Every finding on record at Good Samaritan Society Canistota

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (7) with risk for developing skin wounds caused by prolonged pressure and expressed discomfort in areas of irritated skin around her suprapubic catheter (a flexible tubing surgically placed through the abdomen into the bladder to drain urine) insertion site and in her abdominal fold was assessed for irritation and her physician was notified of those skin conditions to determine and order treatment to promote healing and prevent those areas from worsening or developing into pressure wounds. Findings include:1. Observation and interview on 03/17/26 at 11:04 a.m. with resident 7 revealed she was in her room, seated in her wheelchair. There was catheter tubing that extended from her shorts, connected to the catheter bag (a device used to collect urine), and was clipped to her wheelchair. She stated that she had problems with her catheter and that it bleeds every day. She indicated, It is bad down here (pointed to her groin area). 2. Review of resident 7's electronic medical record (EMR) revealed her admission to the facility was on 11/8/21. Her 2/19/26 Brief Interview of Mental Status assessment score was a 15, which indicated her cognition was intact.Her diagnoses included: neuromuscular dysfunction of the bladder (caused by nerve damage that interrupts signals between the brain and bladder, leading to poor bladder control); Type 2 diabetes with chronic kidney disease; Cystostomy status (a surgical opening into the bladder to allow for urinary drainage); retention of urine, (inability to fully empty the bladder); dermatitis (skin inflammation); and morbid obesity (excessive weight that significantly impacts health and well-being).Her 1/6/26 skin observation assessment indicated she had a moist/pink abdominal fold, and her groin area was pink and moist. The treatment indicated for those areas was Nystatin External Powder and was last documented as administered on 12/31/25.Her skin observation assessments indicated that on 1/13/26, her skin observation assessment indicated her groin was pink [and] moist. On 1/20/26, abdomen had s/p [status post] pink area and scattered bruising [due to] insulin injections. On 1/27/26, her abdomen had pink skin under abdominal fold and her groin was pink [and] moist skin. On 2/3/26, her abdomen had pink and moist under abdominal folds and her groin was pink moist. On 2/17/26, her abdomen had irritation under abdominal fold, and the listed treatment of Nystatin External Powder was last documented as administered on 12/31/25. On 2/24/26, her abdomen was pink, moist under abdominal folds [and] scattered bruising from insulin administration. On 3/3/26, the assessment indicated her Skin check was completed - no skin conditions observed/skin condition resolved and no new skin issues noted. There were no medications or treatments listed.Resident 7's skin observation assessments completed on 1/13/26, 1/20/26, 1/27/26, 2/3/26, and 2/24/26, indicated there were no treatments that will or are being done on the skin conditions. Resident 7's 3/17/26 skin assessment indicated she had an abdominal fold with intermittent serous drainage, pink in color, and the only intervention identified was to clean the area.Her 3/24/26 nurse's progress note indicated her skin was warm, dry, and the color was within normal limits. There was a skin condition labeled 001 located on her perineum (the skin between the genitals and anus) that had not been evaluated, was classified as moisture-associated skin damage (MASD), and was acquired in the facility. She had a second skin condition that the staff were monitoring, labeled 002 located on her abdomen, classified as MASD, and was acquired in the facility. There were no measurements for these skin conditions documented. Resident 7's physician was notified of these skin conditions.Her physician's orders included a 6/8/24 order for catheter care BID [twice a day], and a 5/28/25 order to change her suprapubic sponge each day. The physician order to change her suprapubic sponge each day was discontinued in October 2025.Her physician's orders included an order on 4/30/25 for InterDry to be applied to the affected area as needed for MASD. On 9/17/26, this order was put on hold, resumed on 9/29/25, put on hold on 2/7/26 as she was admitted to the hospital, and was resumed again on 2/10/26.She had a 1/5/26, physician's order to Change catheter every month and PRN [as needed] if dislodged or plugged and unable to clear with irrigation.3. Observation and interview on 3/23/26 at 3:56 p.m. with resident 7 revealed she had a nighttime catheter bag clipped onto her bed frame that held a moderate amount of clear yellow urine. She indicated she had a suprapubic catheter, that the insertion site was sore and sometimes had blood. Resident 7 stated the staff did not use a sponge or ointment when they cleaned that site and wished they would use a sponge.Resident 7 pulled up her shirt and separated her abdominal fold where her suprapubic catheter site was, which revealed a pink, shiny area that appeared moist, without a split sponge (pre-cut sterile dressing designed to fit snugly around catheters, used to absorb drainage). She stated the staff would clean the insertion site by wiping it in the morning and at night with a wet wipe.4. Interview on 3/23/26 at 4:05 p.m. with medication assistant (MA) G revealed that resident 7 had her catheter flushed twice a day. The nurse would cleanse the catheter insertion site, and the certified nursing assistants (CNAs) and medication aides MAs would also cleanse the insertion site if they were providing resident care and saw drainage from the site. She was not aware of any gauze or creams being applied to resident 7's catheter insertion site.5. Interview on 3/23/26 at 4:10 p.m. with CNA/environmental services supervisor (ESS) J, who was scheduled to work the evening of 3/23/26 as a CNA, revealed she was not aware of any blood in resident 7's urine or bleeding at her catheter insertion site.6. Observation and interview on 3/23/26 at 4:15 p.m. with registered nurse (RN) F regarding resident 7's suprapubic catheter revealed there was no known history of blood in her urine. Sometimes there was serous (clear watery fluid) drainage at her suprapubic insertion site, which was in an abdominal fold, and she believed it was related to friction and from being tugged on. RN F often would see resident 7 in the morning when resident 7 woke up. RN F would flush her catheter at that time; otherwise, she did not see the serous drainage. When CNAs completed catheter care for resident 7, they would wipe the drainage at the catheter insertion site and cleanse the area each morning and night, as needed.RN F stated there were no physician-ordered creams for resident 7, as the abdominal fold area was open. She would apply a split sponge, as needed, if she had one. She indicated she had none with her that morning (3/23/26) and was not able to get back to resident 7's room to apply one to her abdominal fold. She confirmed there was no physician order for a split sponge.RN F examined resident 7's abdominal fold, which had a split in the skin and granulation (new, connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) tissue with a small opening. RN F stated the doctor was aware of the site and skin issue. She indicated that resident 7 reported pain when she was asked about it. She indicated that the CNAs and bath aides reported residents' skin concerns to the nurses. She stated that the residents' skin assessments were completed for residents with a Braden Scale (a tool used to assess the risk for developing skin ulcers caused by prolonged pressure) score greater than 18, and resident 7 had a physician order for nurse skin assessments.7. Observation and interview on 3/24/26 at 10:18 a.m. with resident 7 revealed that her right-side abdominal fold was pink with a reddened area. The catheter insertion site was red, the skin was granulating (developing new connective tissue and microscopic blood vessels) on each side of the catheter tube at the insertion site, and the area appeared moist. There was no gauze, dressing, or split sponge at the supra-pubic catheter site. Resident 7 reported that it hurt, and she felt pain across her abdomen in the fold. She stated when gauze was placed in the fold, they [staff members] didn't change it, and it [the gauze] was yellow and green. She had, in the past, refused the powder to be placed in the abdominal fold and stated she did not like it. She explained the powder as an irritation too. Resident 7 stated she told various staff members and CNAs that she wanted gauze placed in her abdominal fold, and they said they had to talk to the nurse about that.8. Interview on 3/24/26 at 10:29 a.m. with CNA N regarding resident 7 revealed she cleansed around the suprapubic catheter insertion site, that sometimes had leakage there with blood, and she used a wipe and cleaner to cleanse the area. CNA N indicated resident 7's skin was a little bit red, and that the resident complained that her skin was irritated and itched. CNA N applied a barrier cream to resident 7's skin every time she assisted resident 7 with her catheter care. She stated the area in resident 7's abdominal fold was moist a lot, she had bladder spasms, and CNA N stated she feels urine is leaking into the abdominal fold. Resident 7 did not ask for gauze, and just asks for the cream to be applied in her abdominal fold. CNA N had not seen a split gauze or any other dressing in resident 7's abdominal fold. She indicated the nurse completed the suprapubic catheter insertion site treatment.9. Interview and review of resident 7's EMR on 3/24/26 at 10:47 a.m. with RN E, revealed resident 7's suprapubic catheter care included flushing the catheter twice a day, cleansing the area around her catheter insertion site, and in her abdominal fold with a wipe. When she completed the treatment in the morning, there was extra moisture and serous drainage at the suprapubic catheter insertion site. She indicated she only saw the bloody drainage in the mornings. RN E indicated that resident 7 had bladder spasms and urine leakage at the suprapubic catheter insertion site. She offered to resident 7 to get a physician's order for powder to keep the area dry, but resident 7 refused. Resident 7 had not asked her for gauze to be placed in the abdominal fold or to have a split sponge at the catheter insertion site. Resident 7's suprapubic catheter care treatment order did not include catheter insertion site care or to apply a split sponge. There was a 5/28/25 order from her urologist that included an order for a split sponge. RN E confirmed the split sponge was discontinued in October 2025.RN E confirmed resident 7 had bladder spasms and that her urine back flowed at the suprapubic catheter insertion site, into the abdominal fold, and on to her skin. She reported that resident 7 had not reported or complained to her about her skin being irritated or pain in her abdominal fold. RN E described the skin in resident 7's abdominal fold as being intact, light pink, and moist. She confirmed this description was documented on the 3/17/26 nurse skin assessment and that the resident's weekly skin assessment was due today (3/24/26), but she had not completed it. RN E would clean the skin in the abdominal fold with wipes; resident 7 refused powders, and the CNAs applied barrier cream to her abdominal fold.10. Observation and interview on 3/24/26 at 11:10 a.m. of RN E completing resident 7's weekly skin assessment revealed that resident 7 grimaced and voiced ouch throughout RN E cleansing the area with wipes. She stated ouch and touched her right abdominal area with her hand. Her abdominal fold had a white ointment in it and was observed as being moist. Resident 7 stated the white ointment was not helping her skin heal.The skin in resident 7's abdominal fold was reddened and excoriated (worn off). There was an approximately 6-inch-long by 0.25-inch-wide red streak on the right side of her abdomen in the abdominal fold. There was an approximately one centimeter (cm) area on each side of the supra pubic catheter insertion site that was red, excoriated, and appeared to have new granulation of the skin. The catheter tubing had serous drainage on it, which RN E wiped off with a wipe. RN E spent approximately five minutes using four or more wipes to cleanse resident 7's abdominal fold and the suprapubic site and tubing. Resident 7 continued to wince and voice ouch throughout RN E's cleansing of the area. RN E stated to resident 7 that she was trying to clean her up. RN E then stated she would remove the two tubes of DynaShield skin protectant cream from the bedside so the CNAs would not use it on her abdominal fold.RN E removed her gloves, performed hand hygiene (wash or sanitize hands), and stated she was going to the medication room to get supplies and would be back. She returned to resident 7's room approximately 5 minutes later with wound cleanser spray, a split drain sponge, gauze, and InterDry sheets (specialized, antimicrobial, moisture-wicking textiles designed to manage skin folds and skin-to-skin contact areas). She cleansed the suprapubic catheter insertion site wound with the spray and gauze, placed a split drain sponge around the suprapubic catheter insertion site, and laid the InterDry sheets into the abdominal fold. RN E stated she had not seen the resident's red, newly granulated area around the supra pubic insertion site, and the red excoriated skin in the abdominal fold there before. She stated there was a PRN (as needed) order for the InterDry sheets. She did not use them before but was aware that other nurses had used them for under resident 7's breasts in the summer. She was not certain when the the CNAs started applying the cream in resident 7's abdominal fold and indicated no CNAs had reported to her resident 7's current skin conditions that she first saw during today's (3/24/26) skin assessment.11. Interview and record review on 3/24/26 at 2:20 p.m. with RN F, director of nursing (DON) B, and RN/Minimum Data Set (MDS) nurse C revealed resident 7 had her suprapubic catheter surgically placed on 4/23/25. In October 2025, at the request of the nurses, her provider discontinued the order for the split drain sponge at the suprapubic catheter insertion site because that area was healed. They were aware that resident 7's abdominal fold was moist but were not aware that the suprapubic catheter insertion site was red, appeared excoriated, and had new granulation tissue present.DON B stated the nurses did not use a split sponge at the insertion site, as the physician had discontinued it. Resident 7's physician had ordered InterDry sheets PRN, on 4/30/25 to reduce the moisture in her skin folds. DON B would expect the nurses to use the InterDry sheets in resident 7's abdominal folds to reduce the moisture and to prevent excoriation. Nurse skin assessments were done weekly, and there was no expectation for the nurses to measure the pink area in her folds.12. Review of the provider's 12/8/25 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy revealed Assessment and Documentation of Bruises/Contusions/Skin Tears/Abrasions[.] An abrasion is a wound caused by superficial damage to the skin, no deeper than the epidermis. If a bruise/contusion/skin tear/abrasion is observed on a resident, this should be reported to the nurse immediately. The bruise/contusion/skin tear/abrasion should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation UDA [user defined assessment] and on the resident's care plan.13. Review of the provider's 3/2/26 Catheter: Care, Insertion and Removal, Drainage Bags, Irrigation, Specimen policy revealed, It is important to keep the dressing dry and cleanse the suprapubic skin insertions site using clean technique every day and as necessary. Catheter Care - Indwelling Catheter Catheter care will be completed with morning and bedtime cares and as needed. Observe meatus and surrounding tissue for inflammation, encrustations, swelling, or discharge, ask the resident if burning or discomfort is present.

Based on record review and interview, the provider failed to ensure the code status (emergent treatment a person wishes to receive if their heart or breathing would stop) for thirteen of sixteen sampled residents (1, 3, 5, 6, 9, 23, 26, 40,42, 44, 46, 51, and 58) wishes were determined and accurately documented in the residents' electronic medical records (EMR) at the time of their admission to the facility and one of one sampled resident (46) with discrepancies in his documented code status. Findings include:1. Review of resident 46's EMR revealed that he was admitted to the facility on [DATE]. His [DATE] Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. A banner displayed in his EMR indicated that he wanted to receive (cardiopulmonary resuscitation), an emergency procedure to provide chest compressions and often rescue breathing to preserve brain function and maintain blood circulation (CPR), if his heart or breathing stopped. His care plan had a [DATE] initiated code status focus area that indicated I have a DNR [do not resuscitate] order. A [DATE] physician's order indicated he had a DNR code status. There was no documentation in resident 46's EMR that indicated his code status wishes were for CPR. 2. Review of resident 1, 3, 5, 6, 9, 23, 26, 40, 42, 44, 46, 51, and 58's electronic medical records (EMR) revealed: -Resident 5 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 23 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. -Resident 26 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. -Resident 51 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes -Resident 3 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 9 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. -Resident 42 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 46 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 58 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 1 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated his code status wishes. -Resident 6 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. -Resident 40 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. -Resident 44 was admitted to the facility on [DATE]. No documentation in the resident's EMR indicated her code status wishes. 3. Interview on [DATE] at 10:42 a.m. with administrator A regarding resident's code status revealed the provider did not have a form for the residents or their representatives to sign to indicate the resident's code status wishes. She provided a form that included a signed physician admission standing order with a DNR code status that was used if the resident did not have a formal advanced directive. 4. Interview on [DATE] at 4:16 p.m., with social worker (SW) D, regarding the facility's admission process for obtaining and documenting a residents' code status wishes revealed that the facility reviews their residents' advance directives with the residents during their admission to the facility. She stated the facility did not review the resident's code status wishes with residents when they were admitted to the facility. The facility does not utilize a form for the residents or their representatives to document those wishes. SW D indicated that she would ask residents to verbally state their preferences for their code status at the time of admission. For residents who were admitted from a hospital, their code status was determined based on their hospital discharge documentation. The facility did not have documentation to indicate a resident's code status preference at the time of their admission to the facility. SW D stated the facility followed standing orders from the medical director regarding code status at the time of a resident's admission to the facility. She documented the resident's or their family's preference regarding code status in an admission progress note in the resident's EMR and communicated that information to the nursing staff. The nursing staff would then document that preference in the resident's EMR. 5. Centers for Medicaid and Medicare Services (CMS) State Operations Manual Appendix PP (Guidance to Surveyors for Long Term Care Facilities) definition of code status Do Not Resuscitate (DNR) Order refers to a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. The existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR order.

Based on interview, observation, and policy review, the provider failed to ensure the staff followed infection prevention practices regarding the disinfection of one of one whirlpool by one of one observed certified nursing assistant (CNA) (I), and the prompt cleaning of two of two sampled residents' (6 and 44) bedroom floors observed with bowel movement (BM) on them.Findings include: 1. Observation, interview, and review of whirlpool cleaning instructions on 3/17/26 at 3:22 p.m. with CNA I cleaning the whirlpool revealed he filled the whirlpool with water and disinfectant to a couple of inches up from the bottom of the whirlpool, he used a scrub brush and thoroughly scrubbed all interior surfaces with the disinfectant solution in the bottom of the tub. He then indicated he would let the disinfectant solution sit for ten minutes, drain the tub, and then rinse the tub's interior. He was not sure how to flush the disinfectant from the whirlpool jets. After reviewing the instructions for cleaning and disinfecting the whirlpool, he stated he did not know where the flush button for the whirlpool jets was.2. Observation on 3/19/26 at 10:38 a.m. of the whirlpool revealed the whirlpool door located on the end of the tub was open, with one-fourth inch of water in the bottom of the tub, and suds in the area between the bottom of the tub's edge and where the door closes. Water was filling the reservoir of the tub, and hair on the drain plug, and wrapped around the chain that attached the drain plug to the tub. There was a dry scrub brush lying on the top of the whirlpool. There was no other scrub brush available in the whirlpool room. 3. Observation on 3/17/26 at 10:54 a.m. of resident 6's room revealed two areas of a dark brown substance, both approximately one and one-half inches round in size, dried onto the floor.4. Observation on 3/18/26 at 8:45 a.m. of resident 6's room revealed a staff member on her knees, scrubbing the dark substance on the floor that was identified on 3/17/26, with a washcloth.5. Observation on 3/18/26 at 8:49 a.m. of resident 44's room revealed she was not in her room. There was a small brown stain on her pillow, a brown streak located on the sheet on the edge of her bed, a two-inch round formed piece of BM on the floor, additional bedding, and a pair of shorts with an incontinent (involuntary urine or bowel leakage) brief inside of them with BM smeared throughout.6. Observation on 3/18/26 at 9:32 a.m., of resident 44's room revealed the same conditions as observed above, and at 11:00 a.m., those areas were clean.7. Interview on 3/24/26 at 1:50 p.m. with director of nursing (DON) B, registered nurse (RN) Minimum Data Set (MDS) C nurse, and environmental services supervisor (ESS) J revealed ESS J stated that resident rooms were to be swept and mopped daily. There were no housekeepers to be scheduled on the weekends, so no sweeping or mopping was completed then. EES J had discovered urine on the floor in resident 44's room, but no BM. DON B stated that anytime there was urine or BM on the floor, someone from the nursing department was to clean that up. She then stated resident 44 would take herself to the bathroom, but is not very good at it, and required staff assistance with cleaning and dressing herself. She expected fluids to be cleaned up immediately and the bed linens to be changed when soiled.DON B stated two CNAs were scheduled to work as bath aides Monday through Friday. DON B indicated she did not complete audits for cleaning the whirlpool. She expected the whirlpool to be cleaned and disinfected after each resident's use. She was not aware that CNA I did not know how to clean the whirlpool jets.8. Review of the provider's undated Whirlpool System Cleaning instructions for rinsing the whirlpool jets revealed Press and hold the Disinfectant Button located on the left side of the tub. As the button is held down, the properly mixed cleaning solutions is running through the air injection system and out all of the air jets. Release the button after you see solution coming out of all the air jets and you have 1 to 1 1/2 [one and a half] gallons of disinfectant solution [disinfectant and water combined] in the foot well of the tub. Using the long handled brush, .thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. Let disinfectant stay on surface for 10 minutes . Remove the plug from the drain. Rinse the tub's interior surfaces thoroughly with the shower sprayer. Press and hold the Rinse button located on the left side of the control panel until clear water runs from all the air jets. Then release the Rinse button. 9. Review of the provider's Cleaning Blood and Body Fluid Spill policy revealed the staff were to contain the spill. Block off the area until cleanup and disinfection/sanitization is completed. For hard surfaces body fluids are to be wiped up using a dry cloth or paper towels, then use [a] wet cloth or wipes to remove all visible soil/organic material.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard food safety and sanitation practices in the kitchen and food storage areas where residents' food was stored, prepared, and served.Findings include: 1. Observation on 3/17/26 at 8:20 a.m. of the provider's dry food storage room, canned goods rack, revealed a # (number) 10 can (holds 12-13 cups) of applesauce and a #10 can of dill pickles that both had severe dents at the sealed seam that could cause cracks and entry of bacteria.On the ceiling, a yellow conduit tube had what appeared to be a dust-like substance on it. That substance was approximately two inches long and hanging from various areas of the conduit tube.2. Observation on 3/17/26 at 8:46 a.m. of the dishwashing area revealed a tan-colored residue that covered the top of the dishwasher, and by the far edge, the residue was one-half inch thick. That same residue was on the wall next to the dishwasher. Behind the dishwasher was what appeared to be yellow insulation wrapped around a pipe with a silver covering that was peeling off the yellow insulation. One area of the silver covering was peeled back and measured approximately 2 feet by 5 inches. A second area of peeling was approximately 8 inches long.There was an oscillating table-top fan attached to the wall between the cupboard and the dishwasher that had dust build-up on the fan blades and the front grille. That fan was turned slightly upward and was blowing air into the clean dishwashing area where clean dishes were present.3. Observation at 11:58 a.m. of food service assistant (FSA) M revealed she held a clean Cambro (plastic food storage container) against her apron. After putting the Cambro container in the cupboard, she went to the freezer and took out eight single-serve containers of frozen dessert. She used both of her hands to hold the desserts against her apron, entered the dining room, and served those desserts to various residents.4. Observation on 3/17/26 at 12:19 p.m. of FSA M, in the kitchen, revealed she performed hand hygiene (wash or sanitize hands) at the hand-washing sink, dried her hands on a paper towel, then used one of her clean hands to open the lid of the trash can, and placed the paper towel she dried her hands with in the trash can. That trash can had a step-on pedal to open the lid without touching it.5. Interview on 3/24/26 at 5:25 p.m. with certified dietary manager (CDM) L and administrator A regarding dietary processes revealed, that CDM L was not aware there were dented cans in the dry storage room, and stated they should not be available for use. She was not aware of the accumulated dust on the yellow conduit tube in the storage room, or that the oscillating fan was blowing into the clean dishwashing area while it had dust on the blades and grille.CDM L expected FSA M not to carry clean dishes or food products against her apron and should have used a cart to transport the products. CDM L confirmed there was a foot pedal to open the trash can, and FSA M should not have used her hand to open the trash can.Administrator A acknowledged the above deficient practices and stated, They [dietary staff] have had training [by CDM L).6. Observation and interview on 3/24/26 at 5:35 p.m. with CDM L in the kitchen revealed she was aware of the tan-colored residue that covered the top of the dishwasher and on the wall next to the dishwasher. She stated that it was cleaned after each meal service. She agreed the amount of food particle residue on the dishwasher could not have accumulated after one missed cleaning.CDM L stated the silver covering over the yellow insulation around the pipe behind the dishwasher was for protection and that it was that way for a while, and should have been replaced.7. Review of the provider's 3/13/26 Food Supply Storage policy revealed there was no guidance regarding the storage of canned goods.8. Review of the provider's 2/1/3/26 Warewashing (the cleaning and sanitizing of utensils and food-contact surfaces of equipment) Mechanical and Manual policy revealed that the warewashing machine was to be cleaned before use, and at a frequency to prevent recontamination of equipment and utensils to ensure that the equipment performed its intended function.9. Review of the provider's 12/3/25 Cleaning Schedule-Food and Nutrition Services policy revealed, Keep fans/grills in unit clean, Ceilings: Check daily for cobwebs, dust and dirt or condensation so it cannot fall from the ceiling, and Fans: clean weekly or as needed.10. Review of the provider's 6/27/25 General Sanitation - Food and Nutrition policy revealed, The location stores, prepares, distributes and serves food under sanitary conditions at all times. and The location's food preparation, kitchen, serving areas and dry storage are cleaned and sanitized on a regular basis to limit contamination and prevent food-borne illness.

Based on observation, interview, record review, and policy review the provider failed to ensure the safe use of devices by two of two certified nursing assistants (CNA) (H and K) observed transferring a resident to and from her wheelchair and her mattress without a gait belt (a waist strap gripped as support for safe mobility and transfers) for one of one sampled resident (11) with Huntington's disease (a progressive genetic disorder that causes the breakdown of nerve cells in the brain and involuntary movements) who needed to be transferred with the assistance of two staff members and the use of a gait belt. That failure put the resident at risk for falling and injury. 1. Observation and Interview on 3/17/26 at 3:33 p.m. with CNAs K and CNA H while assisting resident 11 to stand up from her wheelchair in her room revealed the CNAs were positioned on each side of resident 11 and they had one hand under each of the resident's arms while their other hands held the waistband of the resident's pants. each of her arms and held the back of her pants. The CNA's prompted resident 11 to step forward onto her mattress, and turn, and then the CNAs lowered her to a lying position on her mattress. The CNA's changed her incontinence brief (absorbent, protective garments designed to manage bladder or bowel leakage), then prompted her to stand. Resident 11 pulled herself up to a standing position by holding the CNA's hands while the CNAs held on to the back of her pants. Resident 11 was then prompted to turn and sit down on her wheelchair. CNA K stated that resident 11 could not use a mechanical lift (a device used to safely transfer individuals with limited mobility between beds, chairs, and bathrooms) because she had previously thrown herself out of the lift. 2. Review of resident 11's electronic medical record (EMR) revealed her care plan indicated she was able to transfer to and from her mattress on the floor and her wheelchair with hand-held assistance from two CNAs and the use of a gait belt. The resident could hold the hands of CNAs for transfers. 3. Interview on 3/24/26 at 11:39 with CNA K revealed she was not concerned regarding resident 11's transfers because she held onto the resident's pants. She acknowledged she did not use a gait belt to transfer resident 11 on 3/17/26 and stated that she probably should have. 4. Interview on 3/23/26 at 12:06 p.m. with registered nurse (RN) F revealed that resident 11 was not safe to be transferred with a mechanical lift due to her uncontrolled movements. She expected the CNAs to use a gait belt when transferring resident 11. 5. Interview on 3/24/26 at 8:54 a.m. with director of nursing (DON) B revealed that the CNAs would refer to the residents' care plan (personalized plan that addresses a resident's care needs, goals, and interventions), daily report (information shared between CNAs at a shift change regarding the care of residents) to know how to care for the residents. She expected the CNAs to use a gait belt when they transferred resident 11. 6. Review of the provider's 12/1/25 Care Plan policy revealed, Residents will receive and be provided with the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. The policy did not address the implementation of interventions. 7. Review of the provider's 12/12/25 Safe Resident Handling Program policy revealed, Good Samaritan's goal is to maintain a safe living and working environment for residents and employees.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents'(42 and 46) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessments were accurately coded regarding Pre-admission Screening and Resident Reviews (PASRR), used to screen residents for serious mental health, intellectual disabilities, or developmental disabilities to ensure appropriate placement and specialized services, and Level I PASRRs. Findings include:1. Review of resident 42's electronic medical record (EMR) revealed:*He admitted to the facility on [DATE].*His diagnoses included schizoaffective disorder (hallucinations, delusions, disorganized speech), bipolar type (episodes of mania, extreme highs, and sometimes major depression), traumatic brain injury (TBI), and epilepsy (recurrent, unprovoked seizures).*His 10/28/25 level I (one) PASRR was coded as Yes to the questions: * Does this individual have a confirmed or suspected serious mental illness diagnosis limited to the following?* Does the individual have a confirmed or suspected diagnosis of an intellectual disability (ID) that was prior to the age of 22?*Resident 42 was referred to Maximus for further mental health evaluation and then to the Department of Human Services, Division of Developmental Disabilities (DDD).*His 10/28/25 notice of PASRR Outcome Explanation, indicated The facility should mark yes for question A1500 on the Minimum Data Set' Is the resident currently considered by the state level II [two]PASRR process to have a serious mental illness and/or intellectual disability or a related condition?'*His 11/05/25 comprehensive MDS assessment indicated: *Item A1500 was coded as No to the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?*Item A1510 was not coded, which would have indicated that resident 42 had a serious mental illness or intellectual disability.*Item A1550, conditions related to intellectual disability (ID) and developmental disability (DD), was coded as None of the above to the question, If the resident is [AGE] years of age or older, complete only if A0310A+01.*His 10/30/25 care plan indicated he received an antipsychotic (medications used to manage psychosis, including delusions, hallucinations, and severe agitation) medication related to his schizoaffective disorder, bipolar type, and anticonvulsant (therapeutic agents that stabilize nerve cell membranes, reducing abnormal electrical activity in the brain to prevent seizures) medication related to epilepsy. 2. Review of resident 46's EMR revealed:*He admitted to the facility on [DATE].*His diagnoses included anxiety, behavior, psychotic, and mood disturbance.*His 1/29/26 level I PASRR was coded as No to the question, Does this individual have a confirmed or suspected serious mental illness diagnosis limited to the following disorders?-The question had indicated that if the diagnoses were checked, then mark Yes.*His 2/9/26 notice of PASRR Outcome Explanation indicated, The facility should mark yes for question A1500 on the Minimum Data Set 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.'*His 2/9/26 comprehensive MDS assessment indicated:*Item A1500 was coded as No to the question: Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?*Item A1510 was blank. 3. Interview and record review on 3/16/26 at 4:16 p.m. of resident 46's PASRR level 1 screening when he was admitted to the facility with social worker (SW) D revealed:*She was responsible for completing item A1500 on the comprehensive MDS assessments for all residents. 4. Interview and record review on 3/24/26 at 1:47 p.m. with registered nurse (RN)/ Minimum Data Set (MDS) C, regarding completing residents' comprehensive MDS assessments revealed:* SW D completed the PASRR on the residents' comprehensive MDS assessments, and then RN C signed those assessments to indicate that it was accurate?*She confirmed item A1500 on resident 46's 11/05/25 comprehensive MDS assessment for resident 46 should have been coded as yes. 5. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 revealed section A, item A1500, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (1 and 46) with diagnosed anxiety, behaviors, psychosis, and mood disturbances had a Preadmission Screening and Resident Review (PASRR) reviewed for accuracy to ensure the resident were evaluated for mental health care needs.Findings include:Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (1 and 46) with diagnosed anxiety, behaviors, psychosis, and mood disturbances had a Preadmission Screening and Resident Review (PASRR) reviewed for accuracy to ensure the resident were evaluated for mental health care needs. Findings include: 1. Review of resident 46's electronic medical record (EMR) revealed: *He admitted to the facility on [DATE]. *Resident 46's diagnoses included: anxiety, behaviors, psychosis, and mood disturbances. *On 02/03/26, he had a Brief Interview for Mental Status (BIMS) assessment score of 3, which indicated his cognition was severely impaired. *He had a Level I (one) PASRR completed on 01/29/26. - The question, Does this individual have a confirmed or suspected serious mental illness diagnosis limited to the following disorders? was marked No. 2. Review of resident 1's EMR revealed: *He admitted to the facility on [DATE]. *His 8/20/25 care plan had a focus area that indicated The resident has a psychosocial well-being deficit reliving trauma. The care plan did not indicate what the trauma was. *He had a 2/27/26 BIMS assessment score of 15, which indicated his cognition was intact. *His admission diagnoses included: other signs and symptoms involving cognitive functions and awareness; psychosis; traumatic brain injury; personal history of mental and behavioral disorders; major depressive disorder, and anxiety. 3. Interview and record review on 3/16/26 at 4:16 p.m. with social worker (SW) D regarding resident 46's Level I PASARR when he was admitted to the facility revealed: *She reviewed resident 46's Level I PASRR and acknowledged that it had been completed it incorrectly. *She acknowledged that a Level II (two) PASARR request should have been submitted for resident 46. 4. Interview and review on 3/19/26 at 4:01 p.m. of resident 1's Level 1 PASRR with SW D revealed: *When a resident admitted to the facility, from a hospital, with a Level I PASRR already completed by the hospital, she was responsible for reviewing that PASRR for accuracy and submitting a Level II PASRR to the State Mental Health Agency (SMHA) for additional review when the Level I PASRR was positive (the Level I PASRR has identified a suspected or confirmed serious mental illness (SMI), intellectual disability (ID), or developmental disability (DD). *Resident 1 admitted to the facility from the hospital with a Level I PASRR that was completed by the hospital social worker on 8/15/25. *The Level I PASRR indicated a categorical outcome (an expediated determination made during a Level II evaluation) was being requested and was marked as yes, and the area of IF YES, WHICH ONE? had no areas marked. *SW D reviewed resident 1's 8/15/25 Level I PASRR and did not notice that his mental health diagnoses were not included on that PASRR. *She submitted resident 1's 8/15/25 Level I PASRR to the SMHA on 1/27/26 for Level II PASRR determination. *She indicated a Level II request for resident 1 should have been submitted to the SMHA after he was admitted to the facility on [DATE]. *She did not indicate on Level 1 his additional mental health diagnoses, nor did she complete a new, accurate, Level 1 screen. 5. Interview and record review on 3/24/26 at 1:47 p.m. with registered nurse (RN)/ Minimum Data Set (MDS) C revealed: *She expected each resident's Level I PASRR to be completed and accurate. *She indicated that SW D completed the PASRR on the residents' comprehensive MDS assessments, and then RN/MDS C signed the assessments to indicate that they were completed accurately. *She agreed that resident 46's PASRR on his comprehensive MDS assessment was coded incorrectly and should have been coded as yes. 6. Review of the provider's 5/14/25 Preadmission Screening and Resident Review (PASRR) policy revealed: *The Preadmission Screening and Resident Review (PASRR) is a federal requirement to ensure [the] nursing facility residents with serious mental illness (MI) or intellectual and developmental disability (ID/DD) are: -Identified and evaluated; -Placed in the most appropriate and least restrictive setting available; -Transitioned to an appropriate community setting when they no longer meet criteria for nursing facility placement; -Provided with the MI/ID/DD services they need, including specialized services. *A negative Level I screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later. A positive Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority, known as Level II PASRR, which must be conducted prior to admission to the facility. *Failure to pre-screen residents prior to admission to the facility may result in the failure to identify residents who have or may have MD, ID, or a related condition. A record of the prescreening should be retained in the resident's medical record. *Individuals who have or are suspected to have MD, ID, or a related condition (as indicated by a positive Level I screen) may not be admitted to a Medicaid-certified nursing facility unless approved based on Level II PASRR evaluation and determination. Exemptions to this requirement are specified in 483.20 (k)(2) and may be exercised at the discretion of the State, as specified in the State's PASRR process.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Necessary food safety guidelines were followed for appropriate storage of resident food items. *Proper cleaning procedures were followed for dishes used to store, prepare, and serve residents' food in one of one main kitchen. Findings include: 1. Observation on 12/2/24 at 3:06 p.m. during the initial tour of the main kitchen revealed: *Three uncovered bowls of breakfast cereal stacked on top of each other inside the cupboard above the steam table. *Three soup bowls and three soup cups inside another cupboard with food residue on them. Interview on 12/2/24 at 3:25 p.m. with cook E regarding the items in the above cupboards revealed: *The bowls of breakfast cereal had been put in the cupboard after breakfast. *The booster heater had gone out of the commercial dishwasher and had not been working for two weeks. *The staff were washing the dishes by hand. *The staff were checking water temperatures and sanitizer levels while doing dishes by hand. *The new booster heater was scheduled to be delivered on 12/3/24. Interview and record review on 12/2/24 at 5:03 p.m. with nutrition and food services supervisor D regarding the items in the cupboard and the commercial dishwasher revealed: *She did not know why the bowls of cereal were in the cupboard. *Her expectation was no food items would be stacked on top of each other or uncovered. *She confirmed the booster heater for the commercial dishwasher had gone out two weeks ago. *The soup bowls and cups observed above had been rewashed to ensure they were clean before being used. *The staff were monitoring water temperatures and sanitizer levels while washing dishes by hand. *Review of the documented water temperatures and sanitizer level logs confirmed the levels were in compliance. Observation on 12/4//24 at 3:45 p.m. of the commercial dishwasher in the main kitchen revealed the booster heater was being replaced by a service technician. Review of the provider's 5/7/24 Food-Supply Storage-Food and Nutrition Services policy revealed: *7. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly. *8. Items being prepared for the next meal do not have to be dated and labeled but must be covered. Once meal service is over, cover, date and label trays of individually-portioned items such as desserts, salads, glasses of juice, milk and supplements. Review of the provider's 3/25/24 Warewashing-Mechanical and Manual-Food and Nutrition policy revealed: *Food and nutrition employees ensure that food preparation equipment, dishes and utensils are effectively cleaned, sanitized to destroy potential disease carrying organisms and stored in a protective manner. *Manual Ware Washing. Pots, pans and any other utensils or wares will be scraped, washed, rinsed and sanitized.

Based on interview, record review, and policy review the provider failed to provide bed-hod notices to residents and/or their representatives regarding transfers to the hospital on two of three occasions for two of two sampled residents (9 and 46). Findings include: 1. Interview on 12/3/24 at 8:59 a.m. with resident 9 revealed she: *Had gone to the hospital. *Was there for a long time. *Could not remember why she was in the hospital. Review of resident 9's electronic medical record (EMR) revealed: *She was transported to the emergency department (ED) on 7/23/24 and was admitted to the hospital. *Her power of attorney (POA) was notified by phone of her transfer. *She returned to the facility from the hospital on 7/29/24 with diagnoses of urinary tract infection (UTI) and pneumonia. *Resident 9's POA called the provider on 7/31/24 to inform them he was notified resident 9 was being taken to the ED for an evaluation, but he was not notified she had been admitted . *There was no documentation in her EMR that indicated bed-hold information was given to her or her POA. 2. Interview on 12/3/24 at 9:25 a.m. with resident 46 revealed she did not think she had gone to the hospital recently. Review of resident 46's EMR revealed: *She was transferred to the hospital on 4/21/24. -Her POA was notified by phone of her transfer. -There was no documentation in her EMR that indicated the bed-hold information was given to her or her POA. *She was transferred to the hospital on 6/7/24. -Her POA was notified by phone of her transfer. -A bed-hold was signed by resident 46's POA on 6/10/24. 3. Interview on 12/4/24 at 3:22 p.m. with social worker C regarding the bed-hold notifications revealed: *She was responsible for issuing the bed-hold notifications. *The hospitalization for resident 46 happened on a Sunday and it did not get communicated to her. *She thought it was the nurse's responsibility to issue a bed-hold notification if it was at night or on a weekend. *She would have issued a bed-hold notice on Monday morning. *She agreed the bed-hold notifications were not given to the above residents or their POA. 4. Interview with administrator A at 4:02 p.m. regarding bed-hold notifications revealed: *She knew a resident/responsible party must be notified of the bed-hold when residents transferred to the hospital. *They had a checklist that staff were to follow for transfers. *Her expectation was the social worker would issue the bed-hold notifications during normal business hours and the charge nurse would issue it during nights and weekends. *She agreed bed-hold notifications were not being issued appropriately. 5. Review of the provider's 12/7/23 Bed-Hold policy revealed: *Purpose: To ensure that the resident/resident representative is made aware of the facility's bed hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. *Policy: At the time of admission, transfer or therapeutic leave, the location will provide written information to the resident or resident representative that specifies: -1. The duration of the state bed-hold policy, if any, during which a resident is permitted to return and resume residence. -2. The reserve bed payment policy in the state plan. -3. The location's policy regarding bed-hold periods permitting a resident to return. *In Case of Emergency Transfer. -1. b. The charge nurse is responsible for completion of notification procedures if the transfer occurs at a time the social worker is not at the location. -2. The social worker or designated individual will contact the resident/resident representative to inquire regarding their decision for holding a bed. -3. In cases where the facility was unable to notify the resident representative, the social worker or designated individual will document multiple attempts to reach the resident's representative.

Based on record review, interview, and policy review the provider failed to ensure one of one sampled resident (42) had reviewed and was provided a summary of her baseline care plan within forty eight hours of admission. Findings include: 1. Review of resident 42's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *She was admitted from an inpatient psychiatric facility. *She was diagnosed with unspecified mood [affective] disorder, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, liver cell carcinoma, and long term use of anticoagulants. *Her Brief Interview for Mental Status (BIMS) assessment score was 12 which indicated moderate cognitive impairment. *There was no documentation of a power of attorney (POA) until 9/18/24. *Her baseline care plan was not signed as completed until 11/4/24. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident. 2. Interview on 12/4/24 at 2:25 p.m. with director of nursing (DON) B regarding residents' baseline care plans revealed: *The Minimum Data Set (MDS) nurse F completed the baseline care plans. *She guessed resident 42's baseline care plan had been signed as completed on 11/4/24 at her care conference. 3. Interview on 12/4/24 at 3:11 p.m. with resident 42 about her baseline care plan revealed: *She did not remember reviewing her baseline care plan when she was admitted to the facility. *She did not remember signing a baseline care plan when she was admitted to the facility. 4. Interview on 12/4/24 at 3:46 p.m. with MDS nurse F revealed: *She completed the nursing portion of the baseline care plans. *She did not have any documentation if they had reviewed or given a summary of resident 42's baseline care plan with her at the time of her admission. 5. Review of the provider's revised December 2, 2024 Care Plan policy revealed: *A baseline care plan includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. *A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Use the PN-Care Conference Note/or Matrix equivalent to document that the meeting occurred with the resident and representative and any significant discussion that occurred.

Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to accommodate one of one sampled resident's (2) snack time preferences. Findings include: 1. Review of the provider's 6/24/2024 (SD DOH) (FRI) regarding resident 2 revealed: *On 5/22/24 an incident occurred when resident 2 was offered ice cream. She had stated she wanted ice cream, was told she had already had ice cream and was not allowed more. -Resident 2 became upset and was taken to her room to calm down. *It was later discovered that resident 2 had a right eye that was swollen as well as a bump/bruise from her lateral aspect [tail] of the right eyebrow. *The care plan was updated . *Staff was educated to continue giving ice cream to the resident even if she did already have her normal amounts for the day. *Staff was educated on resident rights and choices. *Resident does not have any weight issues or diabetic concerns to support limiting ice cream at this time. 2. Review of resident 2's electronic medical record (EMR) revealed: *An admitted [DATE]. *Diagnoses that included: Huntington's Disease, Major Depressive Disorder, anxiety, and a history of other mental and behavioral disorders. *A Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. *A 5/21/24 nutritional status progress note (PN) indicated Wt [weight] down significantly since was 191 on 12/1 [12/1/23] . Recommend: 1. Provide diet as ordered assisting with all intake. Provide smaller portions per Res [resident] request. 2. General snacks/hydration per diet order to be offered b/t [between] meals. 3. Monitor intake/wt [weight]. *A 5/22/24 nurse PN indicated: Reported to this nurse, that after [the] resident had her HS [evening] snack, she asked staff for ice cream, which was given to her. Activities staff then asked her later if she wanted ice cream and she stated yes, but was informed that she already had ice cream. Resident began yelling and swearing at staff as well as kicking staff. At this time, resident in room screaming, as she wants ice cream. Informed resident that she already had her ice cream. Resident yelling and stating, oh what ever, and pack my shit I'm leaving. *A 6/8/24 nurse PN indicated: Reported to this nurse, that resident in living room screaming as she requested candy, but had just finished with HS [evening] snack and also ice cream. Stated she would need to wait, and began screaming. *A 6/15/24 nurse PN indicated: This morning at ~ [approximately] 0600 [6:00 a.m.] resident in [her] room screaming because she wanted candy and ice cream. CNA [certified nursing assistant] had informed [the] resident that it was almost breakfast. Resident then yelling oh, whatever. Get the hell out of here. *A 7/1/24 nurse PN indicated: Reported to this nurse, that this past evening, resident requesting ice cream for the second time, plus an HS snack and staff told her she would have to wait, as other residents wanted and needed snacks as well. Resident then began screaming and leaning forward in her broda chair [a specialized wheelchair], then throwing herself back into [the] chair. 3.Observation on 8/19/24 at 2:59 p.m. with resident 2 in the main dining room revealed: *She had involuntary movements that included movements of her head, and upper body and she kicked her leg out in front of her repeatedly. *She reached for and drank juice from a cup with two handles. *A staff member assisted her with eating the cake with a fork. *She wiped her own face with her clothing protector. Interview on 8/19/24 at 3:40 p.m. with resident 2 and her male friend revealed: *Her friend brought ice cream to the facility regularly. -It was stored in the shared resident freezer. *She stated she wanted ice cream for a snack but could not get the ice cream when she wanted it. *She stated, I don't have any independence. *She preferred ice cream because it was easy to swallow. *This was a long-standing preference as her friend had provided ice cream for her in her previous living environment. Interview on 8/20/24 at 8:50 a.m. with certified nurse aide (CNA) E regarding resident 2 revealed: *Resident 2 required assistance with eating meals and snacks. -She was able to drink from a 2-handle cup or eat a peanut butter cup if it was opened for her and the paper was removed. -She required assistance with using utensils. *Resident 2 was able to make her needs known. *Resident 2 had behaviors that included cussing at staff, hitting, and kicking. *If resident 2 asked for ice cream at 6:00 a.m. she would be reminded that breakfast was served at 8:30 a.m. and encouraged to wait til breakfast. Interview on 8/20/24 at 9:01 a.m. with registered nurse (RN) F regarding resident 2 revealed: *Resident 2 had a history of getting very angry and required time to calm down in those circumstances for her safety and the safety of the staff. *RN F expected that when resident 2 requested ice cream it would be provided to her. -She stated, I would not want to start the day on the wrong foot. *She was not aware if resident 2 had a recent weight loss. Interview on 8/20/24 at 9:06 a.m. with director of nursing (DON) B regarding resident 2 revealed she: *Started in her role as DON on 6/24/24, after the incident on 5/22/24 occurred. *Expected that if a resident requested a candy or ice cream at midnight or 6:00 a.m., they would be allowed it or an alternative. *Stated, This is their home. *She was not aware that resident 2 had not received snacks when she requested them. Interview on 8/20/24 at 11:13 a.m. with supervisor, nutrition and food service D revealed: *A snack was served daily at 3:00 p.m. in the dining room which included ice cream once a week. *Snacks were kept in the nurse station for residents. *The nurses were able to access the main kitchen and resident refrigerators at all times. *Personal food items brought from outside the facility were stored in the resident unit refrigerator. Observation on 8/20/24 at 12:51 p.m. of the day room freezer revealed four containers of ice cream and 17 peanut butter cups. Interview on 8/20/24 at 12:52 p.m. with certified nurse aide (CNA) E revealed: *The peanut butter cups and at least two of the containers of ice cream belonged to resident 2. -Resident 2's friend brought her snacks and did not always label the items he placed into the freezer. Interview on 8/20/24 at 9:14 a.m. and again at 2:07 p.m. with administrator A revealed: *She expected that if a resident requested ice cream that ice cream or an alternative would have been provided. *The incident on 5/22/24 occurred during the hiring transition of the administrator and director of nursing. *She had contacted the previous interim DON regarding the incident and confirmed that the investigation and education provided were done verbally. -There was no documentation of the investigation or education provided. *She confirmed that the care plan had not been updated to reflect the resident's preferences. 4. Review of the provider's January 2022 Resident's Rights for Skilled Nursing Facilities policy revealed: *The resident has a right to and the facility must promote and facilitate self-determination through support of resident choice. *The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

Based on review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure the care plan was revised to reflect the current snack preferences for one of one sampled resident (2). Findings include: 1. Review of the provider's 6/24/2024 (SD DOH) (FRI) regarding resident 2 revealed: *On 5/22/24 an incident occurred when resident 2 was offered ice cream. She had stated she wanted ice cream, was told she had already had ice cream and was not allowed more. -Resident 2 became upset and was taken to her room to calm down. *It was later discovered that resident 2 had a right eye that was swollen as well as a bump/bruise from her lateral aspect [tail] of the right eyebrow. *The care plan was updated . *Staff was educated to continue giving ice cream to the resident even if she did already have her normal amounts for the day. *Staff was educated on resident rights and choices. *Resident does not have any weight issues or diabetic concerns to support limiting ice cream at this time. 2. Review of resident 2's electronic medical record (EMR) revealed: *An admitted [DATE]. *Diagnoses that included: Huntington's Disease, Major Depressive Disorder, anxiety, and a history of other mental and behavioral disorders. *A Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. *A 5/21/24 nutritional status progress note (PN) indicated Wt [weight] down significantly since was 191 on 12/1 [12/1/23] . Recommend: 1. Provide diet as ordered assisting with all intake. Provide smaller portions per Res [resident] request. 2. General snacks/hydration per diet order to be offered b/t [between] meals. 3. Monitor intake/wt [weight]. *A 5/22/24 nurse PN indicated: Reported to this nurse, that after [the] resident had her HS [evening] snack, she asked staff for ice cream, which was given to her. Activities staff then asked her later if she wanted ice cream and she stated yes, but was informed that she already had ice cream. Resident began yelling and swearing at staff as well as kicking staff. At this time, resident in room screaming, as she wants ice cream. Informed resident that she already had her ice cream. Resident yelling and stating, oh what ever, and pack my shit I'm leaving. *A 6/8/24 nurse PN indicated: Reported to this nurse, that resident in living room screaming as she requested candy, but had just finished with HS [evening] snack and also ice cream. Stated she would need to wait, and began screaming. *A 6/15/24 nurse PN indicated: This morning at ~ [approximately] 0600 [6:00 a.m.] resident in [her] room screaming because she wanted candy and ice cream. CNA [certified nursing assistant] had informed [the] resident that it was almost breakfast. Resident then yelling oh, whatever. Get the hell out of here. *A 7/1/24 nurse PN indicated: Reported to this nurse, that this past evening, resident requesting ice cream for the second time, plus an HS snack and staff told her she would have to wait, as other residents wanted and needed snacks as well. Resident then began screaming and leaning forward in her broda chair [a specialized wheelchair], then throwing herself back into [the] chair. *The care plan had not been updated to reflect the resident's preference for ice cream, or candy. *The care plan did not indicate that Staff was educated to continue giving ice cream to the resident even if she did already have her normal amounts for the day. 3. Interview on 8/19/24 at 3:40 p.m. with resident 2 and her male friend revealed: *Her friend brought ice cream to the facility regularly. -It was stored in the shared resident freezer. *She stated she wanted ice cream for a snack but could not get the ice cream when she wanted it. *She stated, I don't have any independence. *She preferred ice cream because it was easy to swallow. *This was a long-standing preference as her friend had provided ice cream for her in her previous living environment. Interview on 8/20/24 at 9:14 a.m. and again at 2:07 p.m. with administrator A revealed: *She expected that if a resident requested ice cream that ice cream or an alternative would have been provided. *The incident on 5/22/24 occurred during the hiring transition of the administrator and director of nursing. *She confirmed that the care plan had not been updated to reflect the resident's preferences. 4. Review of the provider's November 1, 2023, Care Plan policy revealed: *Each resident will have an individualized, person-centered, comprehensive plan of care . *Person-centered care- A focus on the resident as the locus of control and supporting the resident in making his or her own choices and having control over their daily life.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, Roam Alert (door alarm) log review, and video review, the provider failed to ensure the safety of one of one sampled resident (1) identified at risk for elopement, who had eloped (left the facility without staff knowledge) after staff turned a door alarm off. Failure of staff to ensure the door alarm was rearmed resulted in the resident's elopement and put him at risk for physical injury or serious harm. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of provider's 7/28/24 SD DOH FRI revealed: *On 7/28/24 resident 1 had wandered throughout the building that night. *Staff had redirected him away from the doors throughout the night. *At 5:00 a.m. staff noticed he was not in his room and initiated a search inside and outside of the building. *The sheriff was notified of the missing resident at 6:20 a.m. *Administrator A and director of nursing (DON) B were notified at 5:40 a.m. *An unidentified staff member found resident 1 wandering at 6:30 a.m. on a nearby road and accompanied resident 1 back to the facility at 6:40 a.m. *The nurse notified emergency medical services who assessed resident 1 at 7:15 a.m. at the facility, found no injuries, and recommended to increase his hydration for the day. -His wander guard (door alarm bracelet) was found to be in working order. *His daughter was notified of the incident. *DON B reviewed the camera footage and discovered resident 1 exited the 100 hallway door at 4:41 a.m. *Approximately one minute before that, certified nursing assistant (CNA) C had responded to resident 1's attempt to exit that door. CNA C entered the bypass door alarm PIN code, which turned the alarm off, redirected resident 1, and then responded to another resident's call light. *Door alarm audits were conducted every Wednesday. *Staff audited door alarms for the rest of day 7/28/24. *DON B revised the provider's Alarms-Bed, Chair and Door Policy on 7/28/24 to include: -If resident is exit seeking, staff will redirect away from door. -Staff will reset alarm. -Stay with the exit door until lock is reset and alert lights are red. -Resident is to be assisted to a common area a good distance away from the exit. -Resetting the alarms needs to be done by using the codes on keypads first, and then using badge to reset if keypad does not reset. -Staff will then start a head count and have eyes on all residents. Once all are accounted for radio an all clear, everyone is here message. -Alarm activated and no resident is in sight. One staff member will check to see which door it is and radio staff to check that door. *Education of the policy and process revision was provided to the staff by DON B. Review of resident 1 electronic medical record (EMR) revealed: *His Brief Interview for Mental Status (BIMS) score was three which indicated he had severe cognitive impairment. *He had diagnoses of: -Dementia with behavioral disturbances. -Anxiety disorder due to psychological condition -Major depressive disorder, recurrent. *His elopement risk assessments dated 10/11/23, 1/12/24, 4/12/24,7/20/24 and 7/28/24 all identified him at risk for elopement. *On 4/13/21 a care plan focus area identified his elopement risk. -An intervention for: Wander guard used to alert staff to resident movements was initiated on 4/13/21. -On 7/28/24 he eloped. -On 7/28/24 an intervention to ensure exit door alarms are in working order was added to his care plan. Review of the provider's Roam Alert (wander guard) log and video camera footage of the incident revealed: *Resident 1 at 4:40 a.m. caused alarm to sound at 100 hallway door. *At 4:41 a.m. CNA C entered a door alarm bypass PIN code. -Resident 1 was redirected by CNA C back up the hallway in a direction away from the door. *At 4:41 a.m. a call light was activated in another resident's room. CNA C walked past resident 1 in the hallway and responded to another resident's call light. *Resident 1 turned around and exited the door at the end of the hallway at 4:41 a.m., unseen by staff. *The Roam alert log indicated Bypass On was detected in the 100 hallway at 4:41 a.m. and Bypass off was detected at 4:42 a.m. Interview on 8/20/24 at 3:00 p.m. with DON B revealed: *15-minute visual checks were started on 7/28/24 upon resident 1's return to the building until 8/1/24 and were then changed to one-hour checks for 24 hours. *His behavior charting was completed every shift. *His behaviors improved after the addition of scheduled Tylenol and Tramadol medications for pain. *An elopement drill was conducted with staff on 7/28/24. *After the door alarm bypass PIN code was entered, it would not alarm and would reactivate after 90 seconds. *Alarms policy was updated and revised on 7/28/24. *Staff education was provided regarding alarm policy changes starting 7/28/24 and was completed 7/30/24 for all staff. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 8/20/24 after: record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding door alarms, response and their alarm deactivation and re-activation process, policy update, and observation and staff interviews revealed the staff understood the education provided and the revised process. Based on the above information, non-compliance at F689 occurred on 7/28/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 8/20/24, the non-compliance is considered past non-compliance.

Based on interview, record review, and policy review the provider failed to ensure one of one resident (23) who had a mental illness had a Preadmission Screening and Resident Review (PASARR) Level II completed timely. Review of resident 23's medical record revealed her: *admitted was 9/15/20. *Diagnosis included bipolar and an 8/25/21 schizoaffective disorder. *7/25/23 Brief Interview of Mental Status was a 15, that score meant she was cognitively intact. *Her care plan included: -She preferred to remain in her room. -She had disruptive behaviors including screaming and cursing at other people. -She had a private room due to the above. -Mental health services were provided to her by a behavioral health agency. Review of resident 23's admission PASARR revealed it: *Was completed on 8/24/20. *Had not included a diagnosis of schizoaffective disorder or any other mental illness diagnosis. Interview on 8/10/23 at 9:42 a.m. with social services G regarding resident PASARRs revealed she: *Had worked in long-term care as a social worker for over [AGE] years at various facilities. -Was hired by the provider January, 2022 *Was well versed in PASARR requirements. *Would have notified the state PASARR nurse consultant for the following: -When a resident had a new diagnosis of mental illness. -When a resident had a medication change that included an antipsychotic or anti-depressant medication. *Was not aware that resident 23 had a new diagnosis of schizoaffective disorder or who had given the resident that diagnosis. -She did not know who had given resident 23 that diagnosis. *Confirmed a new PASARR should have been completed for resident 23 when she received a new diagnosis of schizoaffective disorder on 8/25/21. Interview on 8/10/23 at 9:48 a.m. with administrator A regarding resident PASARR's revealed: *Social services G was responsible for completion of resident PASARR's. *Administrator A had not had training regarding completion of resident PASARR's. *She was not aware a new PASARR should have been completed for resident 23. Review of provider's Pre-Admission Screening and Resident Review (PASARR)-Rehab/Skilled revealed: *Purpose -*To ensure that individuals with retardation, serious mental disorder or intellectual disability receive the care and services they need in the most appropriate setting. -Serious Mental Illness - An individual is considered to have a serious mental disorder if the individual meets the following requirements on diagnosis, level of impairment and duration of illness: --1. Diagnosis: the individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised 1987. Mental disorders include: ---a. A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; or another mental disorder that may lead to a chronic disability . --During the Stay ---1. If the resident is diagnosed with a mental disorder while in the location, the social worker will contact the designated state agency for a Level II screening.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Treatment and documentation had been completed for one of one sampled resident (37) according to the provider's polcy who had skin tears. *Two scheduled nebulized medications ordered by the physician for one of one sampled resident (37) were not obtained from the pharmacy according to the provider's policy. Findings include: 1. Observation and interview on 8/8/23 at 4:08 p.m. with resident 37 revealed: *He was seated in his wheelchair in his room. *Had an approximate three-inch skin tear to his right forearm. *Had a small pencil eraser size open area above his right elbow. *Both areas had a small amount of blood present. *The skin tear on his right forearm had skin rolled back to the edges of the wound. *Resident 37 was unable to explain when or how he had received the skin tear. Interview and observation on 8/8/23 at 4:30 p.m. and again at 5:00 p.m. with registered nurse (RN) C revealed she: *Was not aware of resident 37's skin tear or when he had acquired the skin tear. *Cleansed the areas and applied a non-stick dressing over the skin tear and wrapped Kerlix around his arm. Review of resident 37's medical record by RN C indicated the skin tear had occurred a few days ago when he was repositioned in bed. Observations of resident 37 on 8/9/23 at 8:00 a.m., 10:30 a.m., 2:00 p.m., and 3:30 p.m. revealed he had a non stick dressing applied to his right forearm with tape. *The tape was not completely attached to his skin at multiple points on the dressing. *The dressing appeared to be soiled with the resident's own body fluids. Observation of resident 37 on 8/10/23 at 9:00 a.m. revealed there was no dressing on his right forearm skin tear. The area had a dried blood scab that had sealed it. Review of resident 37's interdisciplinary progress notes revealed on: *7/14/23 at 11:58 a.m. Resident noted to have redness to groin/peri area, skin tear to left arm distal to deltoid, skin tear to left forearm. admitted with both wounds covered with protective dressing from the hospital. *7/18/23 at 5:03 p.m. Mepilex dressings came off to left elbow and left upper arm with bath. Dried skin tear to left upper arm. Skin tear above left elbow open and unable to approximate edges. 4 X 4 to wound and wrapped with Kerlix. *8/1/23 at 5:40 p.m. Family also had questions about skin tear on resident's arm and Charge Nurse stated that resident had rubbed it on the bed linens, causing friction and tearing the skin, when staff were changing and turning him earlier this morning. Family did inform writer that resident does not like his arms wrapped or does not like to have band aids on. Informed them that this was on for his protection and to make sure skin tear stays clean. Review of resident 37's medical record revealed: *His 7/14/23 Nursing Admit Data Collection assessment revealed there was no documentation regarding his skin tears to his left forearm and elbow. *There was no further interdisciplinary progress notes in regards to the skin tears to his left forearm and left elbow after 7/18/23. *There was no documentation on resident 37's July 2023 Medication/Treatment Administration Record (MAR/TAR) regarding the left forearm and elbow skin tears. *There was no documentation that resident 37's physician had been notified or that a treatment had been requested for the left forearm and elbow skin tears. *The skin tear noted on 8/1/23 had not indicated where it was located. *Resident 37's family had not been notified when the skin tear occurred. *The 8/1/23 interdisciplinary progress note was the only documentation in regards to more skin tears. *There was no documentation on resident 37's August MAR/TAR record for the skin tears identified on 8/1/23. *A skin observation assessment had been completed on 8/6/23 and a right elbow and right forearm skin tear was documented as covered with a dressing that was clean, dry, and intact. *There was no documentation in the interdisciplinary notes by RN C after she had observed and placed a dressing on resident 37's right forearm skin tear on 8/8/23. Interview on 8/10/23 at 10:04 a.m. with RN D and RN E revealed: *When a resident was admitted with any type of wound it should have been measured with a description of the wound documented in the medical record, and a physician's order for treatment should have been obtained. *The wound should have been assessed daily or weekly depending on the wound type until it was healed. *They agreed resident 37 should have had weekly skin observations completed and documented. *They were not aware of his left of right forearm skin tears. Review of the provider's Skin Assessment Pressure Ulcer Prevention and Documentation Requirements - Rehab/Skilled revised on 4/26/23 revealed: *All residents will have a comprehensive skin inspection done by the licensed nurse on admission/readmission to identify any skin issues present including, but not limited to, pressure ulcers, and the results will be documented in the legal medical record. *Assessment and Documentation of Bruises/Contusions/Skin Tears/Abrasions included: -If a bruise, contusion, abrasion or skin tear is observed on a resident this should be reported to the nurse immediately. -The bruise/contusion/ abrasion/skin tear should be monitored weekly and any changes and/or progress toward healing should be documented on the Skin Observation user defined assessment and on the resident's care plan. *Other documentation that should have been completed included: -A progress note for communication with the resident and or family/resident representative. -A facsimile to the physician for wound care treatment. 2. Review of resident 37's August 2023 MAR revealed: *He was to have received budesonide inhalation suspension 0.5 milligram (mg) per 2 milliliters (ml) two times a day for chronic obstructive pulmonary disease (COPD). *Ipratropium-albuterol inhalation solution 0.5-2.5 3 mg per 3 ml four times a daily for COPD. *Documentation for those medications: -On 8/8/23 revealed a 4 (indicating the drug was not available) had been documented for both doses of the budesonide and the bedtime dose of the Ipratropium-albuterol. -On 8/9/23 revealed an 8 (indicating to see the nurse's notes) had been documented for the morning dose of the budesonide and the 8:00 a.m., 12:00 noon, and 6:00 p.m. doses of the Ipratropium-albuterol. Review of an 8/8/23 5:20 p.m. interdisciplinary note communication with the pharmacy documented by RN C revealed: Resident noted to be out of Duonebs [ipratropium-albuterol] Budesonide Medications were ordered from [drug store] but did not receive them on delivery this evening. Writer called [drug store] at this time. [Pharmacist] from [drug store] states they are waiting for refill scripts from [physician]. Interview on 8/10/23 at 10:04 a.m. with RN D and RN E revealed: *The director of nursing services (DNS) B provided an education sheet for when medications were not available. All of the nurses were to review it and sign it. *They stated it included information to notify the resident's physician and check the emergency drug kit (E-Kit) to see if the medication would be available. Interview on 8/10/23 at 2:30 p.m. with administrator A and DNS B regarding the documentation of resident 37's skin tears and his missed doses of Ipratropium-albuterol and budesonide nebulizer medications revealed: *They confirmed the documentation of his skin tears, including the assessments, physician notification, and treatments provided had been missed. *Their expectation would have been to follow the skin policy. *The pharmacy had been notified on 8/7/23 of the need to refill the ipratropium-albuterol and budesonide nebulizer medications. *It was not delivered the evening of 8/8/23. That was due to needing his physician to provide a new prescription for those medications. *They confirmed the nurse should have checked to see if the E-Kit had those medications until the pharmacy could deliver them. His physician should have been notified of the missed nebulizer medications in case a substitute could have been used. Review of the provider's revised 8/24/22 Local Pharmacy Medication Ordering - Rehab/Skilled policy revealed: *The policy was specific to new medication orders. *If the medication has not arrived in time for the medication pass, used emergency/contingency kit. *If the medication is not available in the emergency/contingency kit and the pharmacy has not delivered the drug by the scheduled med (medication) pass time, call the pharmacy, and speak to pharmacist to determine why the medication was not delivered. Document details in PCC [Point Click Care-electronic health record]. *If the medication is not available, notify the ordering physician immediately to determine whether the order should be changed or starting the medication can wait until the medication is available from the pharmacy. Document in the PN [progress notes] - Communicate with Pharmacy or PN - Communication/Visit with Physician as appropriate. *Note: Remember, if you wait to re-order a medication until you are out, you need to communicate to the pharmacy you are out of the medication.

Based on observation, interview and policy review the provider failed to: *Ensure resident medications were secured for one of two medication carts four out of five times during the observed medication pass in the dining room. *Ensure expired influenza vaccines in one of one medication refridgerator were removed and disposed of and and were not available for resident use. 1. Observation and interview on 8/9/23 8:25 a.m. of registered nurse (RN) D during the medication pass in the resident dining room revealed: *Her medication cart was located in the doorway into the dining room. *She had walked away from the medication cart and into the dining room to give medications to three residents without locking the medication cart. *There were residents and staff walking past the medication cart that was unlocked while the RN was away from the medication cart. *The unlocked medication cart contained multiple resident medications *RN D agreed that she should have locked the medication cart when she walked away to administer medications to those residents. *She prepared a fourth resident's medications at the medication cart and then walked into the medication room to grab a snack for that resident. -The unlocked medication cart was not in view by the nurse. -There were residents and staff walking past the unlocked medication cart. 2. Observation on 8/9/23 at 8:30 a.m. of the medication room refridgerator revealed there were three boxes in the vaccination fridge containing a total of fifteen influenza vaccines that had expired on 6/30/2023. Interview on 8/10/23 at 1:40 p.m with RN D regarding the expired influenza vaccines revealed: *Pharmacy was to have checked the refridgerator containing those vaccines every month. *She was not aware that those vaccines were expired. Interview on 8/10/23 1:45 p.m. with Director of Nursing Services (DNS) B and staff development coordinator RN F revealed: *The expectation when walking away from a medication cart would have been that the nurse or medication aide would lock the medication cart. *DNS B was not aware if the policy indicated that the pharmacy was to have checked the refridgerator in the medication room for expired vaccines. *RN D stated the expectation would have been that the nursing staff would have checked the expiration date of the vaccine before administration. Review of the provider's March 2023 Medications: Acquisition Receiving Dispensing and Storage policy revealed: *POLICY/PROCEDURE *5. Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas. *6. The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations.

Based on interview, observation, and record review the provider failed to ensure one of one sampled resident (11) received recommended routine dental services to prevent tooth extractions. Interview on 8/7/23 at 5:10 p.m. with resident 11 revealed she: *Was missing a few teeth and her teeth were discolored. *Stated that her tooth hurt and she had an appointment to have it pulled. *Had received Tylenol for the pain. Interview on 8/10/23 at 8:28 a.m. with resident 11 regarding her dental issues revealed she: *Had cream of wheat for breakfast. *Had difficulty chewing solid foods. *Had an upcoming dental appointment to have two teeth pulled on the left side. *Had no help from staff in brushing her teeth and felt she needed more assistance. *Needed to brush her teeth daily. *Had numerous toothbrushes that were kept in her bathroom cupboard, in a yellow plastic basin. Observation on 8/10/23 8:30 a.m. of resident 11's bathroom revealed: *The cupboard contained a yellow plastic basin that had one toothbrush, in the original unopened packaging, that was dated 7/1/23 and in an enclosed toothbrush holder. *On the sink was a battery-operated toothbrush that was dry. *She had no toothpaste. Review of resident 11's medical record revealed: *She was admitted on [DATE]. *Her 7/24/23 Brief Interview of Mental Status score was a 12, meaning her cognition was moderately impaired. *Her diagnoses included intellectual disabilities, Alzheimer's disease, paranoid schizophrenia, psychotic disturbance, mood disturbance, and anxiety. *Her care plan included: -On 9/9/14 she required supervision and cueing with mouth care and brushing her teeth. -On 7/30/20 she was to have assistance with set up to brush her teeth and was able to rinse and spit, -On 7/24/23 she had her own teeth. *Her progress notes included: -On 8/4/2022 her teeth were fine, her last dental appointment was on 7/21/22. --The dentist recommended she have her teeth cleaned at the office every three months. ---She preferred every six months. ----There was no documentation to support she had been to the dentist every six months since 7/21/22. -On 06/14/2023 she had a yearly dental appointment scheduled for 7/18/23. -On 7/6/2023: --She had a toothache on the left side of her mouth. --Was missing most of the teeth on the left side and had a very decayed tooth in the front. --A dentist appointment had been made for 7/7/23. -On 8/7/23 she had an appointment at an oral surgery clinic. --She had returned to the facility with an order to take antibiotics for ten days. --She would have dental surgery after she had received medical clearance from her physician. *There was no documented oral care for the last 30 days in her medical record. Interview on 8/10/23 9:22 a.m. with certified nursing assistant (CNA) J revealed: *Her employment started on March 15, 2023. *She was familiar with resident 11's care needs. -Her dental care was provided PRN (as needed). Interview on 8/10/23 at 9:33 a.m. CNA I revealed: *Her employment started in January, 2023. *She was familiar with resident 11's care needs. -The resident occasionally needed assistance in the bathroom and putting on her undergarments. -The resident was independent in providing her own oral care and would ask staff when she needed toothpaste. Interview on 8/10/23 at 9:40 a.m. social services G regarding dental appointments revealed: *She had been employed with the provider for about two years. *The activity director (AD) H scheduled dental appointments for the residents. -The appointments were yearly and if the resident had complained of dental pain. -Each residents dental information was discussed at each care conference. *AD H would have made six-month appointments if needed. *She had no knowledge of six-month appointment for resident 11. AD H was not available for an interview. Interview on 8/10/23 at 10:01 a.m. and at 11:24 a.m. with administrator A regarding dental appointments revealed: *Dental appointments were made by AD H. *If a resident refused to go to a dental appointment their process would have been the following: -Document in the resident's electronic medical record under the progress notes the reason the resident had refused the dental appointment. -Discussion would have been held regarding the resident's dental status at the next scheduled care conference. -Rescheduling the appointment if the resident would have wanted another appointment. *Resident 11 should have had a dental appointment in January, 2023. *There was no documentation to support resident 11 had refused a six-month appointment. -Her care conferences had not included follow-up to a six-month appointment. *The provider had no dental policy.

Based on observation, interview, job description, and policy review, the provider failed to ensure kitchen floors and storeroom floors were maintained in a sanitary condition for one of one kitchen. Findings include: 1. Observation and interview on 3/21/22 at 4:00 p.m. with certified dietary manager (CDM) B during the initial kitchen tour revealed: *She had worked for the facility for three years and served in her current position for a year. *All floors under and behind equipment, shelving, and service tables had an accumulation of dust balls and food debris. *The floors under the stove, food preparation (prep) table, and the steam table had what appeared to have been an accumulation of dust, grease, and food crumbs. *There was dirt built-up along the edges of the walls and in the corners wherever those areas were exposed and could be seen. *The area under the pipes of the two-compartment sink had particles of food and paper scraps that had collected underneath. *They had normally had a service company come in and power wash the floors, but that had not happened due to the pandemic. *The dietary staff had cleaning checklists that they were to complete, and she reviewed those forms. *There had been daily cleaning checklists for the following dietary staff to complete: -Cooks. -Early assistant (6:00 a.m. to 2:30 p.m.). -Day assistant (7:30 a.m. to 4:00 p.m.). -Evening assistant (after 4:00 p.m.). *Kitchen cleanliness was something that they had been working on. *The p.m. dietary staff were responsible to ensure the floor is scrubbed and cleaned each night. *The checklist had been marked off and initialed as completed for that task. *She agreed that the condition of the floor was not up to standards. Observation on 3/22/22 at 8:00 a.m. of the kitchen and storage areas revealed the floors appeared to remain in the same condition with food and dirt particles as the above observation. Observation and interview on 3/22/22 at 10:50 a.m. with cook C. *The floors appeared to not have been swept and were in a similar state as the above 3/21/22 observation. *The storage rooms appeared to have been unswept, with food and dirt particles throughout the areas. *There were pieces of aluminum foil, individual packets of pepper, scraps of cardboard, and *She stated this had been the usual condition of the floors. *The dietary staff spot cleaned between the breakfast and lunch meals. *She was unsure who was assigned to the task for the day but thought someone had already done this. Observation on 3/22/22 at 11:43 a.m. of the kitchen and storage room floors revealed floors in a similar condition as the above observations. Observation and interview on 3/23/22 at 12:45 p.m. with CDM B revealed: *Her agreement that the floors had not appeared to be clean and should have been. *Review of that days checklist revealed the floor had been cleaned. *Although the checklists had been initialed as completed, the condition of the floor had not been acceptable. Interview on 3/23/22 at 1:40 p.m. with administrator A revealed: *She had been aware of issues with cleanliness in the kitchen. *They had been working on this as a performance improvement plan for several months. *They had revised the kitchen cleaning checklists to improve kitchen cleanliness. *She would expect the storeroom floors and kitchen floors to remain clean. *She agreed CDM B was responsible to ensure the kitchen is maintained in a sanitary condition and had not done so. Review of the provider's Food and Nutrition Supervisor job description responsibilities revealed: This position will be held accountable for complying with all related laws, regulations, company policies and procedures pertaining to his or her position and for fulfilling his or her obligations under the [provider name]'s Corporate Compliance Program. Review of the provider's 3/7/22 Person in charge- Food and Nutrition Services policy revealed: The director of food and nutrition services (DFN) or senior living dining director is the person in charge while on duty and is certified as a food protection manager by ServSafe or equivalent. The DFN is responsible for all aspects of the food and nutrition department including but not limited to daily operations, food safety, food production, sanitation and infection control, personnel training and quality assurance. The DFN will ensure that federal, state, and local guidelines and regulatory requirements are being followed.

Based on observation, interview, record review, admission packet review, and policy review, the provider failed to ensure one of one sampled resident (36) with a visual impairment had received services to ensure he had eye glasses in good repair to maintain his vision. Findings include: 1. Observation and interview on 3/22/22 at 3:27 p.m. with resident 36 revealed he: *Had been a resident at the facility since November 2020. *Squinted during the conversation with this surveyor who was seated approximately three feet from him. *Was able to see me but said my image was very fuzzy. *Had glasses when he was admitted to the facility but had not had them for a long time. *Was unsure of what had happened to his glasses but thought they were lost or stolen. *Wanted to see an eye doctor so he could get a new pair of glasses. *Had not seen an eye doctor since he had come to the nursing home. *Wanted improved vision. Interview on 3/23/22 at 9:09 a.m. with Minimum Data Set (MDS) coordinator D revealed she was familiar with resident 36 and: *Had completed the MDS assessments for him since his admission. *Had thought his vision was good without glasses. *Had him read from a newspaper when she completed the MDS assessments; he did so without difficulty. -Had not thought to have him wear glasses when she assessed him even though he had glasses when admitted to the facility. *She had not considered his vision could have been poor from a distance or that her assessment of his vision may not have been accurate. *Had no knowledge of what happened to his glasses. Interview on 3/23/22 at 10:08 a.m. with licensed social worker (LSW) E revealed she: *Had worked for the provider for a couple of months. *Was unaware that resident 36 had glasses when he was admitted to the facility. *Thought his vision was fairly good as he was able to make eye contact with her when she met with him. *Had not thought to ask about his vision. *Agreed that this should have been caught during his care conferences when all areas of his care are reviewed and with the MDS assessment. Interview on 3/23/22 at 1:42 p.m. with administrator A revealed: *She was unaware of what had happened to resident 36's glasses or location. *An appointment had been made for the resident to see an eye doctor and he had refused to go. *No supporting documentation had been provided to support that an appointment had been made, the resident had refused to attend the appointment, or that a new appointment had been attempted. *She agreed there should have been follow-up to ensure the resident had the best possible vision. Review of the provider's admission packet Resident's Rights for Skilled Nursing Facilities document revealed: The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of the facility. A facility must protect and promote the rights of each resident, including each of the following rights: *A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. *The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge and the provision of services under the State plan for all residents regardless of payment source. Review of the provider's 4/6/21 Eye care- Culture, Eyeglasses, Prosthesis, Services- Rehab/Skilled, Therapy and Rehab policy revealed: *Procedure for eyeglass care: .8. Report to charge nurse any problems with glasses such as broken or missing lens. 9. Encourage resident to wear glasses whenever necessary.

Based on observation, interview, and policy review, the provider failed to maintain appropriate storage location and receptacles for clean and soiled personal protective equipment (PPE) throughout the facility. Findings include: 1. The entrance conference on 10/27/20 at 1:00 p.m. revealed: *The director of nursing services (DNS) A, administrator H, and infection preventionist B were unavailable in person. -They were able to video conference into the entrance conference. *They had thirty-four residents that had tested positive for COVID-19. -This had increased to thirty-seven due to new test results coming in during the survey. *There were approximately twenty staff that had tested positive for COVID-19. *They had utilized a nurse consultant during the outbreak. She was unsure of the exact number of staff that had tested positive for COVID-19. 2. Observation on 10/27/20 between 1:30 p.m. and 3:46 p.m. of thirty three of thirty-three rooms of the four hallways revealed: *Red plastic totes with lids were used for the soiled gowns. *Cardboard boxes with cloth coverings were being used for the clean gowns. *Unidentified staff coming out of rooms with soiled PPE on and removing the gowns and placing them in the red plastic totes. Interview on 10/27/20 between 1:30 p.m. and 3:00 p.m. with bath aide C, office manager D, therapy supervisor E, and registered nurse (RN) I revealed they took off the soiled PPE in the hallway. *Those were the staff working on the hallway due to the outbreak in the facility. 3. Observation on 10/27/20 at 2:31 p.m. revealed certified nursing assistant (CNA) F dressed in PPE including gown, gloves, face shield, and N95 respirator. She went into resident room [ROOM NUMBER] with a vital sign cart, she shut the door. She exited the room at 2:36 p.m. with all the same PPE on and brought the vital sign cart down the hallway and on the opposite side from the above room. *She did not change her PPE prior to cleaning the equipment. *She changed her gloves to clean her face shield and reapplied the face shield. *She then removed her gown. *She wiped her face with her gloved hand. *She then took a box of gloves to another staff person outside another room in the hallway without changing her gloves. 4. Interview with DNS A revealed they had the PPE in the hallways, because they could not fit the bins in the residents' rooms. She reported that was how they had been putting on and taking off their PPE during the COVID-19 outbreak. *She revealed on 10/21/20 when the residents starting testing positive for COVID-19 they were all on the 200 unit except for one individual. Review of the provider's 9/16/20 policy entitled; Emerging Threats-Acute Respiratory Syndromes Coronavirus (COVID)-Enterprise revealed: *Infection prevention and control recommendations (for) individual rooms: -Upon identification of any resident with suspected or positive COVID-19, a Droplet Precautions sign will be posted on the outside of the resident's room. The resident will be isolated in their room with the door closed (include the roommate if applicable). 1. Limit only essential personnel to enter the room with appropriate PPE and respiratory protection. PPE includes: Gloves, Gown, Eye Protection (goggles or face shield). Surgical Masks or N95's if available (always use the process for conservation of supplies-See PPE reuse for long-term care.) -When caring for positive and negative COVID-19 residents, the caregiver will wear the N95 mask for the entire shift and practice reuse. The face shield will be cleaned when moving from providing care for positive COVID-19 resident(s) to providing care for negative COVID-19 residents. *Regarding environmental services and care of equipment: -1. All equipment in the resident's room is considered contaminated. Discard disposable equipment after use. 2. Clean and disinfect environmental surfaces and reusable equipment with an EPA (environmental protection agency)-approved emerging [MEDICAL CONDITION] pathogens product, before removing equipment from the resident room. 4. Nursing staff will wear proper PPE while cleaning reusable medical equipment prior to removal from the room.

Based on observation, record review, interview, and policy review, the provider failed to appropriately assess and identify the resident was at risk for developing pressure ulcers (a sore caused by unrelieved pressure that resulted in damage to tissue) and had not provided interventions upon admission for one of three sampled residents (5) resulting in two facility acquired pressure ulcers. Findings include: 1. Observation on 7/29/14 at 4:20 p.m. of resident 5 revealed she was hunched over sitting in a wheelchair. Review of resident 5's medical record revealed: *An admission date of [DATE]. *There were no pressure ulcers upon admission. *There was no vascular (circulatory) [DIAGNOSES REDACTED]. *A 1/13/14 initial care plan had no documentation of skin issues or interventions. *On 2/7/14 a pressure ulcer had developed on her right heel. *On 2/14/14 a pressure ulcer had developed on her bottom. Review of resident 5's Braden Scale for Predicting Pressure Sore Risk assessments completed on 1/13/14, 1/20/14, 1/27/14, and 2/3/14 revealed: *None of those assessments had been completed by the Minimum Data Set (MDS) coordinator. *The assessments all had the same answers and scores of 19 out of 23. -Scores of 10-12 indicated high risk. -Scores of 13-14 indicated moderate risk. -Scores of 15-18 indicated mild risk. *Under sensory perception staff had rated her a 4 out of 4 meaning she had "No impairment: responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort." *Under moisture staff had rated her a 4 out of 4 meaning"Rarely moist: skin is usually dry; linen requires changing only at routine intervals." *Under activity staff had rated her a 3 out of 4 meaning "Walks occasionally: walks occasionally during day but for very short distance, with or without assistance. Spends majority of each shift in bed or chair." *Under mobility staff had rated her a 3 out of 4 meaning "Slightly limited: makes frequent though slight changes in body or extremity position independently." *Under nutrition staff had rated her a 3 out of 4 meaning "Adequate: eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered." *Under friction and shear staff had rated her a 2 out of 3 meaning "Potential problem: moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down." Review of resident 5's Braden assessment completed on 4/11/14 revealed she had a score of 18. The Braden assessment completed on 7/8/14 revealed she had a score of 16. Those two assessments had been completed by the MDS coordinator. There had been no Braden assessment completed from 2/3/14 to 4/11/14 after she had developed two pressure ulcers. Review of resident 5's 1/19/14 MDS assessment revealed she needed extensive assistance with two people physically helping her to move in bed, transfer, and walk in her room. She also needed total assistance from one person to move around the building in her wheelchair. Walking in the hallway had not occurred. She was occasionally incontinent of bladder. Review of resident 5's 1/19/14 care plan revealed no mention of skin concerns or being at risk for pressure ulcers. There were no interventions to prevent pressure ulcers from developing. Review of resident 5's wound documentation revealed: *On 2/7/14 a pressure ulcer had developed on her right heel. -That pressure ulcer had not been resolved at the time of the survey. *Measurements of the right heel pressure ulcer were as follows: -On 2/7/14 the length had been 1.5 centimeters (cm) and the width had been 1.0 cm. The depth had been unknown. -On 2/11/14 the length had been 1.5 cm and the width had been 1.0 cm. The depth had been unknown. -On 2/18/14 the length had been 1.5 cm and the width had been 1.0 cm. The depth had been unknown. -On 2/25/14 the length had been 1.5 cm and the width had been 1.5 cm. The depth had been unknown. -On 3/4/14 the length had been 1.5 cm and the width had been 1.75 cm. The depth had been unknown. -On 3/11/14 the length had been 1.5 cm and the width had been 2.0 cm. The depth had been unknown. -On 3/18/14 the length had been 1.25 cm and the width had been 2.0 cm. The depth had been unknown. -The next week had no date documented. The length had been 1.25 cm and the width had been 2.0 cm. The depth had been unknown. -On 4/1/14 the length had been 1.75 cm and the width had been 1.25 cm. The depth had been unknown. -On 4/8/14 the length had been 1.75 cm and the width had been 1.25 cm. The depth had been unknown. -On 4/15/14 the length had been 1.25 cm and the width had been 1.25 cm. The depth had been unknown. -On 4/22/14 the length had been 1.7 cm and the width had been 1.9 cm. The depth had been unknown. -On 4/29/14 the length had been 1.75 cm and the width had been 2.0 cm. There had been nothing documented for the depth. -On 5/6/14 the length had been 1.75 cm and the width had been 1.75 cm. There had been nothing documented for the depth. -On 5/13/14 the length had been 1.74 cm and the width had been 1.8 cm. There had been nothing documented for the depth. -On 5/20/14 the length had been 1.5 cm and the width had been 1.75 cm. There had been nothing documented for the depth. -On 5/27/14 the length had been 1.25 cm and the width had been 1.75 cm. There had been nothing documented for the depth. -On 6/3/14 the length had been 1.0 cm and the width had been 1.5 cm. There had been nothing documented for the depth. -On 6/10/14 the length had been 1.0 cm and the width had been 1.25 cm. The depth had been 2.0 millimeters (mm). -On 6/17/14 the length had been 1.2 cm and the width had been 1.7 cm. The depth had been 3.0 mm. -On 6/24/14 the length had been 1.0 cm and the width had been 1.7 cm. The depth had been 2.0 mm. -On 7/1/14 the length had been 0.8 cm and the width had been 1.5 cm. The depth had been 3.0 mm. -On 7/8/14 the length had been 1.4 cm and the width had been 0.6 cm. There had been nothing documented for the depth. -On 7/15/14 the length had been 1.2 cm and the width had been 0.6 cm. There had been nothing documented for the depth. -On 7/23/14 the length had been 1.5 cm and the width had been 1.0 cm. The depth had been 0.3 cm. *On 2/14/14 a pressure ulcer had developed on her bottom. -That pressure ulcer had been resolved on 4/1/14. *Measurements of the pressure ulcer on her bottom were as follows: -On 2/14/14 the length had been 2.2 cm and the width had been 2.0 cm. The depth had been 0.1 cm. -On 2/18/14 the length had been 2.0 cm and the width had been 2.0 cm. The depth had been 0.1 cm. -On 2/25/14 the length had been 2.0 cm and the width had been 1.5 cm. The depth had been 0.1 cm. -On 3/4/14 the length had been 1.0 cm and the width had been 1.0 cm. The depth had been 0.1 cm. -On 3/11/14 the length had been 1.0 cm and the width had been 0.5 cm. The depth had been 0.1 cm. -On 3/18/14 the length had been 0.5 cm and the width had been 0.25 cm. The depth had been 0.1 cm. -On 3/25/14 the length had been 0.25 cm and the width had been 0.25 cm. There had been nothing documented for the depth. -On 4/1/14 it had been healed. *On 2/18/14 a pressure relieving cushion was put into her wheelchair. Review of resident 5's 1/29/14 care plan revealed *A concern for skin integrity related to a decrease in mobility. *The approaches or interventions were: -To monitor and report changes in skin. -Extensive assistance of two staff with toileting on the commode. -Extensive assistance with personal care. -Offer back rub every evening and as needed. -Encourage resident to shift weight. -Provide personal pads and change linens as needed. *On 2/21/14 after the two pressure ulcers had developed staff added 8 ounces of milk at 3:00 p.m. and with the bedtime medication pass. *On 2/27/14 after the two pressure ulcers had developed staff added the following interventions: -"Air mattress to the bed." -"Float right heel when in bed." -"Encourage to lay down one hour per day." Review of resident 5's 4/16/14 and 7/17/14 care plans revealed the same approaches and interventions as mentioned above for nutritional and skin integrity. There were no additional interventions listed. Interview on 7/31/14 at 8:30 a.m. with the director of nursing regarding resident 5 revealed she believed the current ulcer on her right heel was due to pressure. She referred this surveyor to speak with the MDS coordinator regarding the pressure ulcers. Interview on 7/31/14 at 8:55 a.m. with the MDS coordinator regarding resident 5 revealed: *The two pressures ulcers mentioned above had been acquired at the facility. *Upon admission she should have been identified as at risk for developing pressure ulcers due to her mobility issues. *The Braden assessments completed upon admission had not accurately reflected the resident's risk of developing pressure ulcers. *Positioning interventions should have been started upon admission. *Pressure relieving devices should have been used upon admission. *From 2/27/14 through 5/7/14 there had been one documented communication with the physician regarding a normal visit. No changes had been made at that time. *On 5/7/14 the physician had referred the resident to a wound clinic. *On 5/9/14 the wound clinic had ordered the pressure relieving boots to be worn. *The MDS coordinator had not been sharing the wound clinic documentation with the physician. *A multi-vitamin had been started on 5/21/14. *On 6/11/14 there was an order to discontinue the multi-vitamin. *The MDS coordinator had not known why the physician had discontinued the multi-vitamin. *On 5/14/14 [MEDICATION NAME] cream had been ordered for the treatment of [REDACTED]. *That treatment had not changed and was still being used at the time of the survey. Review of the provider's March 2007 Pressure Ulcers policy revealed the provider was to have utilized prevention and assessment interventions. Those interventions were to ensure a resident who entered the facility without pressure ulcers had not developed pressure ulcers. Review of the provider's June 2014 Skin Assessment and Pressure Ulcer Prevention policy revealed: *Residents would be assessed for their risk of developing pressure ulcers upon admission using the Braden assessment tool. *For residents determined to be at risk the Braden assessment tool would be completed for the first four weeks following admission. *Residents who were unable to reposition themselves independently should have been repositioned as directed by the care plan approaches. *Development of an individualized repositioning schedule was recommended based on observation of the resident's skin over a period of time.

Based on observation, record review, interview, and policy review, the provider failed to recognize and appropriately manage the pain control for one of one sampled resident (3) with acute pain. Findings include: 1. Review of resident 3's medical record revealed: *A 7/5/10 admitted . *[DIAGNOSES REDACTED]. Review of resident 3's August 2013 Medication Administration Record [REDACTED] *[MEDICATION NAME] (narcotic) patch 37 micrograms (mcg) every three days. *Tylenol 650 milligrams (mg) every four hours as needed (PRN). *[MEDICATION NAME] 5 percent (%) patch up to 10-12 hours daily. *[MEDICATION NAME] 1% gel two grams to low back and right knee every six hours. Review of resident 3's August 2013 PRN record revealed documentation the PRN Tylenol had been administered only once on 8/28/13 for pain all over and relief had been obtained. Review of resident 3's July 2013 PRN record revealed documentation the PRN Tylenol had been administered six times for left rib pain/backache. There was documentation for three of the doses no relief had been obtained. Review of resident 3's June 2013 PRN record revealed documentation the PRN Tylenol had been administered six times for right hand pain/backache. There was documentation for two of the doses that little to some relief had been obtained. Review of resident 3's Pain Data Collection assessments revealed: *Undated- "Pain from fall 7/16/13 to the left rib cage. Unable to rate his pain at the worst or what is a tolerable rate of pain due to not understanding. Rates his pain 10 (on a 1 to 10 scale with 1 being the least pain, 5 being moderate pain, and 10 being severe pain). Moans and groans. Looks in pain. Pain occurs with movement and describes pain as sharp. Complains of pain when eating. Unable to understand what relieves pain. Is irritable. Tylenol is scheduled pain medication regimen and [MEDICATION NAME] and [MEDICATION NAME] are documented as PRN." There was no documentation of any non-pharmacological interventions for pain control. *8/11/13- "Complains of severe back pain. Had fall 7/16/13. Also has [DIAGNOSES REDACTED]. Receives [MEDICATION NAME] and [MEDICATION NAME] daily." There was no documentation of any non-pharmacological interventions for pain control. Review of resident 3's 5/7/13 interdisciplinary notes by the social worker (SW) revealed "States he has pain and feels sad nearly every day." There was no further documentation in the interdisciplinary notes by the SW. Interview on 8/28/13 at 2:30 p.m. with licensed practical nurse (LPN) C regarding the above revealed: *She had sent a facsimile to the physician on 7/16/13 to inform her he had fallen. *There was no change in pain medication orders documented when the physician had returned the facsimile. *The physician had not been called when he continued to complain of increased pain. Interview on 8/28/13 at 3:00 p.m. with the registered nurse Minimum Data Set (MDS) coordinator regarding resident 3 revealed she: *Had documented the 8/11/13 pain assessment. *Had not informed the physician of his increased pain. Observation on 8/28/13 at 9:20 a.m. of resident 3 revealed: *He was sitting in the dining room at the table in his wheelchair. *He was moving his body back and forth in his wheelchair and showing facial grimacing. *Certified nursing assistant (CNA) T sat down to assist him with his breakfast meal and asked him how he was. *He stated he was "Terrible and hurt all over." CNA T told him he would be getting his whirlpool today and that should help. Interview at that time with CNA T regarding the above revealed she would inform the nurse of his pain. Observation on 8/29/13 at 10:55 a.m. of resident 3 revealed: *He was sitting out in the day room in his wheelchair. *He was showing facial grimacing and shifting his body repeatedly in his wheelchair and saying "Ow, it is terrible." *An unidentified CNA asked him if he wanted to go to lunch and proceeded to push him in his wheelchair to the dining room. *He continued to moan, grimace, and shift his body in the wheelchair at the dining room table. Interview at that time with resident 3 revealed he: *"Was having terrible back pain." *When he was asked to rate the intensity of his pain on a 1 to 10 scale (1 being little pain, 5 being moderate pain, and 10 severe pain), he stated "10" when asked by two different surveyors. Interview on 8/29/13 at 11:05 a.m. with registered nurse (RN) D regarding resident 3 revealed: *She stated his [MEDICATION NAME] had last been changed on 8/26/13 and was next due at bedtime tonight. *He had received his [MEDICATION NAME] gel as scheduled at 6:00 a.m. today. *He had not received any PRN Tylenol since 8/28/13 at 10:00 a.m. *His [MEDICATION NAME] had been put on at 7:00 a.m. this morning. *He has pain once in a great while. The CNAs would usually tell her when he was having pain. *The CNAs had not reported to her today he was experiencing any unusual complaints of pain. "I have not heard anything." *After the above interview RN D went down the hall to administer medications to another resident. She did not go into the dining room to assess resident 3. Interview on 8/29/13 at 11:30 a.m. with CNA U regarding resident 3 revealed: *He had been up in his wheelchair since 8:30 a.m. *He had voiced no unusual complaints of pain. He usually had some degree of pain in his back. *They had transferred him from the bed to his wheelchair at 8:30 a.m. with two staff assistance as usual. *He had refused to use the commode this morning. *He usually went into his recliner after breakfast, but they had not assisted him to do that this morning. *They had just lifted him up in his wheelchair after breakfast to reposition him. Review on 8/29/13 at 1:00 p.m. of resident 3's August 2013 MAR indicated [REDACTED]. Review of resident 3's medical record on 8/29/13 revealed: *No documentation regarding an assessment of his pain. *No documentation the physician had been updated of his mental and physical discomfort related to his pain rating of a 10 in his back. Interview on 8/29/13 at 2:30 p.m. with the director of nursing regarding resident 3 revealed: *She was not aware of the above increased pain he was experiencing. *His pain should have been assessed, and the physician should have been informed. Review of the provider's January 2011 Abuse Definitions policy revealed "Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness."

Based on observation, record review, interview, policy review, and review of the 10/4/13 plan of correction for the 9/5/13 recertification survey, the provider failed to recognize and appropriately manage the pain control for one of one sampled resident (3) with acute pain. Findings include: 1. Observation on 10/31/13 at 12:15 p.m. of resident 3 revealed: *Hw was sitting in his wheelchair at the dining room table. *Certified nursing assistant (CNA) G was feeding him his noon meal. *He was coughing when being assisted to eat. *He was shifting himself slightly in his wheelchair. *His facial expression appeared he was uncomfortable. Interview on 10/31/13 at 12:15 p.m. with resident 3 and CNA G revealed: *The resident stated " I am not very good." He stated he was experiencing pain all over but especially in his legs and back. When questioned by the surveyor regarding his pain rating on a scale of 1 to 10 (1 being little pain a 10 severe pain) stated "8". *CNA G stated "His back pain is chronic in nature." She was unsure how long he had been in pain as she had just started to feed him and had not been taking care of him that morning. *CNA G told this surveyor to go talk to CNA F who had been taking care of the resident that morning. Interview on 10/31/13 at 12:20 p.m. with CNA F regarding resident 3 revealed: *She and another CNA had transferred him out of his recliner into his wheelchair shortly before the noon meal. *He had tolerated being transferred without any unusual complaints. If he complained of back pain it was chronic in nature and being repositioned usually helped. *He had complained of more back pain when she had assisted him out of bed that morning between 7:00 a.m. and 7:15 a.m. *She said she had reported his back pain to the nurse when questioned by this surveyor what she had done when he had complained earlier than morning. Interview on 10/31/13 at 1:10 p.m. with licensed practical nurse (LPN) C and registered nurse (RN) D regarding resident 3 revealed: *RN D stated she had not come to work that day until 8:00 a.m. No one had told her the resident had been complaining of back pain. *LPN C stated she was on duty at 6:00 a.m., and CNA F nor any other CNA had informed her he was having back pain between 7:00 a.m. and 7:30 a.m. *LPN C had administered [MEDICATION NAME] to him at 1:00 p.m. today after CNA G had informed her he was having back pain. He had reported to her the pain rating of his back pain was an 8. Observation on 10/31/13 at 2:00 p.m. of resident 3 revealed: *He was lying in bed with his eyes open. *His facial expression of grimacing (frowning) continued to appear he was in pain. He stated his pain "No better." Continued to report his back pain at an 8. Interview on 10/31/13 at 2:15 p.m. with the director of nursing regarding resident 3 revealed: *CNA F should have reported his back pain to the nurse on duty. *She thought the medical director had talked to the resident's family about pain control, but the family had not wanted to change his medications. The family had wanted him to be more awake and alert, and they thought increasing his pain medications would make him too sleepy. *She thought the medical director had educated the family on the need for pain control and possibly making him more comfortable would ultimately make him a little more sleepy. *She had discussed hospice (end of life care) with the family, and they had not voiced any interest in that option. She was unsure if the medical director had discussed hospice with the family. *She was unsure if the medical director or the nurses had determined to administer Tylenol to him if his pain rating was 0 to 5 and [MEDICATION NAME] if his pain rating was 6 to 10. *The medical director should have been informed when the resident was experiencing break-through pain at a rating of 10. *The medical director had made no changes in his pain medications since the 9/5/13 survey. The resident's condition had continued to deteriorate related to [MEDICAL CONDITION] and metastasis (spreading) to the bone. *The CNAs should have used the Stop and Watch tool (paper to write resident's name and complaints to be given to the nurse. A duplicate copy should have been given to her). *She had not received a Stop and Watch tool today that the resident was complaining of back pain. If she had she would have talked to the nurses about his comfort level. *She confirmed it appeared the resident's pain was not properly managed and controlled. Review of the provider's 10/4/13 completion date plan of correction from the 9/5/13 licensure survey regarding resident 3 revealed: *"From this date forward the facility must ensure the resident's pain is measured when voicing complaints of pain." *"Pain audit was completed and the licensed nurse reported findings to the physician (medical director) on 8/29/13." *"The licensed nurse will continue to use the pain data collection supplemental tool to assist the resident to rate or measure the pain and to communicate with the physician." *"The staff will use the Stop and Watch tool to communicate to the licensed nurse resident pain or discomfort." Review of the provider's January 2011 Abuse Definitions policy revealed "Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Refer to F501, finding 1.

Based on observation, interview, record review, and policy review, the provider failed to ensure necessary care, services, and pain control was provided to attain the highest practicable psychosocial, mental, and physical well being as evidenced by: *Not assessing and managing acute and chronic pain for five of five sampled residents (6, 9 20, 21, and 22). *Multiple nurses documentation of bruises, an abscess, and a broken tooth without assessing one of one sampled resident (10) for pain. *Delayed physician notification of a urinary tract infection with increased pain for one of one sampled resident (5). *Not assessing and managing chronic right wrist pain for one of one sampled resident (11). *Not assessing and managing chronic pain for one of one sampled resident (4). Findings include: 1. Observation on 8/27/13 at 5:30 p.m. of resident 6 revealed she had been in the dining room waiting for her meal. She had been sitting in her wheelchair and had slouched down so her bottom was almost off the seat. Observation on 8/28/13 at 2:30 p.m. of resident 6 revealed: *She had been in her room sitting in her wheelchair. *She had slouched down so her bottom was almost off the seat. *She told this surveyor she had back pain and rated it at a "10" on a scale of 1 to 10 with 10 being the worst pain. *She stated "I have a bad back and it always hurts." Observation on 8/29/13 at 11:05 a.m. of resident 6 revealed she had been in the hallway sitting in her wheelchair. She had slouched down in her wheelchair and reported to this surveyor her back had been hurting. Interview on 8/29/13 at 11:10 a.m. with registered nurse (RN) D confirmed resident 6 frequently had pain. RN D would not have routinely asked resident 6 if she had any pain. She would have waited until she looked uncomfortable or had been seen slouching down in her wheelchair. RN D had not realized the resident was having pain at that time. Review of resident 6's entire medical record revealed: *A 4/6/10 admitted . *[DIAGNOSES REDACTED]. *She was unable to walk and had relied on the use of a wheelchair for locomotion. *She would have laid on the floor or scooted down in her wheelchair when having pain. *She had required the use of oral and topical (directly on the skin) medications and a back stimulator (sends electrical impulses to treat chronic pain) for the relief of her pain. Review of resident 6's physician's orders [REDACTED]. *An order dated 7/25/11 for Tylenol 650 milligrams (mg) every four hours (QID) as needed (PRN) for pain or fever. *An order dated 4/6/10 for [MEDICATION NAME] (pain medication) 100 mg three times a day (TID). *An order dated 4/16/12 for [MEDICATION NAME] 200 mg two tablets every six hours PRN for pain. *There were no non-pharmacological (other than medications) interventions to assist her with her pain except for a back stimulator. The back stimulator had an order date of 1/10/11 and the strength was to have been increased once a day for complaints of pain. Review of resident 6's August 2013 Medication Administration Record [REDACTED]. On 8/29/13 RN D had given her Tylenol 650 mg for complaints of back pain. The medication had not been given until after this surveyor had informed RN D the resident had been complaining of back pain. Review of resident 6's interdisciplinary progress notes (IDPN) revealed no documentation on 8/27/13 or 8/28/13 to indicate the staff had recognized or asked if she had been having any pain on those two days. Review of resident 6's physician's progress notes from 12/10/12 through 6/17/13 revealed documentation she had a [DIAGNOSES REDACTED]. No new orders for any type of pain control had been found after 4/16/12. Review of resident 6's comprehensive care plan dated 6/19/13 revealed: *A focus area that indicated she had a problem with pain related to multiple back problems. *She was to have been encouraged to report any pain. *The staff were to have medicated her for pain as ordered by the physician. *She would lay on the floor independently if she had been experiencing any pain. *The back stimulator was to have been used at midday to help with pain control. *The back stimulator had been the only non-pharmacological intervention for pain control. Interview on 9/4/13 at 10:40 a.m. with the Minimum Data Set (MDS) coordinator revealed: *Resident 6's pain medication should have been reviewed every sixty days by her physician. *The PRN [MEDICATION NAME] order had been the most recent change to her pain medications. *No non-pharmacological interventions had been tried for pain management. Interview on 9/4/13 at 4:30 p.m. with the director of nursing (DON) confirmed resident 6 had a pain management issue. The physician had been notified on 8/30/13 and an order for [REDACTED]. 2. Review of resident's 6, 9 and 20's medical records revealed no interdisciplinary approaches had been used to manage their pain. Refer to F250 findings1, 2, and 3. 3. Review of resident 10's interdisciplinary nurses progress notes between 5/3/13 and 8/25/13 revealed: *Nineteen nurses notes regarding bruises, an abscess, and a broken tooth. Refer to F157. *Two of the nineteen nurses notes stated the resident "Denies pain." *Three of the nineteen nurses notes stated the resident had pain with no noted interventions as follows: -5/4/13 "Resident reports area is less sore." -5/5/13 "Resident reports it barely hurts today." -8/11/13 "Reports sore when stood to transfer." *No previous assessments for pain had been documented. *No other assessments or interventions for pain were documented. Review of resident 10's 7/8/13 physician's orders [REDACTED]. *Tylenol extra strength two tablets (tab) two times per day. *Tylenol 650 milligrams (mg) one tab every four hours as needed for pain. 4. Review of resident 21's medical record revealed: *A 8/7/13 admitted . *[DIAGNOSES REDACTED]. *Activity was up with assistance and stand-by assistance by staff with the walker. *Used a wheelchair for mobility (getting around). Review of resident 21's 8/13/13 admission Minimum Data Set (MDS) assessment revealed: *A brief interview for mental status (BIMS) assessment with a score of 10 (BIMs with a score of 15 indicative of cognitively (mentally) intact.) *He had received no restorative therapy (therapy to improve strength, such as physical or occupational therapies). *He was supervised with set-up assistance for his mobility in the wheelchair. *He had not received any as needed (PRN) pain medications nor had any been offered to him or declined by him. *He had received no non-medication interventions for pain. *He had occasionally experienced pain or hurting the past five days. *He had rated his pain as moderate (on a 1 to10 scale with 1 being little pain, a 5 moderate pain, and a 10 the worst pain) the past five days. Review of resident 21's 8/19/13 psychosocial well-being Resident Care Area Assessment (CAA) by the social worker revealed: *"Indicated he feels his moving is slower than usual and he is using his wheelchair for mobility." *"Is not participating in restorative therapy at this time but will be encouraged to do so to help maintain independence." *"Encourage restorative therapy as available." Review of resident 21's August 2013 Medication Administration Record [REDACTED] *[MEDICATION NAME] 325 milligrams (mg) two tablets every eight hours (6:00 a.m., 2:00 p.m., and 10:00 p.m.) and PRN. *[MEDICATION NAME] (narcotic pain medication) 5/325 mg one tablet every four hours PRN. *The [MEDICATION NAME] was documented as administered five times from 8/7/13 through 8/31/13. There was documentation for four of the doses that pain was "better except aches when I push myself." There was no documentation for the effectiveness of one dose. *[MEDICATION NAME] 325 mg two tablets was documented as administered one time for a headache with no follow-up documentation of the effectiveness. Review of resident 21's 8/12/13 through 8/30/13 Pain Data Collection Tool assessments revealed: *8/12/13- "Complains of pain in right arm at times with movement. It feels like muscle pain. [MEDICATION NAME] does not help. Informed him that he does have a PRN order for [MEDICATION NAME] and he voiced understanding." *8/29/13- "Complains of rib and arm pain. Pain medication at times relieves pain and movement increases pain. Pain control goal is comfort with movement with total pain control." There was no non-pharmacological approaches to pain control documented. There was documentation the current treatment plan was "[MEDICATION NAME] given." *8/30/13- "Rubbing arms when asked and hurts when I push my wheelchair. Sitting still relieves the pain and movement increases the pain. Pain control goal was to sleep comfortably and comfort at rest." There was a non-pharmacological approach to "Massage arms." There was documentation the current treatment plan was [MEDICATION NAME] 325 mg two tablets every eight hours and [MEDICATION NAME] and [MEDICATION NAME] PRN. Interview on 9/4/13 at 5:15 p.m. with resident 21 revealed he stated he: *Had experienced right arm pain for quite awhile. *Did not have pain in his left arm but both arms were getting weaker. *Did not know why he had not received restorative therapy at the facility. *Rated his pain in his right arm at a 5 or 6. *Felt the pain in his right arm really never went away. *Felt his left leg was also getting weaker. *Did not know what medications he was getting for pain as he got quite a few pills. Review of resident 21's September 2013 MAR for 9/4/13 revealed: *There was documentation he had received the PRN [MEDICATION NAME] at 6:00 a.m. instead of the scheduled [MEDICATION NAME]. *There was no documentation the 2:00 p.m. [MEDICATION NAME] had been administered. Interview at that time with licensed practical nurse C regarding resident 21 revealed she: *Had administered the 2:00 p.m. [MEDICATION NAME] to him today but had forgotten to document it. *Had started to give him the PRN [MEDICATION NAME] at 6:00 a.m. instead of his scheduled [MEDICATION NAME] to control his pain when getting up. She thought his pain level was about a "5" in the mornings. *Was not sure why the [MEDICATION NAME] was not administered more since he felt the [MEDICATION NAME] was not relieving his pain. *Agreed he had been on the scheduled [MEDICATION NAME] about a month, and the physician had not been updated it was not controlling his pain. *Agreed he had not received any restorative therapy due to staffing. 5. Review of resident 22's medical record revealed: *A 7/27/10 admitted . *[DIAGNOSES REDACTED]. Review of resident 22's 8/17/13 significant change MDS revealed: *A BIMs score of 3 (indicative of severe cognitive impairment). *Extensive assistance of one staff for transfers. *Functional limitations in both lower extremities (legs). *She received a daily scheduled pain medication program. *She had not received any PRN pain medications nor was any offered or declined. *She had not received any non-medication interventions for pain. Review of resident 22's 8/20/13 cognitive loss/dementia CAA revealed: *"Indications pain is present." *"Impaired decision making and severe cognitive impairment." Review of resident 22's 8/20/13 urinary incontinence CAA revealed: *"Has arthritis in her knees and has pain during transfers." *"Uses the commode at night independently." Review of resident 22's 8/20/13 fall CAA revealed: *"Loss of arm or leg movement." *"Needs assistance with transfers as does have balance problems during transition." *"Has arthritis in her knees and has pain during transfers." *"Transfers at night independently to use the bedside commode." *"Refer to care plan with goals to prevent injury and with safety concerns." Review of resident 22's August 2013 and September 2013 MARs revealed she: *Was not on any scheduled pain medications. *There was no documentation of any refusal of her other scheduled medications. *Had not received any of the [MEDICATION NAME] 500 mg ordered every four hours PRN. *Had received Ben Gay to "affected areas" at bedtime on a daily basis. Review of resident 22's 8/30/13 interdisciplinary notes documented by LPN C revealed: *"Certified nursing assistant (CNA) reports resident complained of discomfort with transfers in knees." *"When questioned resident refused PRN stating they were okay." Review of resident 22's Pain Data Collection Tool assessments revealed: *8/16/13- "No pain. Pain control goals are for resident to sleep comfortably and have comfort at rest. Current treatment scheduled pain regimen is Ben Gay to both knees daily." There was no documentation of any non-pharmacological interventions for pain control. *8/30/13- "Pain in knees. Unable to rate pain. Cries, wrinkles brows, rubs knees and says OH. Pain is with transfers only. Sitting relieves the pain and transfers increase the pain. Cries with transfers. Is on no schedule pain medication regimen and refused PRN pain medications. Pain control goals are for resident to sleep comfortably and have comfort at rest." There was no documentation of any non-pharmacological interventions for pain control. Interview on 9/4/13 at 4:00 p.m. with the director of nursing regarding resident 22 revealed: *The staff assisted her with her transfers at night. The documentation of her being independent was not accurate. *She verified she was not on scheduled pain medication and had not received any PRN pain medication. *There was no documentation the physician had been updated to evaluate her pain regimen with the multiple complaints of pain with transfers. Interview on 9/4/13 at 5:30 p.m. with LPN C regarding resident 22 revealed she: *Did complain of pain only with transfers. *Had chronic pain in her knees as "it was bone on bone." *Did not refuse any of her other scheduled medications. 6. Review of the provider's October 2009 Pain Management policy revealed: *"When a resident is identified as being in pain, the social worker, as part of the interdisciplinary team, will assess the psychosocial well-being of the resident." *Interventions might be non-pharmacological as well as pharmacological. Review of the provider's March 2011 Pain Management procedure revealed "The interdisciplinary team will develop and recommend both pharmacological and non-pharmacological approaches for the resident's care plan." Review of the provider's March 2004 Non-pharmacological Pain Intervention policy revealed non-pharmacological interventions should be considered first. Review of the provider's January 2009 Pain Management Resident Assistance policy revealed: *"The registered nurse (RN) will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological." *"The RN will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan." Surveyor: Review of the provider's revised February 2005 Non-Pharmacological Pain Intervention Purpose revealed: *"Pain can destroy the quality of life, erode the will to live, impair sleep and decrease appetite while also impeding recovery." 7. Review of resident 5's interdisciplinary progress notes revealed: *8/21/13 at 9:15 a.m. Vomited a large amount at breakfast. Temperature 97.6 degrees Fahrenheit (F). *8/21/13 at 12:00 noon Had another emesis (vomited) in room. Temperature 98.6. F. Insulin held due to no intake. Blood glucose 167. *8/21/13 at 5:30 p.m. Temperature 98.8 F. Resident in room and refused room tray. Encouraged to drink Mighty Shake. Resident unable to keep Mighty Shake down. Physician updated with current condition and received orders to hold PM insulin. *8/22/13 at 2:00 p.m. Temperature 98 F. Ate 50 percent of breakfast and dinner. No vomiting noted. Resident required assistance with transfers and dressing. *8/22/13 at 5:00 p.m. Resident rubbing lower back. Complaint of kidneys hurting. *8/22/13 at 9:00 p.m. Resident complained of lower back pain and pain in shoulders. Will attempt to get urine sample. *8/23/13 at 3:50 a.m. Unable to get urine sample. CNA reports very dark urine in pad. Temperature 99.2 F. *8/23/13 at 7:00 a.m. Late entry, urine sample obtained. *8/23/13 at 3:00 p.m. No temperature throughout day. Temperature 98.6 F. Has been out for meals. Appetite good. Still asking for assistance with transfers. *8/24/13 at 3:40 a.m. Resident still complains of low back pain. No temperature throughout day. Asking for additional assistance. When pad changed at 9:00 p.m. very strong smell of ammonia in urine. *8/24/13 at 2:00 p.m. Resident continues to complain of pain in lower back. Appetite poor. Took only cereal for breakfast and dinner. *8/25/13 at 2:00 p.m. Appetite continues to be poor. Up in wheelchair. Out to meals and then to bed. *8/26/13 at 10:00 a.m. Resident continues to complain of back pain. Needs encouragement to eat and drink. Temperature 98 F. *8/26/13 at 3:00 p.m. Physician saw resident. Orders received. Review of a 8/23/13 Pain Management Review form revealed the resident "Complained of back and knee discomfort. Stated it 'started yesterday'. Had GI (gastrointestinal) flu on 8/21/13. Receives sched (scheduled) Tylenol ES (extra strength) one BID (twice daily). UA (urine sample) is being obtained." Review of the urinalysis report received from the laboratory on 8/23/13 revealed it was noted by licensed practical nurse (LPN) C on that date. Documentation on the report included "Complaining of low back pain - urine foul odor - Sat - Cheerios breakfast and dinner." Review of an 8/26/13 physician's orders [REDACTED]. Review of resident 5's August 2013 Medication Administration Record [REDACTED]. He could also have a one time as needed dose per day. He had received the as needed dose on 8/16/13 and 8/21/13. Interview on 8/29/13 at 10:30 a.m. with LPN C revealed:*The UA results had been received on 8/23/13. *She stated his scheduled Tylenol would have covered his pain over the weekend. *That was why she had not called the physician, and the physician would see resident 5 on 8/26/13. *She had not thought of the infection. *She stated "That's my negligence." 8. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Edition, St. Louis, Mo., 2005, pages 1239 through 1241 revealed: *"Nurses care for clients with pain on a daily basis. Therefore it is necessary to monitor pain on a consistent basis along with temperature, pulse, respirations, and blood pressure. In some institutions pain is treated as the fifth vital sign." *"Routine clinical pain assessment and management: -Ask about pain regularly. Assess pain systematically. -Choose pain control options appropriate for the client, family, and setting. -Deliver interventions in a timely, logical, and coordinated fashion. -Empower clients and their families. Enable them to control their course to the greatest extent possible." *"Pain management extends beyond pain relief, encompassing the client's quality of life and ability to work productively, to enjoy recreation, and function normally in the family and society. (Jacox and others, 1994)" 9. Review of resident 11's 5/8/13 annual and 8/3/13 quarterly MDSs revealed she: *Received a scheduled pain medication. *Had received no PRN pain medications. *Had received no non-pharmacological interventions. *Staff was interviewed on her pain indicators. Those indicators included non-verbal and verbal expressions of pain and body/posture indicators of pain. *She had those indicators of pain on a daily basis. Review of resident 11's 7/8/13 physician's orders [REDACTED]. *She had [DIAGNOSES REDACTED]. *She had received [MEDICATION NAME] 650 mg daily for wrist pain since 8/2/12. *She could have received [MEDICATION NAME] 650 mg four times daily as needed for fever. Review of a 5/8/13 Pain Data Collection Tool revealed:*"Per interview with CNA's state res. (resident) braces (R) (right) wrist early in AM et (and) will clench teeth. No distress noted when res @ (at) rest." *Her Pain Assessment in Advanced Dementia (PAINAD) score was 5. That score indicated she had moderate pain. *After completing PAINAD go to number 11 on page 2 to complete pain control goal. *Goals that were checked for resident 11 were to sleep comfortably and to have comfort at rest. *Goal not checked included to have comfort with movement. Review of the Pain Management Review form for resident 11 revealed:*On 11/13/12 "Per staff interview res. will grimace et protect (R) wrist with AM cares. Has improved with sched Tylenol." *On 2/11/13 "Per staff interview _____ (resident 11's name) does grimace and have protective body movements. She is on scheduled APAP ([MEDICATION NAME])." *On 8/1/13 "Per staff interview res does grimace, guards arms/hands with dressing/undressing. She does receive sched Tylenol 650 mg." Review of resident 11's 8/7/13 nursing Interdisciplinary Assessments and Summary Reviews revealed "Staff reported res displays s/s (signs and symptoms) of discomfort when dressing/undressing in hands/arms. Receives sched Tylenol." Review of form #375 Nursing Documentation revealed: *4/30/13 No pain checked. *5/31/13 No answer to pain checked. Documentation of "Tylenol 650 mg q (every) AM." *6/28/13 No pain checked. Documentation of "Tylenol 650 mg q AM." *7/31/13 Pain checked yes. Documentation of "Tylenol 650 mg P.O. (by mouth) daily wrist pain." *8/28/13 No pain checked. Documentation of "APAP 650 mg daily wrist pain." Review of resident 11's 8/7/13 care plan revealed: *A 3/9/11 problem of alteration in comfort related to arthritis. *Goal (no date indicated) would state increased comfort after as needed (PRN) medication had been administered. *Interventions (no dates indicated) "Monitor for nonverbal S/S (signs and symptoms) of discomfort, grimacing, guarding, etc., non-invasive comfort measures, medicate PRN, offer backrub, music, reposition for activity." Preceptor: 10. Review of resident 4's 8/7/13 care plan revealed: *No focus on bladder incontinence. *No individualized plan for pain at night. *No plan or approach to identify when or why the resident puts herself on the floor. *"Patient injury focus" was not specific to the instances of the resident placing herself on the floor or when the resident had been found on the floor. *There was no individualization between the above two different events. Review of the 2/5/13 annual MDS CAA identified urinary incontinence as an area of concern to be care planned. Review of the Pain Data Collection Tool dated 8/30/13 revealed: *Resident was experiencing pain. *Resident described type of pain as "my bladder broke and I need to change." Review of resident 4's Monthly Behaviors Review, Medication Administration Record [REDACTED] *A repeated notation "had noted resident 4 as having a few nights as having difficulty sleeping related to pain" was documented in the Monthly Behaviors Review during May, June, and July 2013. *Tylenol 650 mg was ordered to be given three times a day at morning, noon, and at bedtime. Tylenol was not ordered to be given as needed outside of those scheduled times. *The resident was medicated for complaints of pain at night three times in May 2013, once each in June, July, and August 2013. *Interdisciplinary Progress Note entry on 3/1/13 at 5:50 a.m. documented the resident "keeps putting light on for little things since 4:40 a.m. Resident wants to go to hospital, but has no real complaint or reason why she needs to go there. One time she complains of epigastric (stomach) pain then the next she complains of generalized not feeling well. Resident is usually wet when staff are in there for her complaints. Resident wants staff to do everything for her without any attempt of resident doing the task for herself." The note was signed by registered nurse (RN) S. *Interdisciplinary Progress Note entry on 8/25/13 at 4:00 a.m. documented the resident was "up screaming insisting on her teeth and going to hospital. Advised resident of the time and she needed to sleep" by licensed practical nurse (LPN) O. *Pain Management Review form documented the resident as denying any pain when asked in February, May, and July 2013. *The repeated occurrence of resident 4 "putting self on floor" was documented in the Monthly Behaviors Review as twice in the month before 5/28/13, seven times during the month before 6/18/13, and three times during the month before 7/23/13. The Interdisciplinary Progress Note entry on 1/15/13 at 4:45 p.m. documented by the former social worker (SW) an episode of an event described as purposeful fall by the resident. "Resident sitting outside of nursing station yelling 'Help me.' Nurses were busy helping other residents so they advised resident to wait a moment. Writer then witnessed resident purposely fall from her wheelchair to the floor. Immediately went to assist resident and asked why she put herself on floor. She stated 'That's what I need to do to get any help around here. Two people assisted resident back to her wheelchair." No assessment following that event or incident report on the above event was located. *Interdisciplinary Progress Note entry on 4/10/13 at 4 p.m. documented "At snack time resident stated she just about killed herself. Red mark noted on right side of the for head - marks noted on fingers - no falls noted," by LPN C. No further assessment or incident report on the event was located. *Incident report dated 8/26/13 revealed: resident 4 had received an abrasion on the right leg when another resident had attempted to assist her from the wheelchair to the bed. Interview on 9/4/13 at 9:20 a.m. with the MDS coordinator revealed; *She agreed if resident 4 was on the floor it should have been considered a fall. *She was unable to identify what resident 4 wanted when the resident had put herself on the floor. *She had tried to direct resident 4 to activities after the behaviors had occurred. Interview on 9/4/13 at 10:20 with the SW revealed: *She was unable to identify when resident 4 had started the behavior of putting herself on the floor. *She stated she thought resident 4 wanted one-to-one time when that behavior had occurred. *Staff encouraged or redirected resident 4 to activities. *She could not identify where the documentation of the multiple times of putting herself on the floor during May, June, and July 2013 would be located. Interview on 9/4/13 at 1:55 p.m. with the DON revealed: *She had no response for the bladder incontinence not being care planned for resident 4. *She was unable to answer what pain kept resident 4 awake at night. *She agreed any change in plane (resident going from an above floor position to being on the floor) should have been considered and treated as a fall.

Based on observation, interview, record review, policy review, and review of the 10/4/13 plan of correction review from the 9/5/13 recertification survey, the provider failed to ensure necessary care, services, and pain control was provided to attain the highest practicable psychosocial, mental, and physical well being as evidenced by: *Not assessing and managing acute pain of one of one sampled resident (3) who had verbal and non-verbal complaints of severe pain. That failure created a situation of immediate jeopardy that had a potential for causing the resident to experience physical and emotional distress. *Not assessing and managing chronic pain for six of eight sampled residents (4, 6,11, 16, 22, 31, and 32) identified by the provider as having moderate/severe pain on a constant or frequent basis. NOTICE: Notice of immediate jeopardy was given verbally by the surveyor team to the administrator and director of nursing (DON) regarding resident 3 on 10/31/13 at 2:40 p.m. They were asked for an immediate plan of correction to ensure resident 3's pain was assessed and managed. PLAN: On 10/31/13 at 4:00 p.m. the administrator and the DON provided the surveyors with an initial plan of correction (POC) for resident 3. The written documentation dated 10/31/13 consisted of physician's orders [REDACTED]. Following discussion between the surveyors, the DON, and the administrator was accepted by the surveyors at 4:25 p.m. The immediate POC included: *On 10/31/13 at 2:00 p.m. the social worker (SW) visited with resident 3. He had denied having pain to her. He continued to express feelings of being down, trouble sleeping, feeling tired, as well as feeling bad about himself that he had previously expressed to her on 10/29/13. He responded by silence or nodded head no when asked if he wanted to visit. He shook his head yes when asked if he wanted to rest. The charge nurse was notified of increased depression. *On 10/31/13 at 2:45 p.m. his family was contacted by the SW regarding his increased signs of depression and what he had expressed feeling. Family had no concerns at this time and aware his physician (the medical director) had been called with a change in his pain regime and an antidepressant medication ordered. *On 10/31/13 at 3:00 p.m. a phone conference was held with the administrator, the DON, and resident 3's physician. His physician was informed by the DON of his pain rating of an 8 on a scale of 1 to 10. His medications were reviewed with orders received to increase the [MEDICATION NAME] (narcotic pain patch) from 37 micrograms (mcg) to 50 mcg every three days. Facility staff were to remove the old patch prior to placing on the new patch. [MEDICATION NAME] sulfate (narcotic pain medication) was ordered 0.25 milliliter (ml) every four hours as needed (PRN) for severe pain. *His physician was informed of his physical health questionnaire (PHQ) score of 12/27 on 10/29/13 suggesting moderate depression. The resident had expressed he did not want to talk about his feelings with the SW. [MEDICATION NAME] (antidepressant medication) 10 milligrams (mg) was ordered daily. *The family was contacted by the DON on 10/31/13 at 3:15 p.m. and aware of physician's orders [REDACTED]. Education was given to the family regarding the pain scale and his pain rating of 8 that showed the severe pain he was having in his back. *The [MEDICATION NAME] 37 mcg was removed on 10/31/13 at 3:30 p.m. and the [MEDICATION NAME] 50 mcg patch was applied. He was also given [MEDICATION NAME] sulfate 0.25 ml by mouth at that time. The [MEDICATION NAME] would be administered in the morning. (An antidepressant medication does not have immediate results and usually is eight weeks to reach a therapeutic level and an improvement in mood). *Resident 3's pain would be monitored for relief of immediate pain and on a 24 hour basis for ongoing pain related to his [MEDICAL CONDITION] diagnosis. *Certified nurse aide staff and the registered nurse on duty received education on reporting and assessing pain for the residents. Staff reporting for duty would receive education through the shift reporting process. *The DON, administrator, and the SW would be meeting with resident 3's family to further address pain management and provided education about hospice services. *The pain management policy and procedure would be reviewed and revised as necessary with re-education on 11/6/13 about pain management and their role and responsibility. *Other residents identified with pain would be reassessed with [REDACTED]. Removal of IJ: During the survey on 10/31/13 at 4:25 p.m. the surveyors confirmed removal of the IJ situation. Prior to leaving the facility on 10/31/13 at 5:30 p.m. the surveyors confirmed the components outlined in the above plan of correction had been implemented. Resident 3 was resting in bed with his eyes closed. Findings include: 1. Review of resident 3's medical record revealed: *A 7/5/10 admitted . *[DIAGNOSES REDACTED]. Review of resident 3's September 2013 through October 2013 medication administration records revealed the following documentation regarding pain medication: *Tylenol was to have been administered for a pain rating of 1 to 5 on a scale of 1 to 10 with 1 being little pain and 10 being severe pain. *[MEDICATION NAME] (pain medication for moderate to severe pain) was to have been administered for a pain rating of 6 to 10. *9/1/13- [MEDICATION NAME] (pain medication) 50 milligrams (mg) had been documented as administered for a headache with a pain rating of 10. *9/2/13- [MEDICATION NAME] 50 mg had been documented as administered for unrated left side pain. *9/3/13- [MEDICATION NAME] 50 mg had been documented as administered twice for complaints of pain all over and left shoulder pain for a pain rating of 10. *9/4/13- [MEDICATION NAME] 50 mg had been documented as administered for hurting all over for a pain rating of 6. *9/11/13- [MEDICATION NAME] 50 mg had been documented as administered for complaints of low back pain for a pain rating of 10. *9/14/13- [MEDICATION NAME] 50 mg had been documented as administered for low back pain for a pain rating of 6 or 7. *9/19/13- [MEDICATION NAME] 50 mg had been documented as administered for yelling. *Tylenol 650 mg had been documented as administered on 9/2/13, 9/5/13, 9/6/13, 9/8/13, 9/13/13, twice on 9/21/13, 10/5/13, 10/19/13, and 10/29/13. Reason documented for medication was "lower back pain." The pain rating had either not been documented, had been a 3 to 4 pain rating, or had been unable to rate pain and had been moaning. Review of resident 3's 10/28/13 pain assessment completed by the Minimum Data Set registered nurse revealed: *"Not new origin of pain/intensity." *"Is resident at high risk for pain was neither checked yes or no." *"Is current medication regime (plan) working was checked yes." *"Recommended pain management plan was [MEDICATION NAME] (narcotic pain medication) 37 micrograms every 3rd day, [MEDICATION NAME] topical every six hours, Tylenol for pain rating of 0 to 5, and [MEDICATION NAME] for pain rating of 6 to 10." (Review of resident 3's medical record revealed that pain regime had not been changed since 5/4/12 by his physician)." *"Has the medical provider been notified was checked no." Review of resident 3's 8/26/13 physician's progress notes revealed: *"He has had ongoing health concerns and has slowly lost weight over time." *"He has [MEDICAL CONDITION] and back pain that is presumed to be secondary to metastases (spreading) of the bone." *"He has some dementia (memory loss). Nursing has not noted any significant change at this point." *"He occasionally falls but is mostly in a wheelchair now." *"He denies any new concerns or complaints today." *"I reviewed the patient's medications and orders. I will not make any changes at this time." *"His weight loss is due to steady decline for his advanced age and presumed metastatic [MEDICAL CONDITION]." *"We will make changes as indicated or follow-up in 60 days." Review of resident 3's 10/28/13 physician's orders [REDACTED]." There were no accompanying physician's progress notes for that onsite visit. Observation on 10/31/13 at 12:15 p.m. of resident 3 revealed: *He was sitting in his wheelchair at the dining room table. *Certified nursing assistant (CNA) G was feeding him his noon meal. *He was coughing when being assisted to eat. *He was shifting himself slightly in his wheelchair. *His facial expression appeared he was uncomfortable. Interview at that time during the above observation with resident 3 and CNA G revealed: *The resident stated "I am not very good." He stated he was experiencing pain all over,but especially in his legs and back with a pain rating of 8 on a 1 to 10 scale. *CNA G stated "His back pain is chronic in nature." She was unsure how long he had been in pain as she had just started to feed him and had not provided any other care for him that morning. *CNA G told the surveyor to go talk to CNA F who had been taking care of the resident that morning. Interview on 10/31/13 at 12:20 p.m. with CNA F regarding resident 3 revealed: *She and another CNA had transferred him out of his recliner into his wheelchair shortly before the noon meal. *He tolerated being transferred without any unusual complaints. If he complained of back pain it was chronic in nature and being repositioned usually helped. *He had complained of more back pain when she had assisted him out of bed that morning between 7:00 a.m. and 7:15 a.m. *She said she had reported his back pain to the nurse when questioned by the surveyor what she had done. Interview on 10/31/13 at 1:10 p.m. with licensed practical nurse (LPN) C and registered nurse (RN) D regarding resident 3 revealed: *RN D stated she had not come to work that day until 8:00 a.m. No one had told her the resident had been complaining of back pain. *LPN C stated she was on duty at 6:00 a.m. and CNA F nor any other CNA had informed her he was having back pain between 7:00 a.m. and 7:30 a.m. *LPN C had administered [MEDICATION NAME] to him at 1:00 p.m. today after CNA G had informed her he was having back pain. He had reported to her the pain rating of his back pain was a 8. Observation on 10/31/13 at 2:00 p.m. of resident 3 revealed: *He was lying in bed with his eyes open. *His facial expression continued to appear he was in pain and he stated his pain "No better." He continued to report his back pain at an 8. Interview on 10/31/13 at 2:15 p.m. with the director of nursing (DON)regarding resident 3 revealed: *CNA F should have reported his back pain to the nurse on duty. *She thought the medical director had talked to the resident's family about pain control, but the family had not wanted to change his medications. They wanted him to be more awake and alert and thought increasing his pain medications would make him too sleepy. *She thought the medical director had educated the family on the need for pain control and possibly making him more comfortable would ultimately make him a little more sleepy. *She had discussed hospice (end of life care) with the family and they had not voiced any interest. She was unsure if the medical director had discussed hospice with the family. 2. Review of resident 4's 10/22/13 faxed communication to the physician revealed "Left foot great toe and middle toe skin underneath nailbeds appear to be purple (bruised) in color. Left great toe also has bruising around the sides of the toe." Interview on 10/31/13 at 10:45 a.m. with the DON regarding resident 4 revealed: *An incident report had been completed for the bruising of the left great toe. *The origin of the injury to the toes was not known. Interview on 10/31/13 at 10:50 a.m. with LPN C regarding resident 4 revealed: *Her left great toe was black. She would likely loose her nail on that toe. *It was unknown how the bruising occurred, but likely the toe had been run over by her wheelchair. *The toe injury should have been put on her care plan initially when it had occurred. Observation on 10/31/13 at 11:00 a.m. of resident 4's left great toe with LPN C revealed the toe continued bruised and had red drainage around the nail edges. The resident did state "yes" when asked if having pain in the toe but no visible facial distress or discomfort when toe cleaned and palpated by LPN C. Review of resident 4's 10/21/13 pain data collection tool revealed: *"Resident is verbalizing discomfort or pain at this time was checked yes." *"Type of pain was left foot great toe." *"Resident was unable to state pain rating at it's least, worst, or a tolerable rate of pain for her." *"Verbalizes vocal expressions of pain "ow" upon palpation of toe and grimaces (facial expressions of distress)." *"On scheduled [MEDICATION NAME] 650 mg three times a day and [MEDICATION NAME] 400 mg every four to six hours PRN pain." Review of resident 4's October 2013 PRN record revealed [MEDICATION NAME] had been administered on the following dates: *10/3/13- Reason given was headache with no pain rating when the medication had been administered or the follow-up effectiveness. *10/7/13- Reason given was "Pain.".There was no pain rating when the medication had been administered or the follow-up effectiveness. *10/15/13- Reason given was "Pain leg." There was no pain rating when the medication had been administered or the follow-up effectiveness. *10/21/13- Reason given was "Ow and facial grimacing with palpation left great toe." *10/24/13- Reason given was "Headache with a pain rating of 5." No follow-up pain rating was documented. *After 10/21/12 to 10/31/13 no further PRN [MEDICATION NAME] had been administered for left great toe pain. Review of resident 4's 8/7/13 care plan revealed no documentation regarding the left great toe pain. Review of resident 4's 10/31/13 nursing progress notes revealed no documentation the physician had been informed of the continued bruising and red drainage. 3. Review of resident 6's undated pain data collection tool revealed: *"Complains of back pain when moves in bed." *"Pain rated at zero at it's least, seven at it's worst, and four to five as a tolerable pain rating." *"Vocal expressions and verbal complaints "It hurts." *"Duration and frequency when pain occurs is when transfers from chair to bed." *"Pain pills relieve the pain. Has nausea and vomiting when experiencing pain and gets angry." *"Current treatment scheduled pain medication regime plan was [MEDICATION NAME] lower back on in the morning and off at bedtime. PRN [MEDICATION NAME]." Review of resident 6's PRN medication record revealed documentation the following pain medications had been administered: *[MEDICATION NAME] three times. Two times were for back discomfort and once was for mouth pain. There had been no documentation of her pain rating prior to administration of the [MEDICATION NAME] or for it's follow-up effectiveness. *[MEDICATION NAME] had been administered six times for back pain with pain ratings varying from 5 to unable to rate but pain is terrible. There was no documentation of a pain rating for the follow-up effectiveness of the [MEDICATION NAME]. Review of resident 6's physician's progress notes revealed "Chronic pain controlled." 4. Review of resident 16's September 2013 MAR indicated [REDACTED]. There had been no documentation of a pain rating prior to the administration of the [MEDICATION NAME] or the effectiveness of the medication. Review of resident 16's 9/26/13 physician's orders [REDACTED]." Review of resident 16's October 2013 PRN record revealed [MEDICATION NAME] 25 mg had been administered for "Pain." There was no follow-up documentation as to the effectiveness of the medication. Review of resident 16's 10/18/13 pain data collection tool revealed: *"Is resident at risk for pain was checked no." *"Unable to determine what non-pharmalogical interventions work as resident unable to participate in assessment." *"Current pain medication regime working was checked yes." Review of resident 16's pain data collection tool revealed it was left blank with the exception of the following: *"Occasional negative vocalization, facial grimacing, rigid, striking out, fists clenched, knees pulled up, and pulling/pushing away." *"Pain rating score was 5 indicative of moderate pain." 5. Review of resident 22's 9/30/13 nursing progress notes revealed: *"PRN Tylenol used over the weekend at 7:00 a.m., 11:30 a.m., and 4:00 p.m. to see if Tylenol would help with pain in knees during transfers." *"Resident only complains of pain during transfers. Tylenol did not make a difference." *"Referred to social services." *There was no further nursing documentation regarding her pain with transfers or physician notification regarding Tylenol not being an effective control of knee pain. Review of resident 22's 10/11/13 SW progress notes revealed: *"Resident in room in recliner." *"Denied any pain or discomfort. Attempted to visit with resident if has pain during transfers. Unable or missed intent of conversation." *There was no documentation a transfer had been observed. Review of resident 22's 10/14/13 physician's progress notes revealed: *"She is in a wheelchair." *"She verbalizes very little." *"She recently had a dose reduction in her [MEDICATION NAME] (mood/behavior altering medication). Does have more episodes of what appear to be anxiety type agitation." *"Has a history of dementia (memory loss) with behavioral dyscontrol and anxiety." *"She is alert but does not try to verbalize any responses. She is in no acute distress." Review of resident 22's October 2013 PRN record revealed: *[MEDICATION NAME] had been documented as administered two times on 10/16/13 at 1:30 a.m. and 11:40 a.m. for knee/leg pain. *There was documentation resident "Unable to rate pain." *There had been no other documentation of any pain medications that had been administered for control of pain in knees with transfers. Review of resident 22's 8/21/13 care plan revealed: *"Alteration in comfort related to arthritis." *"Goal to state increase comfort with activities." *"Encourage resident to report increased discomfort." *"Medicate as ordered. Topical as ordered." *"Offer reposition, music, back rub, or activity. Provide reassurance and support." *There was no documentation of complaints of pain in her knees during transfers. Interview on 10/31/13 at 11:50 a.m. with CNA X regarding resident 22 revealed she often did complain of pain in her knees during transfers. Interview on 10/31/13 at 11:55 a.m. with LPN C regarding resident 22 revealed: *"She had chronic pain in her knees with transfers. Her knees were (Bone on bone}." *"She received a topical ointment to her knees at bedtime." *"The physician had not been contacted or notified Tylenol was an effective medication for control of her knee pain." *"They had not consistently administered the PRN Tylenol as it was not effective." 6. Review of resident 31's 10/12/13 pain data collection tool revealed: *"Verbalizes complaints of left side pain/discomfort." *"Verbalizes pain rating at present 8." *"Pain at it's least 1, pain at it's worst 10, and I don't know what is a tolerable rate of pain." *"Massages side to show writer location." *"Resident feels pain medication relieves the pain. Standing and walking increase the pain." *"If having pain can't sleep at night." *"PRN pain medications [MEDICATION NAME] (narcotic pain medication) and Tylenol." Review of resident 31's October 2013 PRN record revealed the following had been documented as administered: *[MEDICATION NAME] three times for tooth pain and left side pain with a pain rating of 7 to 8 prior to administration and one follow-up documentation was "Some help and pain rating was 6." *[MEDICATION NAME] (antianxiety medication) five times for yelling, restless, unable to sleep, and wound up. Follow-up documentation had often been "No change in behavior." Review of resident 31's 10/25/13 through 10/31/13 nursing progress notes revealed: *10/25/13 at 3:00 a.m.- "Awake all night yelling and unable to sleep." (PRN record revealed no pain medication had been administered since 8:00 p.m. on 10/25/13). *10/31/13 at 2:30 a.m.- "Awake all night very restless talking loudly and moaning. At times yelling. Rocks in chair in corner. At times will hit mug on floor or shake walker on the ground. Have tried snacks, tea, and rubbing lotion on legs. Resident has had no relief from interventions. (PRN record revealed [MEDICATION NAME] (mood/behavior altering medication) had been administered on 10/31/13 at 12:30 a.m. with "No relief." No pain medication had been documented as administered since 10/25/13. Observation on 10/31/13 at 9:30 a.m. of resident 31 revealed: *She was up sitting in the lounge outside the nurse's station. *She continued to yell and scream. Her speech was slurred and difficult to understand. *LPN C administered [MEDICATION NAME] (liquid antacid) to her for upper [MEDICAL CONDITION] pain. She stated that usually would help her if she was having pain. There had been no follow-up documentation if the [MEDICATION NAME] had helped her. Interview on 10/31/13 at 9:45 a.m. with the DON regarding resident 31 revealed she: *Had been the nurse on during the 10/31/13 night shift. *Had not administered any pain medication to her as the staff had not thought she was having pain. They should have administered the [MEDICATION NAME] to her to see if that would have helped her sleep. 7. Review of resident 32's 10/25/13 pain data collection tool revealed: *"Verbalizing pain/discomfort in left foot." *"Verbal descriptors of pain at present was voiced 10." *"I don't know when asked to rate his pain at his least and what is a tolerable rate of pain for you. Voiced 10 when asked how do you rate your pain at it's worst." *"Standing or walking increases the pain. Sitting down helps relieve the pain." *"Hurts when I walk." *"PRN pain medications of [MEDICATION NAME]." *"Encouraged resident to sit down and take weight off foot." *"Goal was comfort with movement." Review of resident 32's October 2013 PRN record revealed the following pain medications had been documented as administered: *[MEDICATION NAME] had been documented as administered seven times for headache, left knee pain, and left back discomfort. Pain ratings had either not been documented or had been documented a 10 pain rating. There had been no pain ratings documented for the effectiveness of the [MEDICATION NAME] for six of the doses. *[MEDICATION NAME] had been documented as administered four times for hand pain, headache, and being "achy". There had no pain ratings documented for three of the doses prior to the administration of the [MEDICATION NAME]. There had been no pain ratings documented for any of the doses and documentation "Little relief to better." *[MEDICATION NAME] had been documented as administered four times for anxiety with documentation "Little help to resting in bed." Review of resident 32's 9/11/13 care plan revealed: *Pain related to [MEDICAL CONDITION] joint disease (arthritis in joints) with varied complaints of headache, knee pain, and back pain. *Goal was for resident to be at a comfortable level of pain to perform activities of daily living. *"Medicate as ordered and PRN." *"Validate (confirm) his pain." *"Use numeric pain monitoring tool to access pain." *"Encourage resident to rest quietly with legs up laying in bed." *"Encourage resident to report symptoms of pain. Monitor for signs and symptoms of pain." Interview on 10/31/13 at 2:00 p.m. with the DON regarding findings 2 through 7 revealed it was difficult to determine adequate pain control when PRN medications either had no follow-up documentation or the pain ratings had not been documented prior to and after administration of the pain medications. Review of the provider's revised September 2013 Pain Data Collection and Assessment policy revealed: *"To promote well-being by ensuring that residents are as comfortable as possible." *"To consistently collect information for data collection of pain in a systematic process." *"To determine what pain relief interventions that are specific to the resident that can be utilized and established to aid in maintaining a comfortable level of function and quality of life." *"A pain management plan can include, but not be limited to, a medical regime." *"The care team and nurses must continually monitor and evaluate the pain management plan." *"We may need to readdress her [MEDICATION NAME] depending on behaviors and the perceived psychological discomfort she is having." Review of the provider's 10/4/13 plan of correction for the 9/5/13 licensure survey revealed: *"Care plans had been reviewed and updated to ensure it reflects non-pharmalogical interventions and focus areas to address effective pain control and management." *"The interdisciplinary team must ensure they are meeting the residents' psychosocial well-being and providing a holistic approach in providing care and services to the residents." *"PRN responses with outcomes of the pain medication will be documented by the licensed nurse." *"The licensed nurse will encourage the residents of PRN medications available for pain management if pain is present." *"Pain auditing completed to determine pain management and effectiveness and to measure current paint control and management." *"Review of the residents' MARs to ensure pain medication is scheduled or PRN medication is available and used as needed." *"The physician should have been updated if current pain regimen is not effective for further interventions."

Based on record review and interview, the provider failed to ensure sufficient nursing staff were available to provide restorative care to maintain the highest practicable physical and mental well-being for nine of nine sampled residents (1, 2, 3, 4, 7, 9, 10, 21, and 22). Findings include: 1. Interview on 9/4/13 at 8:20 a.m. with the Minimum Data Set (MDS) coordinator revealed: *Restorative care had not been consistently offered to the residents since February 2013. *February 2013 had been the last month any full time restorative care programs had been offered due to staffing issues. *She had stated "If it happens, it happens. Staff are needed to help with cares on the floor." *Since the decline in restorative care she had noticed an increase in residents': -Pain. -Contractures. -Falls. -A need for assistance with activities of daily living. *She stated "The resident's are missing it." Interview on 9/4/13 at 8:50 a.m. with the director of nursing revealed: *She had not been made aware the residents had not received any full time restorative care since February 2013. *She agreed it was the residents' right to be able to exercise and stated "We are working on it." 2. Refer to F311.

Based on observation, record review, interview, and policy review, the governing body failed to ensure the facility was administered in a manner that ensured: *The physician and the family was notified of multiple bruises, a skin abscess, and a broken tooth for 1 of 14 sampled residents (10). *Acute pain was recognized and managed for 1 of 1 sampled resident (3) with acute pain. *Bruising of unknown origin for 2 of 2 sampled residents (3 and 10) were investigated and reported to the South Dakota Department of Health. *Resident dignity was maintained: -During the administration of insulin for 8 of 8 sampled residents (5, 8, 12, 18, 30, 33, 34, and 35). -During the transportation of 1 of 1 unidentified resident from the resient's room to the whirlpool room. -For 5 of 5 sampled residents (3, 11, 16, 17, and 18) during the dining experience. -For 1 of 1 sampled resident (11) during snack time. *Medically related social services assisted in providing non-pharmacological approaches for pain control for 9 of 9 sampled residents (2, 3, 6, 7, 9, 10, 20, 21, and 22). *All four hallways remained comfortable and odor free. *Chemicals were stored appropriately in 1 of 2 bathing rooms (400 wing). *A vacuum breaker wa on the sink hose in 1 of 1 beauty shop. *Ground fault circuit interrupters (GFCI) were installed on 2 of 3 outlets in the beauty shop. *The floor in 1 of 2 bathing rooms was free from stains and discoloration (400 wing). *Minimum Data Set assessments were accurately coded and reflected the status and needs for 3 of 14 sampled residents (4, 6, and 10). *Care plans for 15 of 21 sampled resident's (2, 3, 4, 5, 6, 7, 9, 10, 14, 15, 16, 19, 20, 21, and 22) were individualized with measurable goals, approaches, and interventions. *Pain was assessed for 1 of 1 sampled resident (2) prior to a dressing change. *physician's orders [REDACTED]. *Professional standards were followed during the administration of medication for 5 of 5 sampled residents (3, 8, 11, 21, and 24). *Professional standards were followed for [MEDICAL CONDITION] care for 1 of 1 sampled resident (12). *An antibiotic ordered by the physician for 1 of 1 sampled resident (5) with an infection was initiated in a timely manner. *Chronic back pain for 1 of 1 sampled resident (6) was assessed and managed. *Chronic right wrist pain was assessed and managed for 1 of 1 sampled resident (11). *Restorative care was provided and maintained for 11 of 11 sampled residents (1, 2, 3, 4, 5, 7, 9, 10, 11, 21, and 22). *Wanderguards were checked daily for 2 of 8 sampled residents (1 and 6) who were at risk for elopement. *An elopement and safe smoking assessment was completed for 1 of 1 sampled resident (15). *Assessments and interventions were in place for 1 of 1 sampled resident (4) who had frequent falls. *Doors were alarmed and/or monitored by staff for 3 of 3 (main entrance, administrative entrance, and outside physical therapy entrance). *Bath aides wore proper personal protective equipment (PPE) in accordance with manufacturer's directions for 2 of 2 bath aides (G and H). *The physician documented the rationale for duplicate [MEDICAL CONDITION] (medications to help with mood) medication therapy for 2 of 2 sampled residents (5 and 6). *Medications were administered with less than a five percent (%) medication error rate for 2 of 12 sampled residents (11 and 24). *Sufficient nursing staff were available to provide restorative care to maintain the highest well-being for 9 of 9 sampled residents (1, 2, 3, 4, 7, 9, 10, 21, and 22). *Food was cooled within the proper time frames. *Cooked meat was not stored directly next to raw meat in a walk-in cooler. *Single-use gloves were not used for a variety of tasks during meal preparation and meal service by employees I, J, and K. *The floor and wall junctions in the walk-in cooler and freezer were not dirty. *Standards, policies, and procedures were maintained or achieved for all fourteen residents (2, 4, 5, 6, 10, 15, 17, 26, 27, 28, 29, 30, 31, and 32) on the behavioral management program/mental health rehabilitative service. *A schedule III pain medication (government controlled) was properly stored and disposed of in a timely manner for 1 of 1 sampled resident (23). *Insulin was not used beyond-the-use date for 1 of 1 sampled resident (8). *Adequate pharmacy consultation rationale (reasoning) was documented for the medication dose reduction of antidepressant medications for 2 of 2 sampled residents (1 and 6). *Adequate pharmacy consultation rationale for medication dose reduction of antipsychotic medications for 15 of 15 sampled residents (2, 4, 5, 6, 8, 10, 15, 17, 26, 27, 28, 29, 30, 31, and 32) on a behavioral management program. *Tracking and trending of infections were completed by the infection control nurse. *All shared residents' bathroom floors and bathing room floors had been effectively disinfected and disinfected between each resident use. *Residents' beauty shop care items were cleaned and disinfected after each use. *Appropriate training for disinfecting after bathing a resident with [MEDICAL CONDITIONS] (a bacteria that causes diarrhea and was contagious) for 1 of 2 bath aides (H). *Appropriate training had occurred for for 2 of 2 bath aides (G and H) for bathing residents with indwelling catheters (a tube inserted into the bladder to drain urine). *Appropriate training had occurred for 1 of 2 bath aides (G) for bathing residents with open wounds. *The facility was operated and administered in a manner that ensured the safety and overall well-being of all its 49 residents. *Resident care policies and procedures were implemented and evaluated to reflect current standards of practice for resident pain management and psychoactive medication. *Documentation occurred daily for testing of the wanderguard personal alarm device for 2 of 8 sampled residents (1 and 6). *Follow-up documentation was completed for 1 of 1 sampled resident (3) with acute rib pain. *Follow-up documentation was completed for 1 of 1 sampled resident (5) with an acute urinary tract infection. Refer to F490, finding 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator had not ensured the safe management and overall well-being of the residents. Refer to F157, F224, F226, F241, F250, F253, F278, F279, F281, F309, F311, F323, F329, F332, F353, F371, F406, F425, F428, F441, F490, F493, F501, F514, and F520.

Based on record review and interview, the provider failed to maintain and provide restorative care for 11 of 11 sampled residents (1, 2, 4, 5, 6, 7, 9, 10, 11, 21, and 22). Findings include: 1. Review of resident 1 and 9's August 2013 restorative plan revealed they had not received restorative therapy since 8/9/13. 2. Review of resident 2, 7, and 10's August 2013 restorative plan revealed they had not received restorative therapy since 8/9/13. Review of the provider's revised 2/05 Non-Pharmacological Pain Intervention Purpose revealed: *"Pain can destroy the quality of life, erode the will to live, impair sleep and decrease appetite while also impeding recovery." *Non-pharmacological interventions may include rehabilitative services. 3. Review of resident 6's 8/2/13 quarterly MDS revealed he had received three days of passive range of motion (PROM) in a seven day time frame. Review of resident 6's May 2013 through August 2013 restorative sheets revealed he should have received: *PROM four to six times a week to all extremities (arms and legs). The PROM was not on the May and June records. There was no documentation from 7/23/13 through 7/30/13 or for August that therapy had been provided. *Ambulate (walk) with front wheeled walker and gait belt 25 to 75 feet. There was no documentation for May, June, or August that therapy had been provided. There were five days documented in July the therapy had been provided. *Hamstring (back of thigh) stretches and heel cords times one minute each. There was no documentation from 7/23/13 through 7/30/13 or for August that therapy had been provided. *Active range of motion (AROM) per instruction sheet (there was no instruction sheet). *AROM to all extremities. There was no documentation from 6/1/13 through 6/15/13, 7/23/13 through 7/30/13 or August that therapy had been provided. 4. Review of resident 21's 8/13/13 admission MDS revealed he had received no restorative therapy. Review of resident 21's medical record revealed no August 2013 restorative record. He had been admitted on [DATE]. Interview on 9/4/13 at 5:15 p.m. with resident 21 revealed he: *Did not have pain in his left arm, but both arms were getting weaker. *Did not know why he had not received restorative therapy at the facility. *Felt his left leg was also getting weaker. Interview on 9/4/13 at 5:30 p.m. with licensed practical nurse (LPN) C regarding resident 21 revealed he had not received any restorative therapy since his admission due to staffing issues. 5. Review of resident 22's 8/21/13 care plan revealed she was to have received AROM to all extremities 4-6 times per week. Review of resident 22's medical record revealed no documentation therapy had been provided in August 2013. 6. Review of resident 5's 8/23/13 quarterly Minimum Data Set revealed he had received no days of active range of motion (AROM) in a seven day time frame. Review of resident 5's August 2013 restorative sheets revealed he should have received: *AROM 4 to 6 times a week to all extremities (arms and legs). There was no documentation from 8/10/13 through 8/31/13 therapy had been provided. 7. Review of resident 11's 8/3/13 quarterly Minimum Data Set revealed she had received three days of passive range of motion (PROM) in a seven day time frame. Review of resident 11's March 2013 through July 2013 restorative sheets revealed she should have received: *PROM 4 to 6 times a week to all extremities (arms and legs). *In March 2013 she had received PROM ten times. She should have received it sixteen times. *In April 2013 she had received PROM twelve times. She should have received it sixteen times. *In June 2013 she had received PROM eleven times. She should have received it sixteen times. *In July 2013 she had received PROM eleven times. She should have received it sixteen times. Preceptor 8. Review of resident 4's restorative plans/approaches during May, June, July, and August 2013 revealed: *Resident participated: -Seventeen days in May 2013. -Sixteen days in June 2013. -Thirteen days in July 2013. -Six of nine days in August 2013. *No restorative care had been documented since 8/9/13. *The resident's request to have Wednesdays and Sundays off had not been consistently followed. The resident participated: -In six of nine requested days off in May 2013. -In four of nine requested days off in June 2013. -In three of nine requested days off in July 2013. -In one requested day off were restorative care was documented in August 2013. 9. Interview on 9/4/13 at 8:20 a.m. with the Minimum Data Set (MDS) coordinator revealed: *Restorative care exercises had not been consistently offered to the residents since February 2013. *February 2013 had been the last month any full time restorative care programs had been offered due to staffing issues. *She stated "If it happens, it happens. Staff are needed to help with cares on the floor." *Since the decline in restorative care exercises she had noticed an increase in: -Pain. -Contractures. -Falls. -Need for assistance with activities of daily living. *She stated "The resident's are missing it." Interview on 9/4/13 at 8:50 a.m. with the director of nursing (DON) revealed: *She had not been made aware the residents had not received any full time restorative care since February 2013. *She agreed it was the residents' right to be able to exercise and stated "We are working on it."

Based on record review, interview, policy review, and the medical director agreement revealed the provider failed to: *Implement and evaluate resident care policies and procedures that reflected current standards of practice for resident pain control and psychoactive medication. *Ensure adequate pain control for two-thirds of the residents (2, 3, 4, 6, 7, 9, 10, 20, 21, and 22) identified with pain on the provider's roster. Findings include: 1. Review of resident 3's medical record revealed: *A 7/5/10 admitted . *[DIAGNOSES REDACTED]. Review of resident 3's August 2013 Medication Administration Record [REDACTED] *[MEDICATION NAME] (narcotic) patch 37 micrograms (mcg) every three days started on 4/13/12. *Tylenol 650 milligrams (mg) every four hours as needed (PRN) started on 7/5/10. *[MEDICATION NAME] 5 percent (%) patch up to ten to twelve daily started on 5/14/12. *[MEDICATION NAME] 1% gel two grams to low back and right knee every six hours started on 4/5/11. Review of resident 3's August 2013 PRN record revealed documentation the PRN Tylenol had been administered once on 8/28/13 for pain all over and relief had been obtained. Review of resident 3's July 2013 PRN record revealed documentation the PRN Tylenol had been administered six times for left rib pain/backache. There was documentation for three of the doses no relief had been obtained. Review of resident 3's June 2013 PRN record revealed documentation the PRN Tylenol had been administered six times for right hand pain/backache. There was documentation for two of the doses for little to some relief had been obtained. Review of resident 3's Pain Data Collection assessments revealed: *Undated- "Pain from fall 7/16/13 to the left rib cage. Unable to rate his pain at the worst or what is a tolerable rate of pain due to not understanding. Rates his pain 10 (on a 1 to 10 scale with 1 being the least pain, 5 being moderate pain, and 10 being severe pain). Moans and groans. Looks in pain. Pain occurs with movement and describes pain as sharp. Complains of pain when eating. Unable to understand what relieves pain. Is irritable. Tylenol is scheduled pain medication regimen and [MEDICATION NAME] and [MEDICATION NAME] are documented as PRN." There was no documentation of any non-pharmacological interventions for pain control. *8/11/13- "Complains of severe back pain. Had fall 7/16/13. Also has [DIAGNOSES REDACTED]. Receives [MEDICATION NAME] and Iododerma patch daily." There was no documentation of any non-pharmacological interventions for pain control. Interview on 8/28/13 at 2:30 p.m. with licensed practical nurse (LPN) C regarding the above revealed: *She had sent a facsimile to the physician on 7/16/13 to inform her the resident fell . *There was no change in pain medication orders documented when the physician had returned the facsimile. *The physician had not been called when he had continued to complain of increased pain. *The physician had not changed any of his pain medication orders since the [MEDICATION NAME] had been increased to 37 mcg from 25 mcg on 4/13/12. *The physician utilized a lot of Tylenol either scheduled or PRN for pain control, so her patients would not be sedated. Interview on 8/28/13 at 3:00 p.m. with the registered nurse Minimum Data Set (MDS) coordinator revealed she: *Had documented the 8/11/13 pain assessment. *Had not informed the physician of his increased pain. Review of the roster sample matrix provided to the surveyors on 8/27/13 at 10:00 a.m. and interview with the director of nursing on 9/4/13 at 8:15 a.m. revealed: *Thirty-six of fifty-five residents had been identified as having moderate/severe pain (constant or frequent). *Five of the thirty-six residents were not on any type of pain medication treatment. *Thirty-three of the thirty-six residents that were identified with pain were patients of the medical director. *Twelve of the thirty-one residents on a pain medication regimen were treated with scheduled Tylenol only. *Ten of the thirty-one residents were treated with scheduled Tylenol and a topical ointment and/or another pain medication for pain control. *Nine of the thirty-one residents were treated with another oral medication for pain control. *She was aware the medical director utilized primarily Tylenol for pain control for her patients. *She confirmed resident 3's pain regimen had not been changed since 4/13/12 despite the fact he often complained or showed signs of pain. Phone interview on 9/4/13 at 10:45 a.m. with the medical director regarding resident 3 revealed: *She was at the facility on a weekly basis and attended a quality of life meeting on a monthly basis. *She was involved in the quality assurance program at the facility. If she was unable to attend the meetings they sent her the information to review. *She knew resident 3's family very well and visited with them often. They had not voiced any concerns regarding his pain medications to her. *Pain was subjective, and she was able to identify when her patients were in pain. *She did not want to use narcotic pain medication if they were not in pain due to the sedating properties, and she did not want them addicted to narcotics. *She would ask a resident if they were having pain, and they would tell her yes. Then after she had left the resident's room they no longer looked like they were experiencing pain. *If a resident's blood pressure and pulse were normal and they were sleeping okay they were likely not experiencing any pain. *A lot of the residents had psychiatric issues and had the potential to misuse pain medications. *She was not aware of the large number of residents identified by the facility as having moderate to severe pain on a constant or frequent basis. *Most of the residents had a PRN Tylenol and/or another pain medication that could have been utilized for break-through pain that the nurses could have administered. *She agreed the nurses must follow-up on any PRN pain medication given as to the effectiveness of pain relief. Refer to F250, findings 1 through 9. Refer to F223, finding 1. Refer to F309, findings 1, 2, 3, 4, 6, and 7. Interview on 9/4/13 at 11:10 a.m. with the medical director confirmed if there was no rationale documented for no GDRs or duplicate drug therapy in the residents' charts it had not been done. She had agreed they needed to document better on the use of antipsychotic medications. Review of the provider's December 2010 Nursing Facility Medical Director Agreement revealed: *"Participate in establishing policies and procedures to enhance and promote the quality of life for residents/clients." *"Implement resident/client care policies regarding use of medications." *"Supervise compliance by attending physicians with requirements for monitoring drug regiment review." *"Supervise resident's drug therapies, to ensure that drug regimens are appropriate, not contraindicated, and properly documented and administered." *"Monitor to ensure that each resident's drug regiment is free from unnecessary drugs and that residents who use anti-psychotic drugs receive GDRs and behavioral interventions, unless clinically contraindicated." Review of the provider's January 2009 Medical Director policies and guidelines revealed: *"Will help ensure that all necessary medical services provided to residents are adequate and appropriate." *"Will advise the center's administration of current medical issues affecting the residents of the center." *"Will serve as patient advocate to secure medically necessary services as needed." Review of the provider's January 2009 Pain Management-Resident Assistance policy revealed: *"All residents will receive interdisciplinary consultations on assistance in managing pain." *"The registered nurse (RN) will assess current pain levels and develop with the physician and interdisciplinary team, interventions which may be non-pharmacological as well as pharmacological." *"The RN will review response to medication intervention and work closely with the physician to assist in the individualized pain measurement plan." Review of the provider's March 2004 Non-Pharmacological Pain Intervention policy revealed "Pain can destroy the quality of life, erode the will to live, impair sleep and decrease appetite while also impeding recovery." Refer to F329, findings 1 and 2. Refer to F428, finding 1.

Based on record review, interview, policy review, and review of the 10/4/13 plan of correction for the 9/5/13 recertification survey, revealed the provider failed to: *Implement and evaluate resident care policies and procedures that reflected current standards of practice for resident pain control and mood problems for one of one sampled resident (3). *Ensure adequate assessment and documentation of pain control according to the provider's policy for six of eight sampled residents (4, 6, 16, 22, 31, and 32) who had been identified with moderate/severe pain. Findings include: 1. Review of resident 3's medical record revealed: *A 7/5/10 admitted . *[DIAGNOSES REDACTED]. Review of resident 3's September 2013 through October 2013 medication administration records revealed the following documentation regarding pain medication: *Tylenol was to have been administered for a pain rating of 1 to 5 on a scale of 1 to 10 with 1 being little pain and 10 severe pain. *[MEDICATION NAME] (pain medication for moderate to severe pain) was to have been administered for a pain rating of 6 to 10. *9/1/13- [MEDICATION NAME] (pain medication) 50 milligrams (mg) had been documented as administered for a headache with a pain rating of 10. *9/2/13- [MEDICATION NAME] 50 mg had been documented as administered for unrated left side pain. *9/3/13- [MEDICATION NAME] 50 mg had been documented as administered twice for complaints of pain all over and left shoulder pain for a pain rating of 10. *9/4/13- [MEDICATION NAME] 50 mg had been documented as administered for hurting all over for a pain rating of 6. *9/11/13- [MEDICATION NAME] 50 mg had been documented as administered for complaints of low back pain for a pain rating of 10. *9/14/13- [MEDICATION NAME] 50 mg had been documented as administered for low back pain for a pain rating of 6 or 7. *9/19/13- [MEDICATION NAME] 50 mg had been documented as administered for yelling. *Tylenol 650 mg was documented as administered on 9/2/13, 9/5/13, 9/6/13, 9/8/13, 9/13/13, twice on 9/21/13, 10/5/13, 10/19/13, and 10/29/13. Reason documented for medication was "lower back pain." The pain rating had been either not documented, had been a 3 to 4 pain rating, or had been unable to rate pain and had been moaning. Review of resident 3's 10/28/13 pain assessment completed by the Minimum Data Set registered nurse revealed: *"Not new origin of pain/intensity." *"Is resident at high risk for pain was neither checked yes or no." *"Is current medication regime working was checked yes." *"Recommended pain management plan was [MEDICATION NAME] (narcotic pain medication) 37 micrograms every 3rd day, [MEDICATION NAME] topical every six hours, Tylenol for pain rating of 0 to 5, and [MEDICATION NAME] for pain rating of 6 to 10." (Review of resident 3's medical record revealed that pain regime had not been changed since 5/4/12 by his physician)." *"Has the medical provider been notified was checked no." Review of resident 3's 8/26/13 physician's progress notes revealed: *"He has had ongoing health concerns and has slowly lost weight over time." *"He has [MEDICAL CONDITION] and back pain that is presumed to be secondary to metastases (spreading) of the bone." *"He has some dementia (memory loss). Nursing has not noted any significant change at this point." *"He occasionally falls but is mostly in a wheelchair now." *"He denies any new concerns or complaints today." *"I reviewed the patient's medications and orders. I will not make any changes at this time." *"His weight loss is due to steady decline for his advanced age and presumed metastatic [MEDICAL CONDITION]." *"We will make changes as indicated or follow-up in 60 days." Review of resident 3's 10/28/13 physician's orders [REDACTED]." There were no accompanying physician's progress notes for that onsite visit. Observation on 10/31/13 at 12:15 p.m. of resident 3 revealed; *He was sitting in his wheelchair at the dining room table. *Certified nursing assistant (CNA) G was feeding him his noon meal. *He was coughing when being assisted to eat. *He was shifting himself slightly in his wheelchair. *His facial expression appeared he was uncomfortable. Interview during the above observation with resident 3 and CNA G revealed: *The resident stated " I am not very good." He stated he was experiencing pain all over but especially in his legs and back with a pain rating of 8. *CNA G stated "His back pain is chronic in nature." She was unsure how long he had been in pain as she had just started to feed him and had not provided any other cares for him that morning. *CNA G told the surveyor to go talk to CNA F who had been taking care of the resident that morning. Interview on 10/31/13 at 12:20 p.m. with CNA F regarding resident 3 revealed: *She and another CNA had transferred him out of his recliner into his wheelchair shortly before the noon meal. *He had tolerated being transferred without any unusual complaints. If he had complained of back pain it was chronic in nature and being repositioned usually helped. *He had complained of more back pain when she had assisted him out of bed that morning between 7:00 a.m. and 7:15 a.m. *She said she had reported his back pain to the nurse when questioned by the surveyor what she had done. Interview on 10/31/13 at 1:10 p.m. with licensed practical nurse (LPN) C and registered nurse (RN) D regarding resident 3 revealed: *RN D stated she had not come to work that day until 8:00 a.m. No one had told her the resident had been complaining of back pain. *LPN C stated she was on duty and CNA F or any other CNA had informed her he was having back pain between 7:00 a.m. and 7:30 a.m. *LPN C had administered [MEDICATION NAME] to him at 1:00 p.m. today after CNA G had informed her he was having back pain. He had reported to her the pain rating of his back pain was a 8. Observation on 10/31/13 at 2:00 p.m. of resident 3 revealed: *He was lying in bed with his eyes open. *His facial expression continued to appear he was in pain and he stated his pain "No better." Continued to report his back pain at an 8. Interview on 10/31/13 at 2:15 p.m. with the director of nursing regarding resident 3 revealed: *CNA F should have reported his back pain to the nurse on duty. *She thought the medical director had talked to the resident's family about pain control, but the family had not wanted to change his medications. They wanted him to be more awake and alert and thought increasing his pain medications would make him too sleepy. *She thought the medical director had educated the family on the need for pain control and possibly making him more comfortable would ultimately make him a little more sleepy. *She had discussed hospice (end of life care) with the family and they had not voiced any interest. She was unsure if the medical director had discussed hospice with the family. *She agreed the roster matrix that was provided to the surveyors today showed thirty-three of the forty-five residents were identified with having moderate/severe pain on a constant or frequent basis. Most of the residents (likely greater than seventy-five percent were patients of the medical director). 2. Refer to F309, findings 2, 3, 4, 5, 6, and 7. 3. Review of the provider's revised September 2013 Pain Data Collection and Assessment policy revealed: *"To promote well-being by ensuring that residents are as comfortable as possible." *"To consistently collect information for data collection of pain in a systematic process." *"To determine what pain relief interventions that are specific to the resident that can be utilized and established to aid in maintaining a comfortable level of function and quality of life." *"A pain management plan can include, but not be limited to, a medical regime." *"The care team and nurses must continually monitor and evaluate the pain management plan." Review of the provider's 10/4/13 completion date for the plan of correction from the 9/5/13 licensure survey revealed: *"The medical director was informed of the deficiency and needs to assist in pain assessment, control, and management." *"The medical director will be provided with policies/procedures related to pain management." *"The medical director will be asked to participate in the quality of life committee meetings on a quarterly basis assisting staff in the management of pain." *"The administrator and the Rehab/Skilled consultants from the national campus will provide education to the medical director regarding the policy/procedures of pain management." *"The administrator will audit medical records of residents with pain issues to assure the medical director is aware of the pain issues and is working toward a management plan with staff." *"The medical director was informed and educated on this tag on 9/29/13."

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all its 49 residents. Findings include: 1. Interview on 8/29/13 at 10:00 a.m. with the administrator revealed: *He had been at the facility less than a year. *The facility had been without a full-time director of nursing (DON) for about two years. *He had hired a full-time DON a month ago. *She had identified several issues that needed to be looked at but had not had enough time to address the issues identified. *Restorative nursing had been compromised at least since February 2013 related to staffing issues. *The staff responsible for infection control and quality assurance also had multiple other duties they were responsible for. *He had reported any concerns to the regional director at the corporate office. He did not have any formal documentation what he had reported to her. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator had not ensured the safe management and overall well-being of the residents. Refer to F157, F224, F226, F241, F250, F253, F278, F279, F281, F309, F311, F323, F329, F332, F353, F371, F406, F425, F428, F441, F490, F493, F501, F514, and F520.

Based on observation, interview, record review, and policy review, the provider failed to ensure professional standards had been followed by: *Pre-medicating one of one resident (2) prior to performing a dressing change that caused the resident pain. *Following physician's orders [REDACTED]. *For administering medications for five of five sampled residents (3, 8, 11, 21, and 24). *For [MEDICAL CONDITION] care for one of one sampled resident (12). *For obtaining a physician's orders [REDACTED]. *For obtaining a physician's orders [REDACTED]. Findings include: 1. Observation on 8/28/13 at 10:15 a.m. of licensed practical nurse (LPN) A while performing a dressing change on resident 2 revealed: *She had not washed her hands before putting on her gloves. *She removed the old dressing and her soiled gloves. *The resident had began to curse and yell out "it hurts." *The resident's wound had started to slightly bleed. *She put on new gloves and had not washed her hands. *She applied Resinol cream to the resident's wound. *She removed her gloves and washed her hands for less than ten seconds. *She left the resident's room and had not assessed his pain. Review of resident 2's 7/29/13 physician's orders [REDACTED]. *Tylenol 650 milligrams (mg) every four hours as needed (PRN) for pain. *[MEDICATION NAME] 400 mg every four hours PRN for pain. Interview with LPN A revealed she had never thought of giving a pain medication prior to performing resident 10's dressing change. Interview on 9/4/13 at 3:40 p.m. with the director of nursing (DON) revealed she would expect nursing staff to premedicate residents prior to performing a dressing change if it would cause the resident pain or discomfort. 2. Review of resident 3's 5/9/13 physician's orders [REDACTED]. *1500-2000 cubic centimeters (cc) fluid restriction daily. *[DIAGNOSES REDACTED]. Review of resident 3's undated dietary card revealed "1500 cc fluid restriction." Interview on 8/28/13 at 10:00 a.m. with the dietary manager regarding resident 3 revealed: *He was not sure exactly what his fluid restriction was. He stated he used to know, and thought it was 2000-2500 cc day. *Dietary served the following liquids to him at meals: -Hot chocolate 210 cc with breakfast, lunch, and supper (total 630 cc). -Water 180 cc with breakfast, lunch, and supper per family request (total 540 cc). -Milk 180 cc with breakfast meal. -Juice 180 cc with breakfast meal. *Dietary offered a total of 1530 cc a day, but the resident seldom consumed it all. *Dietary was responsible for the documentation of meal fluid intake. *Nursing documented the amount of fluid he consumed in his room. He was unsure how much fluid nursing gave him in his room. *He was doubtful he ever went over the 1500-2000 cc a day fluid restriction. Review of resident 3's 3/1/13 through 8/27/13 daily fluid monitoring record revealed: *There was documentation daily fluid intakes ranged from 360 cc to 1640 ccs. *There were three days no fluid intake had been recorded for the breakfast meal. *There were sixteen days no fluid intake had been recorded for the noon meal. *There were twenty-nine days no fluid intake had been recorded for the supper meal. *There was one day no fluid intake had been recorded for breakfast and the noon meal. *There was one day no fluid intake had been recorded for breakfast and the supper meal. *There were two days no fluid intake had been recorded for the noon and supper meal. Interview on 8/28/13 at 11:00 a.m. with the dietary manager regarding resident 3 revealed: *The days when fluid intake had not been recorded for a meal they had no idea if the 1500-2000 cc a day fluid restriction had been followed. *His daily fluid intake records were often not accurate. *His care plan did not give specific parameters regarding his fluid restriction and only said "Fluid restriction. Fluids as scheduled with resident." 3. Observation of resident 3 on 8/28/13 from 9:10 a.m. to 9:20 a.m. revealed: *He was sitting at the dining room table with his uneaten breakfast in front of him. *He had made no attempt to feed himself after his food had been placed on the table at 9:00 a.m. *LPN A had administered 17 grams of [MEDICATION NAME] mixed in 30 cc applesauce by a teaspoon to him. She then offered him a bite of egg after he had taken the [MEDICATION NAME]. She did not offer him any fluids with the [MEDICATION NAME]. Interview at that time with LPN A regarding the above revealed: *He disliked the thickened liquids, and it was hard to mix the [MEDICATION NAME] in with fluid. *She knew usually four to eight ounces of fluid should have been given with the [MEDICATION NAME]. *He seemed to accept the [MEDICATION NAME] when mixed with a small amount of applesauce. 4. Observation on 9/3/13 at 5:15 p.m. of resident 21's September Medication Administration Record [REDACTED]. Interview at that time with LPN C regarding the above revealed she had given the 2:00 p.m. [MEDICATION NAME] and had not documented that and would now. 5. Observations of a liquid potassium supplement not diluted for resident 11 and an extended release medication crushed for resident 24 as directed by manufacturer recommendations were done by RN D. Refer to F332. 6. Observation and interview on 8/28/13 at 12:03 p.m. revealed LPN C prepared resident 8's medications. The medication [MEDICATION NAME] (for an [MEDICAL CONDITION] bowel disease) 250 mg was included. When LPN C was asked what the medication was for she stated she did not know but would look it up later. She gave the medication to resident 8 and continued with the rest of her medication pass. 7. Review of resident 5's medical record revealed on 8/22/13 at 5:00 p.m. he had complaints of low back pain and a positive urinalysis (UA) on 8/23/13 indicated a urinary tract infection. Interview on 8/29/13 at 10:30 a.m. with LPN C revealed she had not notified resident 5's physician when the UA results had been received on 8/23/13. Refer to F309, finding 5. 8. Observation and interview on 8/28/13 at 2:00 p.m. revealed LPN C had not followed professional standards while performing [MEDICAL CONDITION] care for resident 12. Refer to F441, finding 6. Preceptor: 9. Record review of resident 15's physician's orders [REDACTED]. Interview on 9/4/13 at 2:00 p.m. with the DON revealed: *She was unable to locate the present code status for resident 15 in the medical record. *She agreed a code status was required for all residents upon admission. 10. Observation on 8/28/13 at 2:00 p.m. of resident 12's [MEDICAL CONDITION] (trach) care performed by LPN C revealed: *The resident was not placed in a comfortable or usual position [MEDICAL CONDITION]. *She told the resident "This works better when you are sitting up in your chair." *The resident was placed in an almost flat position with the head of bed only slightly raised. *No barrier was used to put the equipment on brought in to complete [MEDICAL CONDITION]. *LPN C reached into the top of square sterile fluid container provided in the kit to get it to pop open with a nonsterile glove on. *Time to breathe or deep breaths encouraged were not consistently offered between suctioning attempts. *The oxygen source was not replaced or offered to be replaced during the procedure. *Suctioning catheter was not consistently cleared with saline between suctioning attempts. *LPN C did not maintain one clean, sterile glove and one soiled glove. She touched nonsterile items with the glove that should have remained sterile and touched sterile items with the nonsterile (dirty) glove. LPN C moved the suction catheter between clean and dirty hands during the procedure. *LPN C did not reapply the oxygen source at the completion of the procedure. The resident put on the call light and waited for a CNA to respond for the oxygen to be reattached. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, Mo., 2005, pp. 802, 1102-3, and 1105 revealed:*Client should have assumed comfortable a position for the nurse and client, usually Semi Fowler (partially sitting up) or sitting upright with head hyperextended (tilted back as far as possible) unless contraindicated. *An area or object is contaminated if touched by any object that is not sterile. *Client should have been encouraged to deep breathe and cough between suctioning attempts. *Oxygen source should have been reapplied as needed during the procedure. *Suction catheter should have been cleared of secretions using sterile fluid between suctioning attempts. *Client's oxygen source should have been immediately reattached following the procedure.

Based on record review, interview, and 10/4/13 plan of correction review from the 9/5/13 recertification survey, the provider failed to ensure professional standards were followed for the administration of an antihypertensive (high blood pressure medication) for one of one sampled resident (11). Findings include: 1. Review of resident 11's October 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. At the top of the MAR indicated [REDACTED]." Interview on 10/31/13 at 11:00 a.m. with registered nurse D regarding resident 11revealed she: *Crushed the resident's [MEDICATION NAME] all the time. *Was not aware it should not have been crushed. Review of the provider's revised January 2012 medications not to be crushed list revealed [MEDICATION NAME] ER should not have been crushed, as it was a timed release formation. Review of the provider's 10/4/13 completion date for the plan of correction review from the 9/5/13 licensure survey revealed "Resident 11 will not have [MEDICATION NAME] crushed."

Based on random observation, interview, record review, testing, and policy and procedure review, the provider failed to ensure: *Wanderguards (an alarming device worn by the resident to alert the staff when attempting to exit the facility) were checked daily for two of eight sampled residents (1 and 6) who were at risk for elopement. *Chemicals were secured in two two wings. *An elopement and safe smoking assessment was completed for one of two residents (15) who smoked. *Assessments and interventions were in place for one of eight sampled residents (4) with reoccurring falls. *Four of four doors were alarmed and/or were monitored (main entrance, administrative entrance, dining room entrance, and outpatient physical therapy entrance). *Outside contractor's tools and tool kits were secured at all times. *Bath aides wore proper personal protective equipment (PPE) in accordance with manufacture's directions. Findings include: Surveyor: 1. Observation on 8/28/13 at 4:30 p.m. of resident 1 revealed: *He had wandered down the hall to the main entrance. *He was holding the door open and had been trying to go outside. *The main entrance door to the facility was alarming. Observation on 8/29/13 at 11:00 a.m. of resident 1 revealed he had attempted to go outside through the double-doors located by the nurses station. Review of resident 1's interdisciplinary progress notes (IDPN) from 7/1/13 through 8/27/13 revealed he had been exit seeking forty-three times. Review of resident 1's 8/7/13 comprehensive care plan revealed he was at risk for elopement and the staff were to have checked his Wanderguard daily. Review of resident 1's certified nursing assistant (CNA) Wanderguard documentation from 7/1/13 through 8/28/13 revealed: *The following dates had not been found on the printed form to indicate his Wanderguard had been checked on those dates: -7/1/13, 7/3/13 through 7/5/13, 7/9/13 through 7/9/13 through 7/11/13, 713/13, 7/14/13, 7/16/13 through 7/19/13, 7/23/13, 7/25/13, and 7/31/13. -8/1/13 through 8/4/13, 8/6/13 through 8/9/13, 8/13/13, 8/18/13, 8/21/13, and 8/25/13 through 8/27/13. 2. Observation on 8/29/13 at 10:55 a.m. of resident 6 revealed she had been attempting to open the main entrance door to go outside. Review of resident 6's 6/19/13 comprehensive care plan revealed she had been an elopement risk and her Wanderguard should have been checked daily. Review of resident 1's CNA Wanderguard documentation from 8/1/13 through 8/27/13 revealed: *The following dates had not been found on the printed form to indicate her Wanderguard had been checked: -8/4/13, 8/9/13, 8/15/13, 8/21/13 through 8/23/13, and 8/26/13. Interview on 9/4/13 at 10:50 a.m. with the director of nursing (DON) revealed: *The CNAs should have been checking and documenting on all eight resident's Wanderguards daily. *She had agreed if it was not documented it had not been done. 3. Observation on 8/27/13 at 9:00 a.m. of the 200 wing revealed: *A large cart labeled Trash with a cloth bag hanging on one side. *Inside of the cloth bag contained the following chemicals: -One 8 ounce (oz) can of Glade lavender spray. -One 19 oz can of Envy disinfectant spray. -One plastic container of Lysol disinfectant wipes. *A large cart labeled Soiled linen cart with a cloth bag hanging on one side containing one plastic container of Lysol disinfectant wipes. *Twelve unidentified residents wandered up and down the hallway where the cart was located. Observation on 8/28/13 at 8:30 a.m. of the 100 wing revealed: *A large cart labeled Trash with a cloth bag hanging on one side. The cloth bag had contained the following chemicals: -One plastic container of Clorox disinfectant wipes. -One plastic container of Lysol disinfectant wipes. *A large cart labeled Soiled linen cart with a cloth bag hanging on one side. The cloth bag had contained the following chemicals: -One 8 oz can of Glade lavender spray. -One plastic container of Clorox disinfectant wipes. -On 19 oz can of Envy disinfectant spray. *Several unidentified residents wandered up and down the hallway where the cart was located. Interview on 8/28/13 at 9:20 a.m. with CNA F revealed the chemicals had always been stored on the sides of the carts. The staff had used the chemicals to keep the carts clean and to eliminate odor. Interview on 8/28/13 at 2:30 p.m. with the environmental service director confirmed the above chemicals should have been locked up and stored in a more secure manner. Surveyor: 4. Observation on 8/28/13 at 3:30 p.m. revealed resident 15 was located by this surveyor by the administrative entrance door. Resident 15 asked "Go outside boss and sit in the shade? Go outside boss and sit in the shade?" This surveyor did not respond and resident 15 then went outside. The door alarm did not sound, and no one checked on the resident. This surveyor then asked an unidentified aide if resident 15 should have gone outside. The aide went to get the resident, told him it was too hot to sit outside, and brought him back into the facility. Note: The temperature was 93 F (Fahrenheit) and the dew point was 73 percent according to the National Weather Service at that time of day in the provider's city. The combined temperature and dew point percentage gave an actual heat index of 105 F to 106 F. 5. Observation on 8/27/13 at 11:55 a.m. revealed an alarm did not sound when the east exit door off of the dining room was opened. Three unidentified residents were noted in that area. Observation on 8/28/13 at 3:30 p.m. revealed resident 15 exited the south entry door. An alarm did not sound when the resident exited the facility. Observation on 9/4/13 at 3:35 p.m. revealed seven unidentified residents sat in the dining room unattended. Three of those seven residents sat directly next to an unlocked dining door that led to the restorative therapy room. The restorative therapy (RT) room had an unlocked door that led to the outpatient physical therapy (PT) room. The PT room had an outside exit door that was not alarmed. This surveyor opened that outside exit door at 3:35 p.m. and sat until 3:40 p.m. No alarm sounded and no staff came to check on that door or the status of the person who opened that door. Interview on 8/28/13 at 3:15 p.m. with the environmental services director and the administrator revealed they were aware the three above stated doors were not alarmed during the day nor were they monitored by staff on a continual basis. 6. Observation on 8/27/13 at 11:58 a.m. revealed two cloth bucket caddies of tools sat on the floor directly outside of resident room 102. No one was noted in that area who would have been responsible for those tools. Interview on 8/28/13 at 3:15 p.m. with the environmental services director and the administrator revealed they were not aware the ventilation contractors had left their tools unattended in the hallway. The administrator stated they had previously encountered contractors who had left their tools unattended in the facility and had tried to monitor the contractors to ensure it did not happen again. Surveyor: 7. Observation on 8/27/13 at 11:10 a.m. of CNA G revealed: *She had been disinfecting the whirlpool tub. *She had used a long handled brush to scrub the exposed areas of the tub and chair. *She had worn a pair of gloves but had not put on protective eyewear. Observation on 8/28/13 at 9:30 a.m. of CNA H revealed: *She had been disinfecting the whirlpool tub. *She had used a long handled brush to scrub the exposed areas of the tub and chair. *She had not worn gloves or protective eyewear. Interview on 9/4/13 at 10:50 a.m. with the director of nursing (DON) confirmed the staff should have worn personal protective equipment while disinfecting the whirlpool tub. Review of the manufacturer's undated System Cleaning policy of the whirlpool tub revealed "Personnel should wear protective glasses and gloves to prevent disinfectant from damaging their eyes or skin." Surveyor: Review of the October 2008 policy and procedure titled Alarms: Bed, Chair and Door revealed the following: -"Policy: The center will ensure that a system is in place for all bed, chair, and door alarms and these alarms are in proper working order. Alarms will be installed and placed according to the manufacturer's instructions. -Procedure: 1. Alarms are to be checked for proper operations and/or battery charge as follows: *Standard door alarms - Environmental Services are to check weekly. *Wandering alert door alarms - Environmental Services are to check weekly. *Bracelets, bed, personal and motion alarms - Rehab or Nursing are to check daily to see if alarm sounds." No mention or document was provided regarding the monitoring or interruption of the door alarms during the daytime of nighttime hours. Review of the February 2005 dated procedure titled Personal Protective Equipment revealed: *"2. It is the center's responsibility to ensure that appropriate personal protective equipment is readily accessible and that employees use it. 7. Gowns and other protective body clothing should be worn in any occupational exposure situation." Preceptor 8. Review of resident 4's Interdisciplinary Notes revealed: *Five falls had occurred between 12/1/12 and 8/28/13. *One instance was where the resident had put herself on the floor. *No documentation had been made regarding a fall on 1/23/13. Review of resident 4's Incident Report Forms revealed: *Six incident report forms had been completed for falls between 12/1/12 and 8/28/13. *No incident report form had been completed for an instance where the resident had placed herself on the floor on 1/15/13. Review of resident 4's Monthly Behavior Review revealed: *Two episodes of the resident putting herself on the floor were identified the month before 5/28/13. *Seven episodes of the resident putting herself on the floor were identified the month before 6/18/13. *Three episodes of the resident putting herself on the floor were identified the month before 7/23/13. Review of resident 4's 8/7/13 Care Plan revealed: *Alterations in mood and behavior: -Staff were to document and report behaviors that included "putting self on floor." -Staff were to educate the resident on safety concerns. *Potential for injury related to resident places self on floor revealed: -Last fall listed as 6/6/13 had been crossed off and had been replaced with 8/17/13. -The fall on 7/30/13 was not listed. -No estimated resolution date was listed. -"Drops to knees then lies on floor yelling 'Help me I fell ' " was written under plan and approach. Interview on 9/4/13 at 9:20 a.m. with the Minimum Data Set (MDS) coordinator revealed: *She agreed a resident on the floor should have been considered a fall. *She stated not all episodes of the resident being found located on the floor were documented. *She stated staff tried to redirect the resident after episodes of the resident placing herself on the floor. Interview on 9/4/13 at 10:20 a.m. with the social worker (SW) revealed: *She did not know when the behavior of putting herself on the floor had begun. *She did not consider the behavior of putting herself on the floor as a fall. *She was unable to identify where instances of putting herself on the floor were documented in the medical record. *She believed the resident wanted one-to-one attention when she placed herself on the floor. *She had encouraged the resident to participate in activities when the behavior was exhibited. Interview on 9/4/13 at 1:55 p.m. with the DON revealed: *No fall log for the facility had existed until this last month. *Any change in position of the resident from standing or sitting to being found on the floor should have been considered a fall. 9. Observation on 8/28/13 at 3:30 p.m. revealed resident 15 was located by a surveyor by the administrative entrance door. Refer to finding 4. 10. Observation on 8/28/13 at 6:00 p.m. revealed: *Resident 15 was not wearing a Wanderguard *There was a small tin can on the patio table by the front entrance that contained used cigarette butts. Review of the 7/31/13 care plan for resident 15 revealed: *The resident had moderately impaired decision making, identified on 6/25/09 *The resident had been encouraged to sit outdoors, weather permitting. *The resident had enjoyed going for walks with staff, weather permitting. *"At times smokes cigarette butts left over in ashtray" had been written under plan and approaches on the 7/31/13 on Care Plan Review of 7-31-13 Tobacco Use Assessment form revealed: *The resident had been identified as needing "smoking related interventions of monitoring, observation and/or assistance." *"Occasional smoking of other residents cigarette butts left in ashtray" had been written under interventions. Interview on 9/4/13 at 2:00 p.m. with the DON regarding resident 15 revealed: *There had not been an elopement assessment completed on the resident. *She agreed an elopement assessment should have been completed on him. *She agreed his care plan was confusing. *She agreed the resident needed supervision when outside. *She agreed the resident should not have been smoking cigarettes without supervision. *She agreed the resident should not have had access to used cigarette butts. *She agreed "smoking cigarette butts" should not have been documented under interventions on 7/31/13 Tobacco Use Assessment or written in as plan/approach on the 7-31-13 on Care Plan.

Based on observation, interview, record review, and policy review, the provider failed to prevent, document, and notify the physician of a pressure ulcer for one of one resident (2). Findings include: 1. Review of the resident 2's entire medical record revealed: *His weight had been declining over the past several months. *His cognitive status had been declining over the past several months. *He was always incontinent of bowel and bladder. *He required total assistance for all of his activities of daily living including mobility. *His 10/17/12 care plan goal for skin integrity was "Will be free from skin breakdown and/or redness." The interventions to achieve that goal were: -"Monitor and report changes." -"Assist with toileting use urinal or toilet." -"Offer back rubs every night and as needed." -"Monitor skin with cares report red areas to nurse." Observations and interviews on 11/27/12 from 9:45 a.m. through 2:00 p.m. of resident 2 revealed: *He was placed in his wheelchair and brought to the dining room at 9:45 a.m. *He remained in his wheelchair position unchanged, in several locations until 1:45 p.m. when he was brought back to his room. Upon placing the resident into bed it was found by the certified nursing assistants (CNA) that he had been incontinent of bowel and bladder. As the CNAs were cleaning up the resident this surveyor noted a quarter sized reddened area on the fold of his right buttock. That area was bright red and down the center the skin had begun to crack open. When CNAs H and I were asked how long the above area had been present they stated for some time. *The CNAs had reported to nursing regarding the above noted area. *CNA I and other CNAs had been treating that open area with A & D ointment. *CNA H and I confirmed the resident was unable to reposition himself. Review of resident 2's entire medical record immediately following the above observations and interviews revealed: *No physician's order was present for A & D ointment. *No nursing or physician documentation was present related to the above open area. Observation and interview on 11/27/12 at 3:05 p.m. with LPN C in resident 2's room revealed: *She confirmed CNAs had reported an area of breakdown in his right buttock fold, but she could not remember when. *Upon visualizing the area with this surveyor she confirmed it was a stage I pressure ulcer. *He was not on any formal repositioning program. *He was at high risk for skin breakdown related to incontinence, nutritional status, and mental status. *The physician had not been notified of the stage I pressure ulcer. *No pressure ulcer documentation or tracking had been initiated for the pressure ulcer. Interview and policy review on 11/27/12 at 3:45 a.m. with the director of nursing and the administrator regarding resident 2 revealed they agreed: *Proper documentation, treatment, and physician notification of resident 2's pressure ulcer to his right buttock fold had not occurred per the provider's revised March 2007 pressure ulcer policy which sites this regulation. *His care plan was not complete, followed, and up-to-date related to pressure ulcers/skin care as outlined in the provider's revised January 2009 care plan policy. *His was at high risk for pressure ulcer development and should had been repositioned at least every two hours. Review of resident 2's entire medical record on 11/28/12 at 8:00 a.m. revealed: *The physician had now been notified of the pressure ulcer and had given orders for its care. *Documentation of the pressure ulcer had been initialized by the provider.