14 stated she thought the resident had an air mattress and wheelchair cushion though could not remember when the items were put in place. On 8/20/15 at 1:30 pm copies of the OT and PT notes were provided and indicated the need for a seating clinic. On 8/20/15 at 1:40 pm Staff 1 (Administrator) was asked about the seating clinic and pressure relief used in the resident's wheelchair. Staff 1 stated Resident 1 used the facility's wheelchair so the therapy department assessed the pressure relief provided. On 8/20/15 at 1:50 pm Staff 3 (Physical Therapy Assistant) stated she thought the resident had her/his own wheelchair because the wheelchair was in such poor condition. Staff 3 was asked about the documentation regarding the need for a seating clinic. Staff 3 stated the procedure was for the physician to write an order for [REDACTED]. Staff 3 stated she remembered the wheelchair the resident used was well worn or well used. Staff 3 remembered the resident requested two cushions in the wheelchair, one on top of the other. Staff 3 was unable to provide documentation regarding the cushions and the resident's request. On 8/20/15 at 2:15 pm Staff 5 (RN) reviewed the resident's record and stated the first time she saw Resident 1's sacral ulcer was on 4/21/15. Staff 5 stated it did not appear to be a Stage 2 pressure ulcer as it had been identified by the nursing staff on 4/16/15. Staff 5 stated the ulcer had a lot of slough which Staff 5 stated would indicate the ulcer was unstageable. Staff 5 stated she thought the resident had a pressure cushion in her/his wheelchair though could not remember when the air overlay mattress was put in place. Staff 5 thought the facility staff followed physician's orders regarding wound treatments. Staff 5 acknowledged there was no documentation the wound treatments were provided as ordered. On 8/25/15 at 2:45 pm Staff 2 (DNS) stated the facility was unable to know if the resident was seen at the local hospital seating clinic though there was no follow up by the facility. Staff 2 stated the facility would have provided a wheelchair cushion upon admission. Staff 2 stated there was no documentation a seating clinic or assessment of the wheelchair cushion was done. Staff 2 stated the RD's recommendations were usually sent to the resident's physician to determine what the physician wanted done. Staff 2 stated there was no documentation the recommendations were sent to the resident's physician. Staff 2 was asked to provide any additional information regarding treatments not provided as ordered and supplements not provided when the resident ate 50 percent or less of meals. No additional information was provided. On 8/26/15 at 2:00 pm Witness 2 (Facility Physician) reviewed the resident's record and indicated the resident was seen on 4/17/15 and 4/22/15. Witness 2 stated there was no documentation he assessed the resident's sacral pressure ulcer. Witness 2 stated the resident's ulcers were assessed by the wound care physician. On 8/31/15 at 2:00 pm Staff 6 (RN) stated she worked at the facility until the middle of May 2015. Staff 6 remembered she provided dressing changes for Resident 1's sacral pressure ulcer. Staff 6 stated there would be documentation in the resident's record regarding the dressings provided. On 8/31/15 at 4:11 pm Staff 16 (RN) stated she conducted a skin assessment of Resident 1 when she/he was admitted . Staff 16 stated she worked at the local hospital emergency department prior to being hired at the facility. Staff 16 stated she learned she inaccurately assessed the resident's sacral ulcer. Staff 16 stated she should have assessed the resident's ulcer as a Stage 3 pressure ulcer due to presence of slough in the ulcer. Staff 16 was asked about the physician's orders when the resident was admitted . Staff 16 stated the physician's order was not specific as to when the treatments were to be completed. Staff 16 stated the standard procedure was to contact the physician by fax for specific instructions. Staff 16 stated there would be a fax in the resident's record regarding clarification. On 8/31/15 at 4:38 pm Staff 9 (CNA) stated the resident did not have an air mattress on her/his bed when she/he was admitted to the facility. Staff 9 stated the air mattress was not in place until the resident was at the facility for 2-3 weeks. Staff 9 was asked about a wheelchair cushion used in the resident's wheelchair and she stated when the resident was admitted the staff used a thick black cushion. Then the staff used an egg crate cushion and Staff 9 stated she observed the resident had both the thick black cushion and the egg crate cushion in the wheelchair. Staff 9 was unable to recall if Resident 1 had a seating evaluation.

Based on observation, interview and record review it was determined the facility failed to provide supervision to ensure an environment free of accident hazards for 5 of 5 sampled residents (#s 12, 18, 78, 94 and 119 ) who smoked independently. All residents were identified to be at risk for injury from fire hazards due to the lack of monitoring of smoking materials and smoking practices, and lack of appropriate response to smoking behaviors which posed a hazard to the individuals. This placed residents at risk for immediate jeopardy and constituted substandard quality of care. Findings include: The facility smoking policy identified the following: - Staff were responsible for ensuring that residents smoked in a safe manner, - residents could not smoke on the grounds except "in/ near" the smoking building in the backyard, - smoking assessments were to be completed on admission with all new residents supervised until the assessment was complete, - residents would be allowed to smoke and use smoking materials only as specified in their care plan per their smoking assessment, - for smokers designated as independent, smoking materials would be kept in a locked box/and or drawer with access by that resident and staff, and - matches would not be used on facility grounds. 1. Resident 119 was admitted in 12/2013 with [DIAGNOSES REDACTED]. A 12/24/13 Admission Smoking Assessment identified a history of smoking related incidents with a decision to continue supervision "per facility policy for short term residents." The facility's designated smoking area was in the backyard with a concrete pathway which lead to a "smoking building." Residents passed the back hall nurse's station which had a locked drawer with resident smoking materials and exited the door to the backyard in order to smoke. On 2/26/14 at 4:36 pm, Resident 119 was observed in a motorized wheelchair in the backyard of the facility, reading a book and smoking a cigarette. No staff were present. The resident shared that she/he smoked on the pathway to the smoking shelter in order to "catch some sunshine." Staff had directed her/him to stay on the path so she/he would not get too close to the building. Ashes from the cigarette were tossed to the cement as the resident spoke. Resident 119 stated to her/his knowledge, there had been no assessment prior to smoking independently - she/he had simply told them what she/he was doing. Although the resident had initially kept cigarettes at the nurse's station, she/he had stopped doing that after problems with theft. When asked if lighters were kept at the nurse's station, the resident replied staff would be lucky to have one to light the supervised resident's cigarettes. The resident would not confirm where she/he kept her/his lighter and ended the interview. A 2/27/14 New Onset Smoking Reassessment identified the resident was now deemed to be independent with smoking. Re-education was provided regarding the smoking policy and adherence to the policy would be monitored. A 2/27/14 entry on the In-Room Care Plan noted that the resident was independent with smoking and staff were to remind her/him all lighting materials were to be locked in the longterm care nurse's station (in the back of the building). Staff were also to redirect the resident if smoking in non-designated areas. On 2/28/14 at 9:40 am, the resident was observed lighting a cigarette on a concrete path, approximately two feet away from the facility (in a non-designated smoking area) and away from the only receptacle used to extinguish and dispose of cigarettes in the smoking shelter. On 2/28/14 at 2:32 pm, the resident was observed in bed in her/his room. Four cigarette butts were on the floor in front of her/his motorized wheelchair. Staff 17, RN Charge Nurse, and Staff 21, CNA, confirmed in 2/28/14 interviews at 2:38 pm and 2:42 pm that Resident 119 was an independent smoker who carried cigarettes with her/him and the lighter was kept at the back nurses station. Staff 17 was informed of the observed cigarette butts in Resident 119's room on 2/28/14 at 2:45 pm. Staff 17 immediately questioned the resident which was overheard by the surveyor standing at the resident's door. Resident 119 stated the cigarette butts had been in her/his lap when she/he entered the building and she/he forgot them. Resident 119 had intended to put them in the trash can (an inappropriate receptacle for cigarette butts) when entering the building, but had been side tracked. Although Staff 17 reinforced that placing cigarette butts in your lap was not a safe practice and could be a fire hazard, the resident stated they were out prior to putting them in her/his lap. The resident stated she/he would put the cigarette butts in the receptacle from then on. Progress notes from 2/28/14 reflected the RNCM and DNS had been notified of the smoking incident. A follow-up note, on the same date, indicated the RNCM had spoken to the resident who had shared her/his story of why cigarette butts were found in her/his room. The resident acknowledged her/his mistake and voiced understanding that she/he had to put out cigarettes in the ash tray available in the smoking area. No further review of the resident's non-compliance with the policy or plan to monitor the resident was added to the resident's care plan. The back nurse's station locked storage for smoking materials was observed with Staff 6, LPN on 2/28/14 at 4:08 pm and no cigarette lighters were found. According to Staff 6, no lighters were kept for the independent smokers at the back nurse's station. On 3/3/14 at 12:37 pm, Resident 119 was observed in the backyard smoking approximately 25 feet away from the back door and approximately two feet away from the facility (a designated non-smoking area) with no cigarette receptacle near her/him. Although the resident had told Staff 17 and the RNCM she/he would put the cigarettes out in the designated ash tray/receptacle the day before, Resident 119 extinguished a cigarette on the motorized wheelchair, then held the butt in her/his hand. In interviews on 3/3/14 at 3:24 pm and 3/4/14 at 8:40 am, Staff 7, LPN charge nurse for the back hall, stated that she did not know Resident 119 (who resided on another hall) and was only aware of the independent smokers on her assigned hall. When asked if there was a list of who was a supervised or independent smoker, she confirmed there was not and stated "that would be nice." Staff 22, CMA on the back hall, stated in a 3/3/14 interview at 3:26 pm she might or might not know the independent smokers. All independent smokers were supposed to give their lighters to the nurses on the back hall, but she was unaware of the process and did not usually get involved with the smokers. Staff 22 was frequently positioned in the hall with a clear view of the back door leading to the smoking area. When interviewed on 3/5/14 at 10:52 am, Staff 4, RNCM, stated Resident 119 had always been safe to smoke independently, but there had been so many residents trying to use the same smoking area it was decided short term residents would be supervised. When deemed independent, the resident was allowed to carry cigarettes, but the lighter was to remain at the back nurse's station in a locked area. According to Staff 4, Resident 119 did not have a locked box in her/his room and the only person who would keep track of the resident's smoking materials and routine would be the nurse at the back hall. 2. Resident 94 was admitted in 9/12/13 with [DIAGNOSES REDACTED]. A 9/12/13 Admission Smoking assessment identified the smoking policy had been explained and the resident voiced understanding. Resident 94 was assessed to have no risk factors on the assessment and was identified to be a supervised smoker. Progress Notes from 9/12/13 through 12/19/13 revealed seven incidents of non-compliance with the facility's smoking policy. For example, on 12/13/13 the resident was found smoking two times outside of the door to the Transitional Care Unit (TCU) side entrance. The resident refused to go to the designated smoking area. Two days later, on 12/15/13, the resident remained non-compliant with use of the designated smoking areas and times. Resident 94 continued to smoke outside the TCU entrance and when reminded of the risks of smoking in that area stated "It doesn't matter to me, it shouldn't matter to you." A 12/30/13 Significant Change Smoking Assessment identified the resident had independent cognitive skills, recognized the designated smoking area, exhibited the proper storage of smoking materials and had a history free of smoking related incidents. There was no mention of the resident's repeated non-compliance with the smoking policy and the resident was identified to be an independent smoker. A 1/7/14 Progress Note stated a strong smell of cigarette smoke was noted from the resident's room and housekeeping reported emptying several cigarette butts from the resident's trash. The resident denied smoking in the room and the facility smoking policy was reinforced. On 1/11/14, the resident was readmitted to the facility after a hospital stay. A corresponding Progress Note identified while preparing the resident's room, a sack full of cigarette butts, loose tobacco, rolled burnt pieces of rolled cigarettes, matches and empty beer cans were found in the room. Per progress notes the resident left the faciity on [DATE] and did not return. A 1/19/14 1st Quarter Smoking Assessment identified cognition and memory recall were not adequate, but the resident was deemed to be independent with smoking. No plan of care was found in relation to the resident's non-compliance with the smoking policy including the lack of proper storage of smoking materials, smoking in inappropriate areas on the facility grounds and the potential fire hazards. In a 3/6/14 interview at 11:50 am, Staff 19, CNA, stated the resident was non-compliant with the smoking rules and would often go out the door of the TCU and smoke right outside of the door. Staff 19 tried to monitor her/his actions, especially if the resident had been drinking. On 3/7/14 at 2:06 pm, Staff 16, RN Charge Nurse, stated the resident did not want to follow the rules and was often a detriment to her/his own care and well being. The resident was non-compliant with the smoking rules and would curse at staff in response to redirection and explanation. The door to the TCU was often propped open by the resident when smoking and if staff closed the door, the resident would bang on it disrupting the other residents. Staff 16 called the DNS, Administrator, the physician and the police on several occasions. Staff also reported smelling smoke coming from the resident's room on several occasions, although Staff 16 was never able to confirm that smoking had occurred in the facility. Resident 94 discharged against medical advice on 1/20/14. 3. Resident 12 was admitted to the facility in 1/2014 and readmitted in 2/2014 with [DIAGNOSES REDACTED]. On 2/27/14 at 9:07 am a Smoking Assessment was completed. It indicated Resident 12 knew how to store smoking materials and exhibited proper storage. The resident had been safe with supervised smoking since re-admission and was deemed to be an independent smoker. No care plan for smoking was found in the resident's electronic medical record nor in the In-Room Care Plan. On 2/27/14 at 10:58 am Resident 12 was observed in her/his room with a pack of cigarettes on the bedside table. Resident 12 got up from bed to use the bathroom and left the pack of cigarettes unsecured on the bedside table. Upon return from the bathroom the resident stated she/he was supposed to turn in her/his cigarettes and lighter but didn't because they would be stolen. Instead, the resident hid her/his smoking materials from staff. Directly across the hall from Resident 12 was Resident 57, a longterm resident with a [DIAGNOSES REDACTED]. take their items. In interview on 2/28/14 at 1:56 pm Staff 12, CNA, stated she would sometimes supervise the smokers who required it. She confirmed there was no list of supervised smokers nor did the care plans identify who was to be supervised. The nurses would relay the information by word of mouth. She stated independent smokers were allowed to keep their cigarettes but had to turn in their lighters to be locked up. On 2/28/14 at 2:03 pm Staff 6, LPN, confirmed his understanding of the smoking policy was independent smokers had to turn their lighters in to be locked up. He stated most of the independent smokers were noncompliant and there was no way to keep track of who had a lighter. Staff 6 stated Resident 12 had been smoking independently the entire week and confirmed the resident did not turn a lighter in to be locked up. This was despite Resident 12's assessment to be an independent smoker the day before. Staff 13, CNA, was interviewed on 2/28/14 at 2:50 pm and stated all independent residents kept their lighters locked up at the nurse's station. During the interview Resident 12 walked out of her/his room and walked past Staff 13 who was standing at the back nurse's station and told the surveyor that she/he was going to smoke. The resident walked straight outside without retrieving a lighter from the locked area at the nurse's station. Resident 12 was then observed to take a cigarette and lighter out of her/his coat pocket and to light the cigarette and smoke. Resident 12 stated in a 2/28/14 interview at 2:59 pm, she/he was assessed to be an independent smoker yesterday (2/27/14). The resident had smoked independently before then and lied to staff about smoking independently when asked. Resident 12 lit up another cigarette. When asked if she/he was allowed to keep the lighter she/he stated everybody did what they wanted and some people got away with things and others didn't. "One person who works here will tell you one thing and another person who works here will tell you the exact opposite." On 2/28/14 at 4:06 pm Staff 6, LPN, was asked which independent smokers had their lighters locked up. He unlocked the drawer at the nurses station and was not able to find any lighters. He then opened an unlocked desk drawer and showed a lighter which he stated he kept for people who needed it. In interview on 3/4/14 at 8:40 am Staff 7, LPN, stated Resident 12 was a supervised smoker. When informed the resident was recently assessed to be an independent smoker Staff 7 confirmed that with the RNCM. Staff 7 then stated, "They usually let me know. Sometimes they don't." When asked if there was a list of who was a supervised or independent smoker she confirmed there was not and stated, "That would be nice." On 3/4/14 at 9:00 am Staff 3, RNCM, stated residents who were independent smokers had to request their cigarettes and lighters to smoke then turn them in at the nurses station when finished. When asked how staff were made aware of who was independent and who was supervised, she stated she let the nurses know verbally because they had the keys to the smoking materials. When asked if staff were given guidance for Resident 12's smoking on the Care Plan she stated she wasn't sure and the resident's Care Plan was not yet completed due to the resident's recent readmission. On 3/4/14 at 9:49 am, Staff 3 stated she had reviewed the policy and residents who were deemed independent with smoking could carry their cigarettes with them, but had to lock up the lighter. 4. Resident 78 was first admitted to the facility in 12/2013 and readmitted in 2/2014 with [DIAGNOSES REDACTED]. On 2/17/14 a Smoking Assessment was completed and identified Resident 78 could smoke independently. The same day an electronic Care Plan for smoking was created and referred to the In-Room Care Plan. According to Progress Notes Resident 78 left the faciity on [DATE], was admitted to the hospital for psychiatric evaluation on 2/22/14, and was re-admitted to the facility on [DATE]. The Admission Nursing Database dated 2/28/14 included a section for safety. Resident 78's safety judgment was deemed impulsive. The resident was identified to be a smoker and the form indicated smoking would be supervised. No other current Smoking Assessment was found in the medical record. The In-Room Care Plan last updated 3/2/14 did not address smoking nor give staff guidance on to how to supervise Resident 78's smoking. On 3/4/14 at 12:42 pm Staff 23, PT, moved a coat left behind by a resident in the therapy room. A lighter fell out of the coat pocket onto the floor. Staff 23 stated the coat belonged to Resident 78. At 12:53 pm Resident 78 was observed to walk back into the therapy room using a walker and put on the coat and left. In interview on 3/5/14 at 12:07 pm Staff 24, LPN, stated she completed Resident 78's initial Smoking Assessment and had not noticed the Admission Nursing Database indicated the resident would be supervised until re-assessed. She stated she had been told by Staff 4, RNCM, another Smoking Assessment was not necessary because she had visualized the resident smoking safely. The resident kept her/his cigarettes and returned her/his lighter to a nurse to be locked up each time. The incident of the lighter falling out of the coat pocket was discussed with Staff 24. She stated she was unaware the resident had kept a lighter in her/his coat pocket. On 3/5/14 at 12:30 pm Staff 4, RNCM, confirmed she did not realize Resident 78 was a supervised smoker based on the Admission Nursing Database and there was a need for another Smoking Assessment. On 3/5/14 at 1:15 pm Staff 24, LPN, completed another Smoking Assessment for Resident 78. It indicated the resident had a history free of smoking related incidents. The assessment did not reflect the resident failed to turn in her/his lighter and left it unattended with two documented wanderers in the building. Resident 78 was deemed to be an independent smoker. 5. Resident 18 was a long term resident in the facility. A 2/21/14 3rd Quarter Smoking Assessment identified the resident was independent with smoking with no memory or cognitive issues, had knowledge of where the designated smoking area was and how to handle smoking materials appropriately. The current careplan, last reviewed on 11/12/13, identified that the resident was able to verbalize the smoking policy and to follow it. On 2/26/14 at 3:51 pm, the resident was observed to leave her/his room, meet another resident in the hall and propelled her/his wheelchair to the backyard. A few minutes later, the resident entered the facility with an unlit cigarette in her/his mouth. Resident 18 quickly put it in a pocket and returned outside. In a 2/26/14 interview at 3:55 pm, Staff 6, LPN Charge Nurse, stated the resident was an independent smoker which meant she/he could access the backyard without assistance to smoke, although Resident 18 usually smoked in the front of the building which was not a designated smoking area. Staff 6 checked on the two residents in the backyard and confirmed that both were smoking, although he did not know the name of the other resident with Resident 18. Staff 6 stated it was possible that Resident 18 had a lighter with her/him and she/he was often non-compliant. The resident would sometimes give staff the lighter if in a good mood, but would ask for it back within three minutes. On 2/26/14 at 4:01 pm, Resident 18 stated the rules for smoking included smoking only in the smoking shed (in the backyard), put an apron on when smoking, use the ashtray and make sure there were no cigarette butts on the ground. The lighters were to be kept behind the nurse's desk in a locked drawer and you had to borrow one even if you were an independent smoker. Resident 18 confirmed she/he had cigarettes with her/him, but did not offer where her/his lighter was. On 2/27/14 at 9:41 am, Resident 18 was observed to wheel her/himself out of the facility to the smoking area. A pack of cigarettes was carried in one hand and a lighter was pulled out of a bag hanging off of the wheelchair. The back nurse's station locked storage for smoking materials was observed with Staff 6, LPN on 2/28/14 at 4:08 pm and no cigarette lighters were found. According to Staff 6, no lighters were kept for the independent smokers at the back nurse's station. In a 3/5/14 interview at 11:01 am, Staff 3, RNCM, stated an assessment was completed for each resident who smoked. Most residents were already independent smokers when they came, but they were still supervised initially. Staff as well as other residents informed her of any noted safety risks, but she avoided making direct observations as she was allergic to smoke. Staff 3 confirmed there was no systematic method for staff to ensure observations were made of each independent smoker and a method for gathering accurate and complete information. Residents were allowed to carry their cigarettes, but had to turn the lighters into the nurse or CNA at the back nurse's station per policy. It was impossible to track the lighters and Staff 3 was not surprised the locked drawer contained no lighters when checked. According to Staff 3 the back hall nurse's station had been promised a list of smokers about a month ago, but still did not have that reference. 6. On 3/5/14 at 2:06 pm, following consultation with Nursing Facility Survey Unit supervisors, the surveyors informed Staff 1, Administrator, and Staff 25, Regional RN Consultant, the lack of monitoring of independent smokers and their smoking supplies; lack of response to known violations of the smoking policy; and the presence of known wandering residents constituted a situation of immediate jeopardy to residents. Surveyors requested a plan of correction to immediately protect residents from fire hazards. A plan of correction was provided by the facility which assured resident safety related to smoking as follows: 1). A comprehensive review of the smoking policy and procedure will be conducted by 3/6/14. This will include designation of control of smoking materials. 2). All cigarette butts will be cleaned up from the trash receptacles and outdoor areas immediately and daily by Maintenance or Housekeeping. 3). All staff will be in-serviced on the current Smoking Policy and Procedure by 3/13/14. 4). A binder has been placed at each nurse's station that distinguishes supervised and independent smokers, which will be updated as needed. 5). All independent smokers' rooms will be checked to ensure smoking materials are stored properly immediately and every shift, this will be added to the resident's medical record. 6). All independent smokers will be re-assessed, this includes smoking observation by 3/13/14. 7). All independent smokers will have a lock box or locked drawer to store smoking materials by 3/6/14. Additional aspects of the plan of correction indicated: 1). Random audits of the smoking and non-smoking areas will be conducted twice a shift to monitor compliance and cleanliness. 2). Re-education of smokers regarding adherence to the smoking policy. 3). Re-education of RCM's and LN's on how to properly complete a smoking assessment. 4). Follow up with independent smokers would occur upon return from community visits to ensure smoking materials were stored properly. The immediate jeopardy was abated on 3/5/14 at 4:58 pm.

Based on observation, interview and record review it was determined the facility failed to prevent skin injury for 1 of 3 (#1) sampled residents who received a hot pack treatment without Physician's orders. Resident 1 sustained a burn as a result. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with Physician's orders for multiple pain medications. There were no Physician's orders for non-pharmacological pain treatments such as cold or heat packs. The 1/5/12 In Room Care Plan identified the resident was alert and oriented to person, place, and time and but was occasionally forgetful. The resident required one to two-person assistance for ADLs due to [MEDICAL CONDITION]. On 1/12/12 at 9:30 am a nursing note identified "around" 1:00 am the resident "requested a warm towel" from the CNA (Staff 4) "to keep herself warm." The resident was found with a burn measuring 14 cm x 10 cm on the trunk and 8 cm x 8 cm on the breast. The note indicated the resident reported no discomfort from the burn site and the wound was covered with a [MEDICATION NAME] dressing. The note indicated the resident had a previously scheduled medical appointment with her/his Primary Care Physician. The 1/12/12 facility's Incident Investigation identified the resident requested a cold pack for her/his left shoulder and a warm pack to warm her/him after going outside to smoke. The investigation indicated facility staff (Staff 4) gave the hot pack to the resident, who was unable to feel the heat due to paraplegic. The resident had no sensation on the abdomen and was burned. In addition, the investigation identified the resident had "no order for cold or warm packs." On 1/20/12 a Physician's Progress Note identified the resident had a 2nd degree burn measuring 6 cm in diameter to the left side upper abdomen and a 3-4 cm diameter round involving the left breast/areola. On 4/3/12 at 10:45 am Resident 1 was observed in her/his room with a large clean dressing on her/his abdomen. The resident stated (on 1/12/12) she/he "asked for something" to warm her/him because she/he was cold. Resident 1 reported Staff 4, CNA, handed her/him a wet towel that had been heating up in the microwave, placed in plastic bags, and wrapped in a pillow case. The resident stated she/he was sedated and on "a lot of medication" at the time. The next thing the resident recalled was waking up with a "3rd degree burn" and a "major blister." The resident reported the area "hurt" at the time of the incident and felt "tender" at the time of the interview. In interview on 4/4/12 at 8:10 am Staff 4, CNA, confirmed working the night shift starting on 1/11/12. She reported Resident 1 complained of pain and requested pain medication and a hot pack before going out to smoke. Staff 4 reported she made the resident a hot pack and handed it to her/him, but was unaware of where the resident placed the pack on her/his body before going outside to smoke. Staff 4 stated she had made Resident 1 hot packs on occasion previous to the incident. In interview on 4/4/12 at 8:35 am Staff 3, LPN, confirmed working the night shift starting on 1/11/12. She reported being unaware Resident 1 requested a hot pack (on 1/12/12) or that Staff 4 brought the resident one. In interview on 4/4/12 at 8:45 am Witness 1, Complainant, stated the resident reported facility staff made her/him a hot pack, positioned it on her/him, "never came back" to remove it and as a result sustained a burn. In interview on 4/4/13 at 10:30 am Staff 6, CNA, confirmed working the day shift on 1/12/12 and finding Resident 1 with a burn and a hot pack made out of a towel wrapped in a pillowcase. Staff 6 reported the resident complained of pain at the injury site.

Based on observation, interview and record review it was determined the facility failed to ensure CNAs performed only duties within their scope of practice or under the direction of a nurse related to preparing and distributing hot pack treatments for 1 of 3 (#1) sampled residents who requested hot packs. The resident experienced a skin burn as a result. Findings include: Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides Authorized Duties and Standards for Certified Nursing Assistants 851-063-0030 (6) Standards of Care for Certified Nursing Assistants. In the process of client care the CNA shall consistently (d) Follow the care plan as directed by the licensed nurse. Conduct Unbecoming a Nursing Assistant 851-063-0090 (6) Conduct related to achieving and maintaining clinical competency: (b) Performing acts beyond the authorized duties for which the individual is certified. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with Physician's orders for multiple pain medications. There were no Physician's orders for non-pharmacological pain treatments such as cold or hot packs. The 1/5/12 in-room and comprehensive care plans identified the resident was alert and oriented to person, place and time but was occasionally forgetful. The resident required one to two-person assistance for ADLs due to [MEDICAL CONDITION]. The comprehensive plan indicated the facility was directed to "explore non-pharmacological methods for reducing pain/promoting comfort" by offering back rubs, repositioning and diversional activities. Cold/Hot packs were not listed as possible interventions. On 1/12/12 at 9:30 am a nursing note identified "around" 1:00 am the resident "requested a warm towel" from the CNA (Staff 4) "to keep (herself/himself) warm." The resident was found with a burn measuring 14 cm x 10 cm on the trunk and 8 cm x 8 cm on the breast. The 1/12/12 facility's Incident Investigation identified the resident requested a cold pack for her/his left shoulder and a warm pack to warm her/him after going outside to smoke. The investigation indicated facility staff gave the hot pack to the resident, who was unable to feel the heat due to paraplegic. The resident had no sensation on the abdomen and was burned. On 1/20/12 a Physician's Progress Note identified the resident had a 2nd degree burn measuring 6 cm in diameter to the left side upper abdomen and a 3-4 cm diameter round involving the left breast/areola. On 4/3/12 at 10:45 am Resident 1 was observed in her/his room with a large clean dressing on her/his abdomen. The resident stated (on 1/12/12) she/he "asked for something" to warm her/him because she/he was cold. Resident 1 reported the CNA (Staff 4) handed her/him a wet towel that had been heating up in the microwave, placed in plastic bags and wrapped in a pillow case. The resident stated she/he was sedated and on "a lot of medication" at the time. The resident recalled waking up with a "3rd degree burn" on her/his abdomen and a "major blister." The resident reported the injured area "hurt" at the time of the incident and felt "tender" at the time of the interview. In interview on 4/4/12 at 8:10 am Staff 4, CNA, confirmed working the night shift starting on 1/11/12. She reported Resident 1 complained of pain and requested pain medication and a hot pack before going out to smoke. Staff 4 reported she made the resident a hot pack and handed it to her/him, but was unaware of where the resident placed the pack on her/his body before going outside to smoke. Staff 4 stated she had made Resident 1 hot packs on occasion previous to the incident. In interview on 4/4/12 at 8:35 am Staff 3, LPN, confirmed working the night shift starting on 1/11/12. She reported being unaware Resident 1 requested a hot pack (on 1/12/12) or that Staff 4 brought the resident one. Staff 3 stated nurses were supposed to place hot packs but reported, in the past, CNAs were directed to do so. In interview on 4/4/13 at 10:30 am Staff 6, CNA, confirmed working the day shift on 1/12/12 and finding Resident 1 with a burn and a hot pack made out of a towel wrapped in a pillowcase. Staff 6 reported the resident complained of pain at the injury site. Staff 6 stated CNAs "used to prepare" hot packs after checking "with the nurse first," and the intervention was care planned for. In interview on 4/4/12 at 3:00 pm, Staff 5, CNA, confirmed working the night shift starting on 1/11/12. She reported finding a cold pack on the resident's bed but was not aware the resident had a hot pack. Staff 5 stated she "would not have given" her/him a hot pack, and did not observe any redness or injury on the resident's torso on her shift.

Based on interview and record reviewing it was determined the facility failed to ensure care planned interventions were in place at the time of a fall and failed to thoroughly assess a resident for injury in a timely manner after a fall for 1 of 3 sampled residents (#1) who had falls. Resident 1 sustained a head injury and a delay in treatment. Resident 1 was admitted to the facility in October 2011 with [DIAGNOSES REDACTED]. The 11/8/11 admission assessment identified the resident made herself/himself understood and was able to understand others. The resident was not steady and only able to stabilize with staff assistance during surface-to-surface transfers. The 11/17/11 care plan identified the resident was alert, oriented and forgetful and primarily spoke a language other than English. The plan indicated the resident required extensive assistance with ADLs (activities of daily living) including transfers and toileting. Staff were directed to toilet the resident upon rising, before meals, at bedtime and as needed throughout the day. The care plan indicated the resident was at high risk for falls and staff interventions included instructions to orient the resident to the call light and place a tab alarm on the resident in bed. On 11/21/11 an Incident/Accident Report identified the resident had a fall out of the wheel chair in the dining room. The resident was placed on neuro checks for a "possible hit to head" and the physician and family were notified. A Neurological Assessment Flow Sheet (neuro check documentation form) identified neuro checks were performed with no change in status noted. On 11/23/11 a physician visit note identified the resident was assessed post fall by the physician and there was no evidence of head injury. On 11/27/11 an Incident/Accident Report completed by the RN (Staff 8) indicated the resident was found lying on the floor beside the bed at 2:10 am. The resident was weak in all four extremities, the side of the resident's face was slightly swollen, and her/his thumb was swollen, bruised and painful. The report identified the resident's alarm (tab) was "off" at the time of the incident. Staff put "gribber rails on" and "placed tab alarm on" to prevent a re-occurrence. The report indicated the resident's family was contacted at 2:25 am, the physician at 2:45 am and the resident was sent out via ambulance for evaluation (no documented time given). On 11/27/11 at 2:25 am a nursing note completed by Staff 8 identified the resident's "faint alarm sounded" and the resident was found lying on the floor beside the bed. The resident's legs, arms and hands were weak, her/his thumb was swollen, bruised and very painful. The right side of the resident's head had a small scrape on it with a small amount of swelling. Ice was applied to the resident's thumb and right side of her/his face. The nursing note documentation of the alarm sounding at the time the resident was found was contradicted by Staff 8 in the incident report where Staff 8 indicated the alarm was off. Facility documentation indicated the resident had struck her/his head as evidenced by the scrape and swelling on the right side, however, there was no documented evidence the facility conducted a neurological assessment to rule out a head injury. On 11/27/11 at 3:00 am it recorded on the resident's MAR (medication administration record) the resident was given pain medication for right thumb pain. On 11/27/11 at 3:15 am a nursing note completed by Staff 8 identified the resident's resident's "face was swollen more so than before" and the family "wanted (the resident) sent to the hospital." On 11/27/11 at 6:39 am a hospital Trauma History and Physical identified the resident had a fall at the facility and complained of head pain. The resident's right hand was negative for fracture. The resident was diagnosed with [REDACTED]. The resident did not return to the facility. During the intake interview and in interview on 1/6/12 at 9:00 am Witness 1, Complainant, stated the resident reported she/he needed to use the bathroom but was unable to reach the call light and the tab alarm was not attached and lying on the floor. Witness 1 stated the resident reported she/he fell out of bed around midnight (on 11/27/11) while attempting to reach "it." The resident reported staff found her/his around 2:00 am when they came to check on her/him. In interview on 1/6/12 at 5:25 am Staff 6, CNA, reported she was assigned to Resident 1 on 11/27/11 during the night. Staff 6 reported she checked on the resident at midnight, asked the resident twice if she/he need to toilet but the resident refused. Staff 6 stated the resident had the call light within reach and the tab alarm was on. In interview on 1/10/12 at 9:20 am Staff 8, RN, stated a CNA (Staff 9) and herself heard the resident's alarm sounding, entered the resident's room and found the resident on the floor. In interview on 1/11/12 at 1:20 pm Staff 9, CNA, reported he was not working on 11/27/11 but heard the resident fell when he returned to work on 11/28/11. The facility's Night Shift Assignment Sheets dated 11/27/11 and 11/28/11 confirmed Staff 9 was not working on 11/27/11. In interview on 1/10/12 at 5:30 am Staff 7, CNA, reported on 11/27/11 around 2:00 am she passed Resident 1's room and saw the resident lying on the floor. She stated the resident was "struggling" and "looked like (she/he) had been there awhile." Staff 7 reported the resident did not have an alarm on at the time. She stated that she alerted the nurse (Staff 8) who assessed the resident and they placed the resident back into bed. Staff 7 reported she attached a tab alarm to the resident. In interview on 1/11/12 at 2:30 Staff 2, DNS, stated Staff 8 reported she conducted neuro checks, however, confirmed there was no evidence of that. Staff 2 stated "the tab alarm probably wasn't on" the resident at the time of the fall as Staff 8's "story changed" regarding the events of the fall. Staff 2 confirmed Staff 7 found the resident.

Based on interview and record review it was determined the facility failed to use a gait belt during a transfer and failed to assess a resident for injury timely after a fall for 1 of 4 sampled residents (#1) who had falls. Resident 1 sustained a fracture and a delay in treatment. Resident 1 was admitted to the facility in 1996 which multiple [DIAGNOSES REDACTED]. The resident's January 2011 Care Plan identified the resident was at risk for falls due to a history of falls, a lack of insight into limitations, and impulsiveness. The plan identified the resident used a self-releasing seat belt in the wheel chair and staff monitored the resident for tiredness and assisted the resident to bed when she/he appeared sleepy or gestured to lie down. The In Room Care Plan (ADL care plan) indicated the resident required extensive assistance and one person for transfer. The facility's transfer policy, revised 12/2010, identified staff were required to use transfer/gait belts during all transfers and ambulation of residents who required hands-on one or two person assistance, unless it was medically contraindicated. The policy indicated if medical contraindications existed, it would be identified on the care plan. On 10/11/11 an Incident/Accident Report identified at 10:00 am the resident had an incident where her/his leg was bent underneath the wheelchair. Staff 5, RN, indicated she was notified of the incident at 1:30 pm by Staff 6, CNA, 3 1/2 hours after the incident. The facility's Accident Prevention policy for CNAs, updated 12/2010, identified CNA responsibilities after a resident fall. The policy identified CNAs should "immediately report it to the nurse" and not move the resident until the nurse directed them to because "if the resident has a fracture-moving them could make it worse." On 10/12/11 the facility's Investigation identified Staff 6, CNA, demonstrated how she transferred Resident 1 out of the wheelchair on 10/11/11, "she did not use her gait belt." Staff 6 reported the resident's legs were under the wheelchair when the resident was stood up, she could not turn the resident to transfer her/him unto the bed and she lowered the resident to the floor. Staff 6 stated the resident's legs were bent under her/him and she straightened them out before requesting assistance to transfer the resident back into bed. The Investigation identified the fall occurred at approximately 10:00 am and Staff 6 did not report the incident to the nurse (Staff 5) until 1:30 pm. In interview on 11/4/11 at 12:40 pm Staff 2, RNCM, reported on 10/11/11 at 10:00 am Staff 6, CNA, attempted to transfer Resident 1 without using a gait belt by grabbing the resident around the waist. She left the resident's leg under the wheelchair and ended up lowering the resident to the floor during the attempt. Staff 2 reported Resident 1's foot was observed dragging after the 1:00 pm smoke break and the nurse (Staff 5) was informed of the fall at that time by a staff member. Staff 2 stated the resident's injury occurred at the time of the fall (at 10:00 am) and movement worsen it making the injury apparent at 1:00 pm. Staff 2 reported Staff 6, CNA, received training during orientations on mandatory gait belt usage and the directive to report all incidents to the nurse immediately, before moving the resident. In interview on 11/4/11 at 12:50 pm Staff 6, CNA, reported on 10/11/11 (at 10:00 am) she entered Resident 1's room, released the resident's seatbelt, and attempted to transfer the resident by "grabbing" her/him around the waist. She reported the resident put all of her/his weight on her and she couldn't get the resident to the bed so she lowered the resident to the floor. Staff 6 stated she did not contact the nurse regarding the fall because she didn't think the resident was in pain. Staff 6 reported after the afternoon smoke break, she noticed the resident wouldn't put weight on the right leg and reported the fall to the nurse. In interview on 11/7/11 at 10:21 am Staff 5, RN, stated on 10/11/11 at 10:00 am Staff 6, CNA, reported the resident had pain in her/his leg and she assessed the leg but found nothing at that time. She stated Staff 6 did not identify the resident had a fall. Staff 5 reported the resident was unable to bear weight on the leg during a transfer in the afternoon and it was then disclosed the resident had fallen at 10:00 am by staff. She stated when the resident's leg was assessed in the afternoon, it was swollen, bruised above the knee to the thigh, and painful. Staff 5 reported she would have assessed the resident's leg differently at 10:00 am had she been told the resident had fallen.

Based on interview and record review it was determined the facility failed to ensure professional standards were followed regarding notifying the nurse of an incident timely for 1 of 4 (#1) sampled resident who had a fall and fracture. The resident experienced a delay in treatment. Findings include: Division 63 Standards and Authorized Duties for Certified Nursing Assistants and Certified Medication Aides Conduct Unbecoming a Nursing Assistant 851-063-0090 (3) Conducted related to communication: (g) Failing to communicate information regarding the client's status to the supervising nurse or other appropriated person in a timely manner. Resident 1 was admitted to the facility in 1996 with multiple [DIAGNOSES REDACTED]. On 10/11/11 an Incident/Accident Report identified at 10:00 am the resident had an incident where her/his leg was bent underneath the wheelchair. Staff 5, RN, indicated she was notified of the incident at 1:30 pm by Staff 6, CNA, 3 1/2 hours after the incident. On 10/12/11 the facility's Investigation identified Staff 6, CNA, reported the resident's legs were under the wheelchair when the resident was stood up, she could not turn the resident to transfer her/him unto the bed and she lowered the resident to the floor. The Investigation identified the fall occurred at approximately 10:00 am and Staff 6 did not report the incident to the nurse (Staff 5) until 1:30 pm. The facility's Accident Prevention policy for CNAs, updated 12/2010, identified CNA responsibilities after a resident fall. The policy identified CNAs should "immediately report it to the nurse" and not move the resident until the nurse directed them to because "if the resident has a fracture-moving them could make it worse." In interview on 11/4/11 at 12:40 pm Staff 2, RNCM, reported on 10/11/11 at 10:00 am Staff 6, CNA, attempted to transfer Resident 1 and ended up lowering the resident to the floor during the attempt. Staff 2 reported Resident 1's foot was observed dragging after the 1:00 pm smoke break and the nurse (Staff 5) was informed of the fall at that time by a staff member. Staff 2 stated the resident's injury occurred at the time of the fall (at 10:00 am) and movement worsen it making the injury apparent at 1:00 pm. In interview on 11/4/11 at 12:50 pm Staff 6, CNA, reported on 10/11/11 (at 10:00 am) she entered Resident 1's room, released the resident's seatbelt, and attempted to transfer the resident but was unable and lowered the resident to the floor. Staff 6 stated she did not contact the nurse regarding the fall because she didn't think the resident was in pain. In interview on 11/4/11 at 1:05 pm Staff 7, CNA, reported learning it was a standard of practice that CNAs immediately contact the nurse if a resident had a fall, was found on the floor, or was lowered to the floor. In interview on 11/7/11 at 10:21 am Staff 5, RN, stated on 10/11/11 at 10:00 am Staff 6, CNA, reported the resident had pain in her/his leg and she assessed the leg but found nothing at that time. She stated Staff 6 did not identify the resident had a fall. Staff 5 reported the resident was unable to bear weight on the leg during a transfer in the afternoon and it was then disclosed the resident had fallen at 10:00 am by staff. She stated when the resident's leg was assessed in the afternoon, it was swollen, bruised above the knee to the thigh, and painful. Staff 5 reported she would have assessed the resident's leg differently at 10:00 am had she been told the resident had fallen. Refer to F309.

Based on interviews and record review, it was determined facility staff failed to identify a change in condition, notify the physician and document nursing services for 1 of 4 sampled residents (#1). The facility failure resulted in Resident 1's continued intermittent nose bleeds. Findings include: According to the State Board of Nursing, Nurse Practice Act regarding Standards of Practice: Standards for All Licensed Nurses "(1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering ... (5) Standards related to licensed nurse's responsibility to assign and supervise care. The licensed nurse: (e) Ensures documentation of the activity ... (e) Provides follow-up on problems and intervenes when needed.... " Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The resident's 9/17/10 Minimum Data Set indicated no problems with short and long term memory, independent in daily decision making, no indicators of [MEDICAL CONDITION]/disordered thinking, able to understand and make herself/himself understood and no behavior symptoms. The resident had 10/29/10 physician's orders [REDACTED]. The 12/1/10 day shift Interdisciplinary Progress Note (IPT) written by Staff 2 (LPN) indicated the resident had a bloody nose during the early part of the day shift. The resident complained of having cold symptoms and nasal congestion. The resident was reminded not to aggravate the inside of her/his nose. The resident denied placing objects inside her/his nose. The documentation indicated the resident's nose bleed had stopped for over three hours. The December 2010 ADL Flowsheet contained documentation on 12/2/10 by Staff 4 (CNA) to indicate Staff 2 (LPN) was informed that Resident 1 had a heavy nose bleed and it continued to bleed throughout the shift. On 12/3/10 Staff 4 documented the resident continued to have a nose bleed during the day shift and Staff 2 was aware of the resident's condition. There was no documentation of the resident's nose bleeds in the 12/2/10 and 12/3/10 IPTs. An interview on 1/4/11 at 9:35 am with Staff 4 (CNA) revealed she was very familiar with Resident 1. Staff 4 stated she was first aware of the resident's nose bleeds on the morning of 12/1/10. Staff 4 stated she worked with the resident until 12/3/10 and the resident's nose bleeds were never gone completely. Staff 4 stated the resident's nose bleeds were worse in the morning and tapered off in the afternoon. Staff 4 stated Staff 2 (LPN) was aware of the resident's nose bleeds. Staff 4 stated she was never aware of the resident inserting items into the resident's nose but the resident held a tissue to her/his nose. Staff 4 stated the resident was concerned about the nose bleeds. An interview on 1/4/11 at 2:30 pm with Staff 7 (CNA) revealed on the beginning of the evening shift of 12/3/10, the resident was observed to have tissues with blood the floor. The resident was observed to have a tissue pressed to her/his nose. Staff 7 stated Staff 2 was informed of the observations and Staff 2 stated the resident had nose bleeds off and on. An interview on 1/4/11 at 8:47 am with Staff 2 (LPN) revealed she was aware of the resident's nose bleeds and determined the resident had no significant loss of blood. Staff 2 stated she was the charge nurse for the resident during the day shift and was aware the resident had intermittent nose bleeds for a period of four days. Staff 2 stated she thought she informed the physician of the resident's nose bleeds. Staff 2 reviewed the resident's record and was unable to locate any documentation the resident's physician was notified. Staff 2 was asked if the anti-coagulation clinic was advised of the resident's intermittent nose bleeds. Staff 2 stated she did not contact the anti-coagulation clinic and could not locate any documentation in the resident's record to indicate the clinic had been contacted. An interview on 1/6/11 at 2:50 pm with Staff 13 (RN) revealed she regularly worked with the resident during the evening shift of 12/1/10 through 12/3/10. Staff 13 stated the resident told her of the nose bleeds she/he had. Staff 13 stated the resident complained of cold symptoms and Staff 13 examined the resident's nose. Staff 13 stated the resident's nose was dry and found no evidence of a nose bleed. Staff 13 was asked if the observation and examination was documented. Staff 13 stated the examination and observation was not documented. An interview on 1/6/11 at 8:50 am with Witness 2 (local anti-coagulation clinic staff) revealed it was expected the anti-coagulation clinic or the resident's physician would be contacted if the resident experienced any unusual bleeding. The Vital Sign Flow Sheet indicated the resident's blood pressure, temperature, pulse and respiration were not taken on 12/1/10 through 12/3/10. The Vital Sign Flow Sheet on 12/4/10 at 12:00 pm (noon) indicated the resident's blood pressure was 150/80, temperature was 100.4 degrees and pulse was 100. The normal blood pressure reading for an adult was 120/80, normal temperature 98.6 degrees and pulse between 50 and 80 beats per minute. A 12/4/10 IPT written at 1:00 pm by Staff 6 (RN) indicated the resident had a nose bleed and complained of being cold and not feeling well. Staff 6 indicated a dose of PRN Tylenol was administered for a temperature of 100.4 degrees and [MEDICATION NAME] (cold medication) was given for cold symptoms. The IPT written at 2:00 pm indicated the resident's temperature increased to 102.2 degrees and an ice pack was provided. The Vital Sign Flow Sheet indicated at 4:00 pm the resident's blood pressure was 142/72, temperature was 101.7 degrees and a pulse of 115. The IPT written at 7:00 pm indicated the resident's temperature remained high at 101.7 degrees and another dose of PRN Tylenol was administered. The resident's nose bleed continued and the resident's head was tilted back, ice pack applied to forehead and bridge of nose and nose pinched. The resident's [MEDICATION NAME] was held until the resident's nose bleed stopped. There was no documentation the resident's physician was notified of the resident's change in condition. An interview on 1/4/11 at 11:42 am with Staff 11 (CMA) revealed on 12/4/10 the resident's nose bleed was very significant. Staff 11 stated Staff 6 (RN) was aware of the resident's condition and the resident had ice packs on her/his forehead and it was very difficult for the resident to swallow. An interview on 1/4/11 at 2:30 pm with Staff 7 (CNA) revealed the resident stated she/he had nose bleeds for three days and was very tired. Staff 7 stated on 12/4/10 the resident refused to have a shower before breakfast because she/he did not feel like it. Staff 7 made observations of blood stained tissues lying on the floor beside the bed. Staff 7 stated the resident was usually a very social person and requested to remain seated in her/his wheel chair to attend Bingo. On 12/4/10, the resident requested to remain in bed and complained of feeling sick. The resident told Staff 7 she/he thought the nurses were aware of her/his condition An interview on 1/4/11 at 12:12 pm with Staff 3 (DNS) and Staff 5 (RNCM) revealed Staff 3 stated she was called about the resident's condition on 12/4/10. Staff 3 stated she encouraged Staff 6 to contact the physician if the resident's nose bleeds and fever continued. Staff 3 stated she did not document her conversation with Staff 6. There was no documentation in the chart that Staff 3 was consulted or notification of the resident's physician. An interview on 1/4/11 at 12:45 pm with Staff 6 (RN) revealed the resident had nose bleeds in the past. Staff 6 stated the resident's nose bleeds were not real heavy on 12/4/10. Staff 6 indicated she monitored the resident's nose bleeds and stated the resident's nose bleed would stop and then restart. Staff 6 stated the resident developed a fever and she decided to hold the [MEDICATION NAME] because of the resident's nose bleeds. Staff 6 stated she did not inform the resident's physician, did not receive physician's orders [REDACTED]. The 12/5/10 IPT written at 12:30 am by Staff 10 (RN) indicated the resident's nose was bleeding, the head of bed was elevated to 40 degrees, temperature 102 degrees, pulse was 134 and oxygen saturation level was 84 percent. The resident was choking and coughing on blood. The resident requested to be transported to the local emergency room . The resident had an emesis of dark red blood and she was described as being pale. The 12/7/10 local hospital's Discharge Summary indicated the resident was admitted to the hospital on [DATE] with severe epistaxis (nose bleed) and was found to be severely [MEDICAL CONDITION] (abnormal decrease in the number of blood platelets). The resident was diagnosed with [REDACTED]. Refer to F-329 Unnecessary medications.

Based on interviews and record review it was determined the facility failed to assess and monitor the continued use of [MEDICATION NAME] (blood thinner) for a resident who experienced adverse consequences of intermittent nose bleeds and failed to monitor the effectiveness of pain medications for 2 of 4 sampled residents (#s 1 and 4). The facility failure resulted in Resident 1's continued intermittent nose bleeds. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's [DATE] Minimum Data Set indicated no problems with short and long term memory, independent in daily decision making, no indicators of [MEDICAL CONDITION]/disordered thinking, able to understand and make herself/himself understood and no behavior symptoms. a. The resident had [DATE] physician's orders [REDACTED]. An interview on [DATE] at 5:15 pm with Witness 1 (Resident 1's family member) revealed the resident contracted pneumonia on [DATE]. Witness 1 indicated the resident started to have nose bleeds on [DATE] or [DATE]. Resident 1 was hospitalized on [DATE] and died at the hospital on [DATE] from a curable form of [MEDICAL CONDITION]. The [DATE] day shift Interdisciplinary Progress Note (IPT) written by Staff 2 (LPN) indicated the resident had a bloody nose during the early part of the day shift. The resident complained of having cold symptoms and nasal congestion. The resident was reminded not to aggravate the inside of her/his nose. The resident denied placing objects inside her/his nose. The documentation indicated the resident's nose bleed stopped for a period of three hours. A [DATE] IPT indicated the anti-coagulation clinic called and there was no change in the resident's current [MEDICATION NAME] (blood thinner) order. The [DATE] Medication Administration Record (MAR) indicated the resident received 3 mg of [MEDICATION NAME] at 8:00 pm on [DATE]. The [DATE] ADL Flowsheet contained documentation on [DATE] by Staff 4 (CNA) to indicate Staff 2 (LPN) was informed that Resident 1 had a heavy nose bleed and it continued to bleed throughout the shift. On [DATE] Staff 4 documented the resident continued to have a nose bleed during the day shift and Staff 2 was aware of the resident's condition. There was no documentation of the resident's nose bleeds in the [DATE] and [DATE] IPTs. The [DATE] MAR indicated the resident received 4 mg of [MEDICATION NAME] at 8:00 pm on [DATE] and 3 mg of [MEDICATION NAME] at 8:00 pm on [DATE]. An interview on [DATE] at 9:35 am with Staff 4 (CNA) revealed she was very familiar with Resident 1. Staff 4 stated she was first aware of the resident's nose bleeds on the morning of [DATE]. Staff 4 stated she worked with the resident until [DATE] and the resident's nose bleeds were never gone completely. Staff 4 stated the resident's nose bleeds were worse in the morning and tapered off in the afternoon. Staff 4 stated Staff 2 (LPN) was aware of the resident's nose bleeds. Staff 4 stated she was never aware of the resident inserting items into the resident's nose but the resident held a tissue to her/his nose. Staff 4 stated the resident was concerned about the nose bleeds. An interview on [DATE] at 2:30 pm with Staff 7 (CNA) revealed on the beginning of the evening shift of [DATE], the resident was observed to have tissues with blood the floor. The resident was observed to have a tissue pressed to her/his nose. Staff 7 stated Staff 2 was informed of the observations and Staff 2 stated the resident had nose bleeds off and on. An interview on [DATE] at 8:47 am with Staff 2 (LPN) revealed she was aware of the resident's nose bleeds and determined the resident had no significant loss of blood. Staff 2 stated she was the charge nurse for the resident during the day shift and was aware the resident had intermittent nose bleeds for a period of four days. Staff 2 verified there was no documentation the physician or anti-coagulation clinic was notified of the resident's intermittent nose bleeds. An interview on [DATE] at 8:50 am with Witness 2 (local anti-coagulation clinic staff) revealed it was expected the anti-coagulation clinic or the resident's physician would be contacted if the resident experienced any unusual bleeding. The [DATE] IPT written at 12:30 am by Staff 10 (RN) indicated the resident's nose was bleeding, the head of bed was elevated to 40 degrees, temperature 102 degrees, pulse was 134 and oxygen saturation level was 84 percent. The resident was choking and coughing on blood. The resident requested to be transported to the local emergency room . The resident had an emesis of dark red blood and she was described as being pale. The [DATE] local hospital's Discharge Summary indicated the resident was admitted to the hospital on [DATE] with severe epistaxis (nose bleed) and was found to be severely [MEDICAL CONDITION] (abnormal decrease in the number of blood platelets). The resident was diagnosed with [REDACTED]. An interview on [DATE] at 2:30 pm with Staff 7 (CNA) revealed the resident stated she/he had nose bleeds for three days and was very tired. Staff 7 stated on [DATE] the resident refused to have a shower before breakfast because she/he did not feel like it. Staff 7 made observations of blood stained tissues lying on the floor beside the bed. Staff 7 stated the resident was usually a very social person and requested to remain seated in her/his wheel chair to attend Bingo. On [DATE], the resident requested to remain in bed and complained of feeling sick. The resident told Staff 7 she/he thought the nurses were aware of her/his condition An interview on [DATE] at 11:42 am with Staff 11 (CMA) revealed on [DATE] the resident's nose bleed was very significant. Staff 11 stated Staff 6 (RN) was aware of the resident's condition and the resident had ice packs on her/his forehead and it was very difficult for the resident to swallow. An interview on [DATE] at 12:45 pm with Staff 6 (RN) revealed the resident had nose bleeds in the past. Staff 6 stated the resident's nose bleeds were not real heavy on [DATE]. Staff 6 indicated she monitored the resident's nose bleeds and stated the resident's nose bleed would stop and then restart. Staff 6 stated the resident developed a fever and she decided to hold the [MEDICATION NAME] because of the resident's nose bleeds. Staff 6 stated she did not inform the resident's physician and did not receive physician's orders [REDACTED]. An interview on [DATE] at 10:29 am with Staff 10 (RN) revealed she was working at the facility on the night of [DATE] and early morning of [DATE]. Staff 10 stated the evening shift reported the resident had a nose bleed though it stopped. Staff 10 stated she observed blood to be running out of the resident's nose onto her/his chest and the resident was transported to the local emergency room . Staff 10 stated she worked with the resident on the night shift of [DATE] through [DATE] and there were no other observations of the resident having nose bleeds though it had been reported the resident had intermittent nose bleeds on earlier shifts. b. The resident was admitted with a physician's orders [REDACTED]. An interview on [DATE] at 5:15 pm with Witness 1 (Resident 1's family member) revealed the resident complained of a headache for two weeks and during that time the resident would not always be given pain medications. Witness 1 stated the resident was told she/he would receive the medications and then the facility staff would not return to the resident's room. The [DATE] Pain Assessment form indicated the resident had acute pain related to left femur fracture and chronic pain related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility was to monitor the effectiveness of the [MEDICATION NAME] (narcotic pain medication) and explore non-pharmacologic interventions. The Pain Assessment form had an area for the Quarter Review of the resident's pain. There was no documentation the resident's pain was assessed after [DATE]. The resident's Quarterly Minimum Data Set was completed on [DATE] and the MDS indicated the resident did not have any pain symptoms in the last seven days. There was no evidence of a quarterly nursing summary of the resident's pain. An interview on [DATE] at 12:21 pm with Staff 3 (DNS) and Staff 5 (RNCM) revealed Staff 5 was on vacation when the quarterly nursing summary needed to be completed and verified a quarterly nursing summary had not been completed. The resident's [DATE] MAR indicated the resident received PRN [MEDICATION NAME] on 35 occasions and the effectiveness of the PRN medication was not documented on 28 occasions. The resident received six PRN doses of Tylenol for pain and no documentation of effectiveness of the medication on five occasions. The resident's [DATE] Medication Administration Record (MAR) indicated the resident received four doses of PRN [MEDICATION NAME] from [DATE] through [DATE] for complaints of "pain" or "knee pain." There was no documentation of the effectiveness of the PRN [MEDICATION NAME] on three occasions. The MAR indicated the resident received PRN Tylenol on three occasions for her legs hurting and "burning." There was no evidence the effectiveness of the Tylenol was assessed on two occasions. There was no documentation the resident complained of headaches in the resident's [DATE] and [DATE] MAR and the resident's Interdisciplinary Progress Notes from [DATE] through [DATE]. An interview on [DATE] at 8:47 am with Staff 2 (LPN) revealed the CMA staff contacted the charge nurse about the resident's request for pain medication and the charge nurse approved the medication to be administered. Once the medication was administered the charge nurse was responsible to document the effectiveness of the pain medications on the MAR or in the Interdisciplinary Progress Notes. Staff 2 reviewed the resident's MAR and Interdisciplinary Progress Notes and verified the effectiveness of the PRN pain medication was not documented. An interview on [DATE] at 9:45 am with Staff 3 (DNS) revealed the effectiveness of the PRN pain medications were to be documented on the MAR or in the Interdisciplinary Progress Notes. Staff 3 verified there was no consistent documentation of the effectiveness of the PRN medications. 2. Resident 4 was admitted to the facility in 2010 with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The resident's [DATE] Medication Administration Record (MAR) indicated the resident received 113 doses of PRN [MEDICATION NAME]. There were 27 times when the effectiveness of the PRN pain medication was documented. The resident's [DATE] MAR indicated the resident received 130 doses of PRN [MEDICATION NAME]. There were 47 occasions when the effectiveness of the PRN pain medication was documented. The [DATE] MAR documented the resident received 134 doses of PRN [MEDICATION NAME]. There were 43 occasions when the effectiveness of the PRN pain medication was documented. An interview on [DATE] at 8:47 am with Staff 2 (LPN) revealed the CMA staff contacted the charge nurse about the resident's request for pain medication and the charge nurse approved the medication to be administered. Once the medication was administered the charge nurse was responsible to document the effectiveness of the pain medications on the MAR or in the Interdisciplinary Progress Notes. Staff 2 reviewed the resident's MAR and Interdisciplinary Progress Notes and verified the effectiveness of the PRN pain medication was not documented. An interview on [DATE] at 9:45 am with Staff 3 (DNS) revealed the effectiveness of the PRN pain medications were to be documented on the MAR or in the Interdisciplinary Progress Notes. Staff 3 verified there was no consistent documentation of the effectiveness of the PRN medications.

Based on interviews and record review, it was determined the facility failed to assess the change of condition of intermittent nose bleeds for 1 of 2 sampled residents (#1) who received anti-coagulation medications. The facility failure resulted in Resident 1's continued intermittent nose bleeds. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had 10/29/10 physician's orders [REDACTED]. The resident's Interdisciplinary Progress Notes and ADL sheets indicated the resident had intermittent nose bleeds from 12/1/10 through 12/4/10. The resident's December 2010 MAR indicated [REDACTED]. There was no documentation the facility assessed the resident's intermittent nose bleeds in relationship to the [MEDICATION NAME] usage. Refer to F-329.