Every finding on record at Hawthorne Healthcare & Wellness Centre, LP

Based on interview and record review, the facility failed to ensure its Payroll Based Journal (a mandated reporting system used by the Centers for Medicare & Medicaid Services (CMS) to collect auditable, employee-level staffing data from long-term care facilities) was submitted for the first fiscal year quarter.This deficient practice resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations. Findings:During a review of the facility's PBJ Staffing Data Report for Fiscal Year Quarter 1, dated 3/19/2026, the PBJ report indicated the facility failed to submit data for the fiscal year one quarter. During an interview, on 3/26/2026 at 3:02 p.m., with the Administrator (Admin), the Admin stated the facility's consulting group was responsible for submitting the PBJ fiscal year information timely. The Admin stated the PBJ was required to be submitted quarterly. During a concurrent interview and record review, on 3/27/2026 at 8;09 a.m., with the Admin, the Admin stated the CMS submission report for the PBJ validation report, dated 2/13/2026, indicated fiscal year 2 was submitted instead of fiscal year 1 which covers October 2025 through December 2025. The Admin stated the risk of not submitting the facility's PBJ in a timely manner could result in not being able to prove care services are being provided to the residents in the facility.During a record review of the State Operations Manual (SOM), dated 7/23/2025, the SOM indicates the facility is responsible for submitting staffing data through the CMS Payroll-Based Journal (PBJ) system. The facility's failure to submit PBJ data, as required, will be reflected on their CASPER report and result in a deficiency citation.

Based on observation, interview and record review, the facility failed to ensure that sweet potatoes fries stored in Freezer 2 in the kitchen were labeled and dated to ensure proper food safety and storage practices. This deficient practice had the potential to place residents at risk for foodborne illnesses.Findings:During an initial observation tour of the kitchen on 3/24/2026 at 8:54 a.m., a clear bag of sweet potato fries stored in Freezer 2 was observed undated and unlabeled.During a concurrent observation and interview, on 3/24/2026 at 8:56 a.m., with the Dietary Services Supervisor (DSS), the DSS stated all food items should be labeled and dated. The DSS stated the risk of not dating and labelling food items could result in staff not being able to identify the food item and possible expiration. During a review of the facility's policy and procedures (P&P), titled Food Storage, dated 11/1/2014, the P&P indicated to Label and date all food items.

Based on observation and interview, the facility failed to provide adequate eating assistance for three of four residents (Resident 1, Resident 7, and Resident 18) by assigning only one staff member to a table where all four residents required assistance. This resulted in Residents 1, 7, and 18 experiencing delays while the staff member assisted another resident. This deficient practice violated the residents' right to be treated with respect and dignity and had the potential to negatively impact their self-esteem, cause emotional distress, and adversely affect their psychosocial well-being.During a review of Resident 1's Face Sheet, the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), long term (current) use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication, and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 11/24/2025, the MDS indicated Resident 1 usually had the ability to make self-understood and usually had the ability to understand others. The MDS indicated Resident 1 was dependent on staff for eating, oral hygiene, toileting, bathing, lower body dressing, and personal hygiene. During a review of Resident 1's History and Physical (H&P) dated 1/29/2026, the H&P indicated Resident 1 could make needs known but could not make medical decisions.During a review of Resident 7's admission Record, the admission record indicated Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including complete paraplegia (total paralysis of the arm, leg, and trunk on the same side of the body), type 2 diabetes, and dysphagia (difficulty swallowing.)During a review of Resident 7's H&P dated 1/27/2026, the H&P indicated Resident 7 did not have the capacity to understand and make decisions.During a review of Resident 7's MDS dated [DATE], the MDS indicated Resident 7 usually had the ability to make self-understood and usually had the ability to understand others. The MDS indicated Resident 7 was dependent on staff for eating, oral hygiene, toileting, bathing, upper and lower body dressing, and personal hygiene.During a review of Resident 18's Face Sheet, the face sheet indicated Resident 18 was initially admitted to the facility on [DATE] with diagnoses that included paraplegia, dysphasia, and personal history of traumatic brain injury.During a review of Resident 18's H&P dated 2/26/2026, the H&P indicated Resident 18 does not have the capacity to understand and make medical decisions.During a review of Resident 18's MDS dated [DATE], the MDS indicated Resident 18 usually had the ability to make self-understood and usually had the ability to understand others. The MDS indicated Resident 18 was dependent on staff for eating, oral hygiene, toileting, bathing, lower body dressing, and personal hygiene.During an observation on 3/24/2026 at 12:11 pm in the dining room, Resident 1, Resident 7, and Resident 18 were seated at a table, with covered food plates in front of them. There was a staff member seated at the table assisting a fourth resident with eating.During an observation on 3/24/2026 at 12:32 pm in the dining room, there was one staff member seated at the table assisting the same resident while Resident 1, Resident 7, and Resident 18 were seated at the table with covered food plates in front of them.During an observation on 3/24/2026 at 12:38 pm in the dining room, three staff members were sitting at the table to assist Resident 1, Resident 7, and Resident 18 with their meals.During an interview on 3/27/2026 at 8:50 am with Certified Nursing Assistant (CNA) 3, CNA 3 stated there are three staff members who assist all the residents in the dining room with eating. CNA 3 stated other CNA's also assist residents in the dining room after they have passed food trays to residents who eat in their rooms. CNA 3 said the residents who are waiting for assistance could feel neglected because they all should eat at the same time.During an interview on 3/27/2026 at 9:13 am with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there are enough staff to assist the residents to eat. LVN 1 stated the residents who are waiting for assistance may feel jealous because they are hungry and someone is eating in front of them.During a review of the Policy and Procedure (P&P) titled Dining Program, effective 2/20/2025, the P&P indicated residents at a given table should generally be served at the same time.

Based on observation, interview, and record review, the facility failed to ensure that a resident's soiled personal clothing was not placed inside the clean linen cart.This failure had the potential to result in cross contamination (a transfer of harmful bacteria from one place to another or one object to another) and place residents at risk for the spread of infection.Findings:During a concurrent observation and interview on 3/24/2026 at 9:25 a.m. with the Infection Preventionist Nurse (IPN) in the resident's hallway, one gray sweater was observed inside the clean linen cart. The IPN stated the soiled gray sweater belonged to a resident, but she did not know which resident it belonged to. The IPN stated residents' personal clothing whether it's clean or dirty should be bagged in a plastic bag and should not be mixed with the facility's clean linen cart. The IPN stated soiled items could contaminate and transfer bacteria to a clean linen. The IPN stated the facility must follow strict guidelines in infection control for residents' safety.During a review of the facility's policy and procedure (P&P) titled, Infection Control Policies and Procedures, dated 1/2012, the P&P indicated The facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on interview and record review, the facility failed to ensure accurate hospice documentation was accurate in the Minimum Data Set (MDS- a federally mandated resident assessment tool) for Resident 60.This deficient practice had the potential to negatively affect Resident 60's plan of care and delivery of necessary care and services.Findings:During a review of Resident 60's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 60 was admitted on [DATE] with diagnoses which included inflammatory polyneuropathy (autoimmune disorders where the immune system attacks peripheral nerves, causing damage to myelin or axons, leading to weakness, numbness, and tingling), chronic obstructive pulmonary disorder (COPD- a chronic lung disease causing difficulty in breathing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).During a review of Resident 60's MDS active diagnosis assessment, dated 11/28/2025, Resident 60's assessment indicated Resident 60 was not on hospice care.During a review of Resident 60's history and physical form (H&P), dated 2/12/2026, the H&P indicated Resident 60 did not have the capacity to understand and make decisions.During a review of Resident 60's MDS, dated [DATE], the MDS indicated Resident 60's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 60 was dependent on staff members with Activities of Daily Living (ADLs).During a concurrent interview and record review, on 03/25/2026 at 3:43 p.m., with the MDSN 2, the MDSN 2 stated Resident 60 had been placed on hospice on 11/21/2025. The MDSN 2 stated Resident 60 was receiving hospice services on 11/28/2025. The MDSN 2 stated Resident 60's active diagnosis for hospice was marked incorrectly on 11/28/2026 indicating Resident 60 was not receiving hospice services. MDSN 2 stated Resident 60's assessment was inaccurate. The MDSN 2 stated the risk of documenting an inaccurate resident diagnosis could result in the possibility of a residents' needs not being met according to inaccurate assessment coding. During a review of the facility's policy and procedures (P&P), titled RAI Process, dated 10/4/2016, the P&P indicated the purpose of the RAI process was To provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements.

Based on interview and record review, the facility failed to implement the physician's orders to draw laboratory tests (a medical analysis of a body sample (blood, urine, tissue) to check health, diagnose diseases and monitor chronic conditions) for one of one sampled resident, (Resident 12).This deficient practice had the potential to result in the delay of the identification of medical concerns, delaying the care and services necessary for Resident 12.Findings:During a review of Resident 12's admission Record, the admission Record indicated, Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included hypothyroidism (a condition when the thyroid gland [a butterfly-shaped or H-shaped gland located in the neck below the Adam's apple] does not make enough thyroid hormones to meet your body's needs), urinary tract infection ([UTI] - an infection in the bladder/urinary tract), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 12's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/25/2025, the MDS indicated, Resident 12 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 12 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 12's History and Physical (H&P), dated 3/24/2026, the H&P indicated, Resident 12 had fluctuating capacity to understand and make decisions.During a review of Resident 12's Order Summary Report (a document containing active orders), dated 3/26/2026, the Order Summary Report indicated, the physician placed a telephone order on 3/12/2026 for Resident 12 to have triiodothyronine 3 level ([T3] - a blood test that measures the level of active T3 hormone in the blood to evaluate thyroid function), Free Thyroxine ([FT4] - a blood test measuring the unbound, active form of T4 hormone produced by the thyroid gland to manage metabolism), and thyroid-stimulating hormone level ([TSH] - a test that measures the amount of TSH in your blood).During a concurrent interview and record review on 3/25/2026 at 2:36 p.m., with the Assistant Director of Nursing (ADON), Resident 12's laboratory results, were reviewed. The ADON stated Resident 12's order for T3, FT4, and TSH level were not completed, and results were not available. The ADON stated there was no documentation that the facility staff made a follow-up call to the laboratory provider to find out what happened with the laboratory results. The ADON stated for whatever reasons, if laboratory orders were not completed, the licensed nursing staff must document and notify the resident's physician. The ADON stated it is important to check Resident 12's T3, FT4, and TSH level for medication dose adjustment since Resident 12 was taking levothyroxine (a drug used to treat hypothyroidism).During an interview on 3/25/2026 at 3:10 p.m., with the Director of Nursing (DON), the DON stated it is important to check Resident 12's T3, FT4, and TSH level to evaluate the effectiveness of his levothyroxine medication and for the physician to provide new interventions if needed.During a review of the facility's policy and procedure (P&P) titled, Laboratory Services, dated 1/1/2012, the P&P indicated, The facility should provide laboratory services in an accurate and timely manner to meet the needs of residents per attending physician orders. The P&P also indicated the nurse documents the time when laboratory results were reported along with the attending physician's response in the resident's medical records.

Based on interview and record review, the facility failed to monitor one of eight sampled residents (Resident 10) behaviors while prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior).This deficient practice had the potential to result in the use of unnecessary psychotropic medication that could cause harm to Resident 10.Findings:During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included paranoid schizophrenia (a chronic mental health disorder where a person experiences intense, irrational suspicion that is characterized by disturbances in thought), major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).During a review of Resident 10's History and Physical (H&P), dated 10/5/2025, the H&P indicated, Resident 10 could make needs known but could not make medical decisions.During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 10 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, lower body dressing, and personal hygiene.During a review of Resident 10's Order Summary Report (a document containing active orders), dated 3/25/2026, the Order Summary Report indicated the physician placed a telephone order on 3/3/2026 for Resident 10 to start on Quetiapine Fumarate (a psychotropic medication, used to treat certain mental/mood disorder) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime (9 p.m.) for other psychotic disorder manifested by increased agitation and verbal aggression and mirtazapine (a drug used to treat depression) 7.5 mg by mouth at bedtime (9 p.m.) for major depressive disorder.During a concurrent interview and record review on 3/25/2026 at 2:50 p.m., with the Assistant Director of Nursing (ADON), Resident 10's Medication Administration Record ([MAR] - a daily documentation record used by licensed nurse to document medications and treatments given to a resident) from 3/3/2026 to 3/25/2026, were reviewed. The ADON stated there was no documented evidence of behavior monitoring of Resident 10's episode of increased agitation, verbal aggression, and depression. The ADON stated if a resident was prescribed with psychotropic medications, there should be an indication, dose, frequency and behavior manifestation. The ADON stated the behavior monitoring should be documented in the MAR by checking Yes or No. The ADON stated, monitoring of behaviors was important in order to keep track and determine if the psychotropic medications were effective and if the facility could attempt a gradual dose reduction ([GDR] - a structured, stepwise, and monitored decrease in medication dosage to determine if a resident can manage with a lower dose or discontinue the drug entirely). The ADON stated a lack of behavior monitoring of Resident 10's psychotropic medications would be considered as an unnecessary medications.During a review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Drug Management, dated 3/24/2024, the P&P indicated, The facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting the health, safety, psychosocial, behavioral, and environment needs of residents.During a review of the facility's P&P titled, Behavior/Psychoactive Medication Management, dated 1/30/2026, the P&P indicated, Any order for psychoactive medications must include a specific behavior manifestation. The P&P did not disclose the frequency and the importance of monitoring resident's behavior.

Based on interview and record review, the facility failed to ensure a recommendation from the Consultant Pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) was acted upon for one of eight sampled residents (Resident 9).This failure had the potential to result in Resident 9 experiencing a delay in treatment. Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrolled fear or worry that interferes with daily life), epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 9's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/29/2026, the MDS indicated, Resident 9's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 9 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 9's History and Physical (H&P), dated 2/23/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions.During a concurrent interview and record review on 3/26/2026 at 9:46 a.m., with the Assistant Director of Nursing (ADON), Resident 9's Consultant Pharmacist Medication Regimen Review ([MRR] - a structured, comprehensive evaluation of a resident's entire medication list, conducted by a pharmacist to ensure safety and effectiveness), dated 12/11/2025, was reviewed. The MRR indicated to please ensure to obtain a Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 key substances in the blood, assessing electrolyte balance, kidney, liver function, and blood sugar), Complete Blood Count ([CBC] - a blood test that checks the overall health of the blood by measuring the number and types of cells), Carbamazepine level (a drug level blood test that measures the amount of seizure-control medication), lipid (a blood test that measures the amount of cholesterol [type of fat] in your blood), Folate level (a blood test that measures the amount of folate [vitamin B9] in your blood to check for deficiency), and vitamin B12 level (a blood test that measures the amount of cobalamin [Vitamin B12] in your bloodstream). The ADON stated the facility failed to take any action on the consultant pharmacist recommendation by not informing Resident 9's physician. The ADON stated there was no documentation by facility staff that the Consultant's Pharmacist MRR recommendation for Resident 9 was completed.During an interview on 3/26/2026 at 10:05 a.m., with the Director of Nursing (DON), the DON stated the MRR by the pharmacy consultant should be completed by the licensed nursing staff at the end of the month. The DON stated the facility's Consultant Pharmacist comes once a month to review residents drug regimen for any medication irregularities and drug interactions (a reaction between two or more drugs). The DON stated it is very important to address the Consultant Pharmacist recommendation in a timely manner for the welfare of the residents.During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated 5/2022, the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber.

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 70) was provided with assistance in obtaining community wheelchair transportation.This deficient practice placed Resident 70 at risk for missed medical appointments and social isolation. Findings:During a review of Resident 70's admission Record, the admission Record indicated, Resident 70 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 70's diagnoses included cerebrovascular accident ([CVA] - stroke, loss of blood flow to a part of the brain) with hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing), and diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing).During a review of Resident 70's History and Physical (H&P), dated 11/13/2025, the H&P indicated Resident 70 had the capacity to understand and make decisions.During a review of Resident 70's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/1/2026, the MDS indicated Resident 70 was independent (decisions consistent and reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 70 required supervision (helper provides verbal cues and/or contact guard assistance as resident completes activity) from staff with toileting hygiene, upper body dressing, and personal hygiene.During a review of Resident 70's care plan, titled The resident had a cerebrovascular accident, revised 3/16/2026, the care plan intervention included to monitor and document resident abilities for activities of daily living and assist resident as needed.During an interview on 3/24/2026 at 10:33 a.m., with Resident 70, Resident 70 stated he asked the Social Service Director (SSD) a month ago to help him complete the application for Access transportation service (a shared-ride, curb to curb transportation system designed for people with disabilities who cannot use traditional fixed-route buses or trains) and schedule an appointment but the SSD did not help him. Resident 70 stated he needed the Access transportation so he could visit his family, church friends, and schedule his own doctor's medical appointment.During an interview on 3/25/2026 at 10:41 a.m., with the SSD, the SSD stated one of the services provided by the facility is to assist and help resident to avail community wheelchair transportation such as the Access transportation services. The SSD stated he did help Resident 70 complete the Access application form and it was mailed out. The SSD stated he received and gave the approval notice of Resident 70's Access application form. The SSD stated he could not provide any documentation that he helped Resident 70 completing the application for Access transportation services. The SSD stated one of his responsibilities is to assist the resident with their daily needs.During an interview on 3/25/2026 at 11:17 a.m., with Resident 70, Resident 70 stated what he received from the SSD last month was a blank application form that was mailed to him by the Access Transportation services. Resident 70 stated he called and requested the application form for Access transportation services since no facility staff were willing to help him. Resident 70 showed an Access transportation application blank form which was not completed. Resident 70 stated he felt that he was not given good customer service and his needs were ignored. During a review of the facility's Social Service Coordinator Job Description, the Social Service Coordinator Job Description indicated one of the principal responsibilities of the Social Service Coordinator is to ensure the resident's psychosocial and care needs are identified and met in accordance with federal, state and company requirements.During a review of the facility's policy and procedure (P&P), titled Social Service Program, dated 5/22/2025, the P&P indicated, Responsibilities of the Social Service Department may include making referrals and obtaining services from outside referrals.

Based on observation, interview and record review, the facility failed to ensure a communication board was provided to Resident 58, who required assistance with communication. This deficient practice had the potential to result in ineffective communication, which could lead to unmet needs and decreased quality of care.Findings:During a review of Resident 58's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 58 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses which included aphasia (a disorder that makes it difficult to speak), (type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (stroke), osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D).During a review of Resident 58's history and physical form (H&P), dated 6/24/2025, the H&P indicated Resident 58 had the capacity to understand and make decisions.During a review of Resident 58's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/12/2026, the MDS indicated Resident 58's cognitive (thinking) skills were cognitively intact. The MDS indicated Resident 58 was dependent on staff members with Activities of Daily Living (ADLs).During a review of Resident 58's care plan, on 3/24/2026, dated 5/2/2022, the care plan indicated to: Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from the resident to ensure understanding. Face resident when CNA speaking. Make eye contact. Turn off TV/radio to reduce environmental noise. Ask Yes/No questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed.Evaluate resident dexterity/ability to use communication board. During an observation, on 3/25/2026 at 3:23 p.m., in Resident 58's room, there was no communication board at the bedside. Resident 58 was nonverbal but attempted to use gestures to communicate.During a concurrent interview and record review, on 3/26/2026 at 10:14 a.m., with MDSN 2, MDSN 2 stated non-verbal residents are provided a communication board with pictures to indicate their needs or a marker to write what they would like to express. MDSN 2 stated Resident 58 was not provided a communication board. MDSN 2 stated Resident 58 used gestures to indicate her needs. MDSN 2 stated Resident 58's care plan indicated Resident 58 should have had a communication board instead of having staff translate her needs. MDSN 2 stated the risk of not providing a communication board could result in not understanding a resident or translating their needs correctly. During a review of the facility's policy and procedures (P&P), titled Accommodation of Residents' Communication Needs dated 2/24/2026, the P&P indicated The following are examples of adaptive devices or accommodations the staff may provide the Resident: A. Writing pad and pen; and B. Communication boards/charts.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for two of 20 sampled residents (Residents 9 and 77) by failing to:Ensure a care plan was developed for Resident 9's use of Lorazepam (drug to relieve anxiety).Ensure a care plan was created for Resident 77's diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought).This failure had the potential to result in a lack of meeting necessary care and addressing medical needs for Residents 9 and 77. Findings: A.During a review of Resident 9's admission Record, the admission Record indicated, Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 9's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrolled fear or worry that interferes with daily life), epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 9's Minimum Data Set ([MDS] – a resident assessment tool), dated 1/29/2026, the MDS indicated, Resident 9's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 9 required moderate assistance (helper does less than half the effort) from staff with oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 9's History and Physical (H&P), dated 2/23/2026, the H&P indicated, Resident 9 did not have the capacity to understand and make decisions. During a review of Resident 9's Order Summary Report (a document containing active orders), dated 3/26/2026, the Order Summary Report indicated, the physician placed a telephone order on 3/1/2026 for Resident 9 to start on Lorazepam 1 milligram ([mg.] – metric unit of measurement, used for medication dosage and/or amount) to give 1 tablet by mouth three times a day (9 a.m., 1 p.m., and 5 p.m.,) for anxiety disorder manifested by inability to relax. During a concurrent interview and record review on 3/26/2026 at 10:17 a.m., with Minimum Data Set Nurse 1 (MDSN 1), Resident 9's care plans were reviewed. MDSN 1 stated there was no comprehensive care plan to address Resident 9's use of Lorazepam. MDSN 1 stated it is important to have a care plan for medication in order to monitor the side-effects or the black box warning (drugs that have special problems, particularly ones that may lead to death or serious injury) of the medication. MDSN 1 stated it is the responsibility of the licensed nurses to develop a comprehensive care plan in order to be aware of each resident's individualized needs. MDSN 1 stated without a resident care plan, the facility staff would not be able to provide the care and services of the residents. B. During a review of Resident 77's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 77 was admitted on [DATE] with diagnoses which included metabolic encephalopathy (a change in how your brain works due to an underlying condition in the body), paranoid schizophrenia (a mental illness characterized by intense, irrational suspicions and delusions that others are plotting against or trying to harm an individual), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) and epilepsy (seizures). During a review of Resident 77's history and physical form (H&P), dated 2/26/2026, the H&P indicated Resident 77 did not have the capacity to understand and make decisions. During a review of Resident 77's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/4/2026, the MDS indicated Resident 77's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 77 was dependent on staff members with Activities of Daily Living (ADLs). During a review of Resident 77s' care plan, on 03/26/2026, there was no schizophrenia care plan noted. During a concurrent interview and record review, on 03/26/2026 at 10:14 a.m., with the MDSN 2, the MDSN 2 stated care plans were initiated to indicate what type of treatment staff would provide for the resident during their stay at the facility according to a resident's diagnosis and needs. The MDSN 2 stated psychiatric diagnosis were required to have a care plan. The MDSN 2 stated she did not see a schizophrenia care plan for Resident 77. The MDSN 2 stated Resident 77 required a care plan for schizophrenia. The MDSN 2 stated the risk of not initiating a care plan for a resident with a psychiatric diagnosis could result in a resident not obtaining the care and services needed according to their diagnosis. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated, The facility must develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights, that includes measurable objectives, and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) Level 1 screenings (a federally required preliminary screening for individuals seeking admission to a Medicaid-certified nursing facility) were completed and resubmitted for two of seven sampled residents (Residents 10 and 12) with diagnoses of mental illness and who were receiving psychotropic medications. This deficient practice had the potential to result in Residents 10 and 12 not being appropriately evaluated and, therefore, not receiving necessary specialized services for mental illness.Findings:A. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 10's diagnoses included paranoid schizophrenia (a chronic mental health disorder where a person experiences intense, irrational suspicion that is characterized by disturbances in thought), major depressive disorder ([MDD] - a mood disorder that cause a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).During a review of Resident 10's History and Physical (H&P), dated 10/5/2025, the H&P indicated Resident 10 can make needs known but could not make medical decisions.During a review of Resident 10's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/12/2026, the MDS indicated Resident 10's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 10 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, lower body dressing, and personal hygiene.During a review of Resident 10's Order Summary Report (a document containing active orders), dated 3/25/2026, the Order Summary Report indicated the physician placed a telephone order on 3/3/2026 for Resident 10 to start on Quetiapine Fumarate (a psychotropic medication, used to treat certain mental/mood disorder) 50 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth at bedtime (9 p.m.) for other psychotic disorder manifested by increased agitation and verbal aggression and Mirtazapine (a drug used to treat depression) 7.5 mg by mouth at bedtime (9 p.m.) for major depressive disorder.During a concurrent interview and record review on 3/25/2026 at 2:08 p.m., with the Director of Nursing (DON), Resident 10's PASARR Level 1 screening completed by the facility on 11/10/2024, was reviewed. The DON stated the PASARR Level 1 screening indicated Resident 10 had no serious mental illness diagnoses. The DON stated Resident 10 had a new mental illness diagnosis of paranoid schizophrenia on 4/2/2025. The DON stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because of the new mental illness diagnosis. The DON stated by not resubmitting the PASARR Level 1 screening, there is a possibility that Resident 10 would not be able to avail the treatment services for his mental illness diagnosis of paranoid schizophrenia.B. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality).During a review of Resident 12's Minimum Data Set ([MDS] - a resident assessment tool), dated 12/25/2025, the MDS indicated, Resident 12 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated Resident 12 required set-up assistance (helper assists only prior to or following the activity) from staff with oral hygiene, upper body dressing, and personal hygiene.During a review of Resident 12's History and Physical (H&P), dated 3/24/2026, the H&P indicated Resident 12 had fluctuating capacity to understand and make decisions.During a review of Resident 12's Order Summary Report (a document containing active orders), dated 3/26/2026, the Order Summary Report indicated, the physician placed a telephone order on 3/23/2026 for Resident 12 to start on Haloperidol (a psychotropic medication, used to treat certain mental/mood disorder) 10 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth two times a day (9 a.m., and 5 p.m.) for schizophrenia manifested by aggressive behavior for 30 days.During a concurrent interview and record review on 3/25/2026 at 2:22 p.m., with the Director of Nursing (DON), Resident 12's PASARR Level 1 screening completed by the facility on 3/18/2021, was reviewed. The DON stated the PASARR Level 1 screening indicated Resident 12 had no serious mental illness diagnoses and was not on prescribed psychotropic medications (any drug that affects brain activities associated with mental processes and behavior). The DON stated the PASARR Level 1 screening also indicated Resident 12's case was closed, and a PASARR level II mental health evaluation was not required. The DON stated the facility should have completed and resubmitted a new PASARR Level 1 screening under Resident Review because Resident 12 had a mental illness diagnoses of paranoid schizophrenia, MDD, and psychosis and Resident 12 was prescribed Haloperidol. The DON stated the facility did not follow the PASARR procedure for resubmitting a PASARR Level 1 screening under Resident Review.During a review of the facility's policy and procedure (P&P), titled Pre-admission Screening Resident Review, dated 6/12/2024, the P&P indicated The facility MDS coordinator will be responsible for accessing and ensure updates to the PASRR are completed per MDS guidelines.

Based on interview and record review, the facility failed to follow-up on dental service for new dentures for one of one sampled resident (Resident 30).This deficient practice had the potential to result in inability to chew food and weight loss for Resident 30.Findings:During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 30's diagnoses included dysphagia (difficulty swallowing), cerebral ischemia (a condition where blood flow to the brain is reduced or blocked), and epilepsy (chronic brain disorder characterized by recurrent unprovoked seizures).During a review of Resident 30's Dental Progress Note, dated 9/3/2025, the Dental Progress Note indicated the dentist recommended a denture for Resident 30.During a review of Resident 30's History and Physical (H&P), dated 2/13/2026, the H&P indicated Resident 30 did not have the capacity to understand and make decisions.During a review of Resident 30's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/27/2026, the MDS indicated Resident 30's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated Resident 30 required moderate assistance (helper does less than half the effort) from staff with toileting hygiene, upper and lower body dressing.During a review of Resident 30's Dental Progress Note, dated 2/5/2026, the Dental Progress Note indicated the dentist recommended a denture for Resident 30.During an interview on 3/24/2026 at 9:50 a.m., with Resident 30, Resident 30 stated she broke her dentures about 3 to 4 months ago. Resident 30 stated she had a hard time eating without her dentures.During an interview on 3/25/2026 at 10:56 a.m., with the Social Service Director (SSD), the SSD stated he was aware that Resident 30 was seen by the dentist on 9/3/2025 and 2/5/2026 but was not aware of the dentist treatment recommendation for Resident 30 to receive a denture. The SSD stated he did not follow-up with the dentist regarding the update of Resident 30's denture. The SSD stated it is important for Resident 30 to receive dentures for her to chew the food properly. The SSD stated the risk of not providing dentures to Resident 30 would result in gum discomfort and pain that would affect her quality of life.During an interview on 3/25/2026 at 11:31 a.m., with the Director of Nursing (DON), the DON stated he was not aware of the dentist treatment recommendations for Resident 30 to receive a denture. The DON stated it is important to follow up with the dentist regarding the status of Resident 30's denture for resident's comfort when eating.During a review of the facility's Social Service Coordinator Job Description, the Social Service Coordinator Job Description indicated to communicate needs and plan of care to resident, families, responsible parties and appropriate staff and to arrange ancillary services that have been determined necessary to maintain the resident's concrete needs.During a review of the facility's policy and procedure (P&P) titled, Oral Healthcare and Dental Services, dated 7/14/2017, the P&P indicated The facility will provide oral healthcare and dental services for preventive care and treatment.

Based on interview and record review, the facility failed to ensure two out of two randomly selected Certified Nurse Assistant's (CNA] 1 and CNA 2) received mandatory effective communications training.This deficient practice had the potential to result in inadequate staff communication skills, which may negatively impact residents' quality of care.Findings:During a concurrent interview and record review on 3/26/2026 at 3:35 p.m. with the Director of Staff Development (DSD), CNA 1 and 2's personnel records were reviewed. The DSD stated CNA 1 was hired on 7/7/2025 and did not have evidence of effective communication training on file. The DSD stated CNA 2 was hired on 3/5/2026 and did not have evidence of effective communication training on file. The DSD stated she was responsible for providing effective communication training for all direct care staff. The DSD stated it was important to provide effective communication training for all direct care staff so staff could adequately interact with residents and other staff to ensure a good working environment and residents' safety.During a review of the Facility Assessment Tool, updated on 3/23/2026, the Facility Assessment Tool indicated the facility's current CNA training program sufficiently addresses their resident population as identified by the Facility Assessment.During a review of facility's Director of Staff Development, Job Description, the DSD Job Description indicated the Director of Staff Development was responsible for planning, implementation, direction and evaluation of the facility's educational programs for all employees. The DSD Job Description indicated the DSD was to coordinate and conduct an effective on-going in-service plan for all employees.

Based on interview and record review, the facility failed to revise and maintain an updated average daily census of the Facility Assessment Tool (a process for evaluating a facility's resident population and identifying the resources needed to provide care and services).This deficient failure had the potential to place residents at risk for not receiving care and services necessary to maintain their highest practicable physical, mental and psychosocial well-being.Findings:During a review of the facility census for 3/23/2026, the facility census indicated, 83 residents resided in the facility.During a review of the facility census for 3/24/2026, the facility census indicated, 83 residents resided in the facility.During a concurrent interview and record review on 3/25/2026 at 11:45 a.m., with the Administrator (ADM), the Facility Assessment Tool, updated 3/23/2026, was reviewed. The ADM stated she was responsible for updating the Facility Assessment Tool. The ADM stated the Facility Assessment Tool should be updated yearly or as needed if there is a change in the facility census or if there are special treatments or services provided to the residents. The ADM stated the assessment provided was the average daily census of 80 residents. The ADM stated the Facility Assessment Tool was not accurate because of the average daily census which was below the actual census of residents residing in the facility. The ADM stated there were three residents who were not accounted for on the Facility Assessment Tool. The ADM stated it is important to indicate the correct average daily census in the Facility Assessment Tool so the facility staff could adequately provide care and support to the residents.During a review of the facility's policy and procedure (P&P) titled, Facility Assessment, dated 4/15/2021, the P&P indicated The Administrator should review and update the Facility Assessment annually and as necessary whenever there is, or the facility plans, for any change that would require a substantial modification to any part of the assessment.

Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Dietary Department-Infection Control. Dietary Aide 1 did not wear a hairnet while working in the kitchen. This failure had the potential for cross contamination and increase the risk of infections among residents. Findings: During an observation on 6/4/2025 at 1:50 p.m., with the Dietary Manager, Dietary Aide 1 was observed working in the kitchen without a hairnet. During a concurrent interview, Dietary Aide 1 stated she removed her hairnet as she was coming to the kitchen door. There was no hairnet was observed in Dietary Aide 1's hand. Dietary Aide 1 did not state how the lack of a hairnet may affect residents. The Dietary manager stated that not wearing a hairnet in the kitchen increased the risk of hair falling and cross contamination to foods and utensils. During a review of the facility policy and procedure titled, Dietary Department-Infection Control, dated 2/29/2024, indicated personal cleanliness was required in sanitary food preparation, clean working attire would be worn, cover head, beard, and mustache with an effective hair restraint, such as hats, hair coverings or nets while in any kitchen and food storage areas.

Based on observation, interview, and record review, the facility failed to: 1. Ensure the correct sized serving scoop was used for 29 of 29 residents on mechanical soft diets. This deficient practice had the potential for resident to receive the wrong caloric intake when not following the menu, resulting in decreased nutritional intake and weight loss. Findings: During an observation on 1/23/2025 at 12:00 p.m. in the kitchen, during serving of the lunch trays, [NAME] 1 (Cook 1) scooped the mechanical soft roast beef onto resident's plates using scoop size number 12 (one-third of a cup). During a review of Cooks Spreadsheet - Winter Menus, dated 1/23/2025, indicated ground roast beef for lunch required the use of scoop number 10 (three-eighths of a cup). During a review of facility list of residents on mechanical soft diets, dated 1/24/2025, indicated there were 29 residents on mechanical soft diets. During an interview on 1/23/2025 at 12:20 p.m. with [NAME] 1, [NAME] 1 stated that the number 12 scoop was used to serve the mechanical soft meat. [NAME] 1 stated the wrong scoop that was used was smaller than what the menu showed. [NAME] 1 stated the menu shows the number 10 scoop which is larger should have been used. [NAME] 1 stated it was important to use the right size scoop, it could possibly cause the resident to get less food and have weight loss. During an interview on 1/23/2025 at 12:35 p.m., with Dietary Supervisor (DS), DS stated cook 1 used the wrong size scoop for the mechanical soft meat. DS stated the scoop number 10 should have been used, it was a larger scoop than the one that was used. The DS stated that using the incorrect scoop size meant the residents could not get enough food and potentially have weight loss. During an interview on 1/24/2025 at 9:00 a.m., with Registered Dietician (RD), RD stated the menu showed which scoop size to be used and should be followed. RD stated not using the correct size scoop has the potential to affect the health of the resident by receiving less intake and potential weight loss. During a review of the facility's policy and procedure (P&P) titled, Menus, dated April 2014, the P&P indicated, food served should adhere to the written menu.

Based on interview and record review, the facility failed to: 1. Obtain blood pressure readings to determine if three of three sampled residents (Resident 36, Resident 65 and Resident 75) have orthostatic hypotension (a form of low blood pressure that happens when standing after lying down or sitting). This deficient practice had the potential for Resident, 36, 65, and 75 to experience a delay in interventions if they were positive for orthostatic hypotension. Findings: a. During a review of Resident 36's Admission Record (Face Sheet), it indicated Resident 36 was readmitted on [DATE] with diagnoses that included failure to thrive (someone who is not developing and growing normally), muscle weakness, muscle wasting (loss of muscle mass and strength), and hypotension (low blood pressure). During a review of Resident 36's Minimum Data Set ([MDS]- a resident assessment tool), dated 10/20/2024, the MDS indicated Resident 36 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn). During a review of Resident 36's Care Plan, dated 10/21/2024, it indicated that Resident 36 was at risk for decreased cardiac output (the amount of blood the heart pumps in one minute), and the intervention included to alert the provider if orthostatic blood pressure was positive. During a review of Resident 36's Order Summary Report, it indicated Resident 36 to have orthostatic blood pressure monitored every Saturday during the day shift. During a review of Resident 36's Blood Pressure Summary, dated 01/2025, Resident 36 had the following blood pressure recorded: 1/4/2025 8:06 a.m. 98/63 lying 1/4/2025 2:00 p.m. 101/64 lying 1/4/2025 3:35 p.m. 105/64 1/4/2025 4:29 p.m. 105/64 standing 1/11/2025 9:49 a.m. 97/62 lying 1/11/2025 1:06 p.m. 102/58 lying 1/11/2025 4:10 p.m. 123/71 lying 1/11/2025 4:28 p.m. 116/59 1/11/2025 4:51 p.m. 116/59 sitting 1/18/2025 2:47 a.m. 101/55 1/18/2025 9:41 a.m. 99/58 lying 1/18/2025 12:16 p.m. 105/64 lying 1/18/2025 4:36 p.m. 116/74 sitting b. During a review of Resident 65's Admission Record (Face Sheet), it indicated Resident 65 was admitted on [DATE] with diagnoses that included muscle weakness, unsteadiness on feet, and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 65's Care Plan, dated 5/10/2024, it indicated that Resident 65 had ineffective peripheral tissue perfusion (delivery of oxygen to body's arms and legs), and the intervention included to alert the provider if orthostatic blood pressure was positive. During a review of Resident 65's Order Summary Report, it indicated Resident 65 to have orthostatic blood pressure monitored every Saturday during the day shift. During a review of Resident 65's Blood Pressure Summary, dated 01/2025, Resident 65 had the following blood pressure recorded: 1/4/2025 11:54 a.m. 112/69 sitting 1/4/2025 2:30 p.m. 114/75 lying 1/11/2025 8:10 a.m. 105/68 sitting 1/11/2025 8:11 a.m. 105/68 sitting 1/11/2025 11:24 p.m. 112/72 lying 1/18/2025 8:57 a.m. 117/63 sitting 1/18/2025 12:33 p.m. 110/65 lying During an interview on 1/23/2025 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated orthostatic blood pressures are taken as ordered by the physician on the specified day and shift. LVN 1 stated the process of taking orthostatic blood pressure was to take a blood pressure when the resident was lying down and then having them sit up, wait 3-5 minutes and take another blood pressure reading. If the resident could stand, they would also take one with the resident standing. LVN 1 stated the orthostatic blood pressure needs to be taken in the order of lying, sitting and standing because they are measuring a change in blood pressure when getting up. During a concurrent interview and record review on 1/23/2025 at 11:15 a.m. with LVN 1, Resident 36 and 65's Blood Pressure Summary were reviewed for 1/4/2025, 1//11/2025, and 1/18/2025. LVN 1 stated based on the times the blood pressure readings were taken and the position the residents were in, a true orthostatic blood pressure reading was not taken on the ordered days. LVN 1 stated it was important to have orthostatic blood pressure be taken correctly so staff can see if there was a change and if so, would need to alert the doctors so they can provide interventions. During a review of the facility's policy and procedure, titled Orthostatic Hypotension, dated 1/1/2012, it indicated orthostatic vital signs would be taken and recorded when ordered by the physician. The procedure for taking orthostatic blood pressure starts with the resident lying down and taking a set of blood pressure, then the resident would either sit or stand and have another blood pressure taken again after 3 minutes. If there was a drop in systolic blood pressure of 20 millimeters of mercury (mm Hg) or a 10 mmHg drop in your diastolic blood pressure within three minutes of standing up, the resident has orthostatic hypotension. 47042 b. During a review of Resident 75's Admission Record, the Admission Record indicated Resident 75 was initially admitted to the facility on [DATE] and last readmitted [DATE]. Resident 75's diagnoses included anxiety disorder (persistent and excessive worry that interferes with daily activities), unspecified psychosis ((a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). During a review of Resident 75's history and physical (H&P), dated 12/14/2024, the H&P indicated Resident 75 did not have the capacity to understand and make decisions. During a review of Resident 75's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/20/2024, the MDS indicated Resident 75 needed maximal assistance on staff for activities of daily living (ADLs) such as toileting, dressing, showering, and positioning. During a concurrent interview and record review on 1/23/2025 at 3:00 p.m. with Director of Nursing (DON), Resident 75's Medication Administration Record (MAR), dated December 2024 and January 2025 were reviewed. The MAR indicated monitor orthostatic blood pressure every week on Saturday for anti-psychotic medication use. Take and record BP lying, sitting and standing if able to do so. Notify MD if noted decline of 20 mmHg or more in SBP or a 10 mmHg in DBP. MAR showed on 12/14/24, 12/21/24, 12/28/24, 1/4/25, 1/11/25 and 1/18/25 only SBP was recorded. DON stated the order showed to take and record orthostatic BP every Saturday, which included parameters to notify the doctor for SBP and DBP. DON stated the record only showed the SBP. DON stated that was not the correct way of documenting BP's. DON stated there would be no way to determine if there was a trend in the DBP and to notify the doctor. DON stated it was important to follow the doctor orders and document correctly. DON stated the resident could potentially lead to dizziness, falls or other health issues. During a review of the facility's policy and procedure, titled Orthostatic Hypotension, dated 1/1/2012, it indicated orthostatic vital signs would be taken and recorded when ordered by the physician.

Based on observation and interview, the facility failed to: 1. Complete a change of condition after Resident 79 self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag), for the second time. This failure resulted in Resident 79 not having a detailed explanation of what occurred and if the physician and responsible party was notified. Findings: During a review of the admission record, the admission record indicated Resident 79 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal and can slow or block the flow of urine from the bladder), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life). During a review of the Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 79 usually had the ability to express ideas and wants, and usually had the ability to understand others. The MDS also indicated Resident 79 was independent with self-care and mobility (walking). During a review of Resident 79's Progress Notes, dated 1/18/2025, the Progress Notes indicated Resident 79 self-removed his catheter. During a review of the Change in Condition Evaluation form, dated 1/13/2025, the Change in Condition indicated Resident 79 had abdominal pain due to foley catheter removal. During a review of the facility's policy and procedure (P&P) titled, Change of Condition Notification, revised April 2015, the P&P indicated VI. Documentation D. Documentation pertaining to a change in the resident's condition will be maintained in the resident's medical record and on the Twenty-Four-Hour report. During a concurrent interview and record review on 1/23/2025 at 3:45 PM with Registered Nurse (RN) 1, Resident 79's Progress Notes, dated 1/18/2025 were reviewed. RN 1 stated the physician and responsible party were notified per the notes, but the Change in Condition form was not completed. RN 1 stated that a resident removing their catheter should have a Change in Condition form completed be completed per facility protocol.

Based on interview and record review, the facility failed to: 1. Update the careplan for one of four sampled residents (Resident 79) after the resident self-removed his indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine into a drainage bag) on two occasions. This failure had the potential to cause complications such as urinary tract infections (UTI - an infection in the bladder/urinary tract), bleeding, and/or pain with urination. Findings: During a review of Resident 79's Admission Record, the Admission Record indicated the facility admitted Resident 79 on 11/15/2024 and readmitted on [DATE], with diagnoses that included benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal and can slow or block the flow of urine from the bladder), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and anxiety disorder (a mental health condition characterized by excessive and persistent worry, fear, and unease that can interfere with daily life). During a review of the Minimum Data Set (MDS - a resident assessment tool), the MDS indicated Resident 79 usually had the ability to express ideas and wants, and usually had the ability to understand others. The MDS also indicated Resident 79 was independent with self-care and mobility (walking). During a review of Resident 79's Progress Notes, dated 1/13/2025 , the Progress Notes indicated Resident 79 self-removed his catheter. During a review of Resident 79's Progress Notes, dated 1/18/2025, the Progress Notes indicated Resident 79 self-removed his catheter. During a review of Resident 79's Care Plan focusing on the Indwelling Catheter, initiated on 11/21/2024 and revised on 11/26/2024, the care plan indicated a goal for Resident 79 included, The resident will be/remain free from catheter-related trauma . During a review of Resident 79's Order Summary Report dated 1/23/2025, the report indicated to change Foley (indwelling) catheter per schedule Q (every) month, as needed for leaking, occlusion, dislodgement . During a concurrent interview and record review on 1/23/2025 at 3:55 p.m. with Registered Nurse (RN) 1, Progress Notes, dated 1/13/2025 and 1/18/2025 were reviewed. RN 1 stated the physician was notified on 1/13/2025 of the catheter dislodgement. There should have been a revision of the care plan to address that the resident pulled the catheter out and monitoring to prevent it happening again. When it happened again on 1/18/2025, the physician was notified, but no care plan revision was done. The physician ordered the catheter to be re-inserted. There should have been monitoring for bleeding and low urine output. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, revised November 2018, the P&P indicated C. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition; During a review of the facility's P&P titled, Indwelling Catheter, with revised date: 9/1/2014, the P&P indicated, Update the resident's Care Plan as necessary.

Based on observation, interview and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and review the pest control company's inspection report to ensure the kitchen is free from cockroaches (small insects that cause spread of bacterial infection) for 73 of 73 vulnerable (susceptible to physical or emotional attack or harm) residents. This failure placed the 73 vulnerable residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such cockroaches, mosquitos, ticks, and fleas), and had the potential for the 73 vulnerable residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On February 20, 2020 at 10:30 AM and at 1:57 PM, respectively, the Los Angeles County Department of Public Health Environmental Health Specialist ((EHS) an environmental inspector who performs inspection of various facilities and properties to determine compliance with applicable State laws and County Ordinance Code sections) and the surveyor observed live cockroaches in the facility's kitchen. On February 20, 2020 at 4:24 PM, the Department declared an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment of death of a resident), and notified the facility's Administrator, Director of Nursing (DON), and Dietary Services Supervisor (DSS). On February 22, 2020 at 12:45 PM, the Department removed the IJ and notified the Administrator and the DON after verifying and confirming on-site that the facility had implemented the acceptable written plan of action as follows: 1. Kitchen kept closed and not used from February 20, 2020 at 12:30 PM. 2. Trashed all opened and not sealed food found in the kitchen during the infestation. 3. Maintenance staff started deep cleaning the kitchen, which includes moving appliances and deep cleaning surfaces. 4. Called Pest Control Company and the company did pest control treatment in the kitchen starting on February 20, 2020 at 7:30 PM. 5. Identified food preparation alternative location was at the conference room. Registered Dietician spear heading the food preparation together with the Dietary Supervisor following the emergency menu. Sanitized the place. Using disposable utensils/ dishes. Emergency menu is comprised of food that were readily served and does not need to be heated according to our policy. 6. Utilized emergency menu during the kitchen closure. 7. Posted emergency menu during the kitchen closure. Findings: A review of the facility's census report, dated February 19, 2020, indicated there were 73 in-house residents in the facility. During an interview with the EHS in the facility on February 20, 2020 at 12:48 PM, the EHS stated she has observed five live and four dead German cockroaches (a small kind of cockroaches), and fecal spotting from the cockroaches. The EHS found the four dead cockroaches under the dishwasher in the kitchen and five live cockroaches under the steam table. During a tour and an observation of the kitchen with the EHS on February 20, 2020 at 12:53 PM, there were two dead cockroaches and one empty casing (hatched egg which could contain 40 or more baby cockroaches) found under the dishwasher. During an interview with the Dietary Services Supervisor (DSS) on February 20, 2020 at 1:22 PM, the DSS said EHS banged on the dishwashing sink, and pointed to the DSS the dead cockroaches found underneath the sink and the live cockroaches found under the steamtable. During an observation of the dry storage area with the DSS on February 20, 2020 at 1:39 PM, in between the salt tank for the water softener and the corner of the wall, there was a black small egg-shaped object. When it was being swept out from that corner with a plastic broom, the egg shape object disintegrated. A black-brown liquid came out of the egg shape object with a stench originating from it. During an observation of the space between the reach-in freezer and the wall adjacent to the DSS's office on February 20, 2020 at 1:46 PM, one dead cockroach was found. During a concurrent re-observation and interview of the shelf under the steamtable, with the cook (Cook 1), on February 20, 2020 at 1:57 PM, a live cockroach (German cockroach) crawled out on the metal pipe from a hole on the shelf under the steamtable. The metal pipe came from under the floor through the hole on the shelf under the steamtable. Cook 1 stated one live cockroach found on the metal pipe crawling out from the hole. Cook 1 raised her voice in surprise to confirm the live roach. During a further observation of the metal pipe under the steamtable on February 20, 2020 at 2:05 PM with Cook 1 and the Dietary Aide (DA) 1, DA 1 pointed out a live cockroach crawling between the feet of the surveyor. The surveyor called the DSS to show the live cockroach. The DSS stepped on the live cockroach to crush it. During a review of the pest control company service report for the past 6 months, the following were indicated: On August 15, 2019 and timed at 7:15 PM (Order ) - roach infestation, product applied for all types of pests (a destructive insect or other animal that attacks crops, food, livestock, etc.); On August 22, 2019 and timed at 7:15 PM (Order ) - kitchen was serviced, product applied without targeted pests; On September 10, 2019 and timed at 7:31 PM (Order ) - German roach infestation, product was applied without targeted pests; On October 24, 2019 and timed at 7:14 PM (Order - kitchen was serviced, product applied without targeted pests; On January 2, 2020 and timed at 7:06 PM (Order ) - kitchen was serviced, product applied without targeted pests. During an interview with the Maintenance Supervisor (MS) on February 26, 2020 at 10:32 AM, the MS said he is responsible for the pest control in the facility including the kitchen. MS stated he received the pest control company service report and did not review the service reports received. MS added the service reports were important to know about the pest control issues in the facility, and to be able to treat the issue appropriately. MS also added the pest control company has not provided him and the facility of any pest control monthly assessment even the initial assessment for the facility. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, retrieved on February 26, 2020 at http://publichealth.lacounty.gov/eh/docs/Specialized/Vector_Management/cockroachMgmt.pdf, indicated the cockroaches may become pests in a structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that love outdoors come into contact with human excrement in sewers or with per dropping, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Center for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on July 2019 and retrieved on February 26, 2020 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in healthcare facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as vector (carrier that transfer an infectious organism from one host to another). During a review of the facility's policy and procedure for Pest Control, revised January 1, 2012, indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests. The Administrator arranges for pest control company to visit and inspect the facility once a year. The pest control company will carry out inspection, evaluation, submit, and carry kitchen was serviced, product applied without targeted pests; actions needed to rid the facility and its grounds of any environmental pests.

Based on observation, interview and record review, the facility failed to prepare and serve food for lunch in a sanitary kitchen environment when cockroaches were found in the kitchen during lunch preparation for 67 of 73 vulnerable residents. This failure placed the 67 vulnerable residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such cockroaches, mosquitos, ticks, and fleas), and had the potential for the 67 vulnerable residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On February 20, 2020 at 10:30 AM and at 1:57 PM, respectively, the Los Angeles County Department of Public Health Environmental Health Specialist (EHS, an environmental inspector who performs inspection of various facilities and properties to determine compliance with applicable State laws and County Ordinance Code sections) and the surveyor observed live cockroaches in the facility's kitchen. On February 20, 2020 at 4:24 PM, the Department declared an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment of death of a resident), and notified the facility's Administrator, Director of Nursing (DON), and Dietary Services Supervisor (DSS). On February 22, 2020 at 12:45 PM, the Department removed the IJ and notified the Administrator and the DON after verifying and confirming on-site that the facility had implemented the acceptable written plan of action as follows: 1. All residents that was served food (67 residents) for lunch will be monitored for any abdominal discomfort i.e., nausea, vomiting, diarrhea, abdominal pain and fever to start 2/20/20 at 3-11 x 72 hours. 2. If above sign and symptom is observed, the attending physician (MD) will be notified as well as responsible party immediately. 3. Emergency Resident Council Meeting will be held tomorrow 02/21/20 at 10am to inform residents at the facility regarding kitchen non-operational use. 4. Identified food preparation alternative location which is at the conference room. Registered Dietician spear heading the food preparation together with the Dietary Supervisor following the emergency menu. Sanitized the place. Facility is using disposable utensils/ dishes. Emergency menu is comprised of food that are readily served and does not need to be heated according to our policy. 5. Utilize emergency menu 6. Posted emergency menu Findings: During an entrance conference with the Administrator and the DON on February 20, 2020 at 12:37 PM, the DON said there were 73 in-house residents in the facility. There were six residents on gastric tube feeding (liquid food through a tube inserted to the stomach through the abdomen). During an interview with the EHS in the facility on February 20, 2020 at 12:48 PM, the EHS said she has observed five live and four dead German cockroaches (a small kind of cockroaches), and fecal spottings from the cockroaches. The EHS found the five live cockroaches under the steam table. The EHS found the four dead cockroaches under the dishwasher in the kitchen. During a tour to the kitchen with the EHS on February 20, 2020 at 12:53 PM, racks of finished lunch trays were found along the hallways. The surveyor observed directly the location where the live and dead cockroaches where found. There were two dead cockroaches and one empty casing (hatched egg which could contain 40 or more baby cockroaches) found under the dishwasher. There were no live cockroaches found. During an interview with the Dietary Services Supervisor (DSS) on February 20, 2020 at 1:22 PM, the DSS said the EHS banged on the dishwashing sink and pointed to the DSS the dead cockroaches found underneath the sink. The EHS also pointed to DSS the live cockroaches found under the steamtable. The DSS stated what the EHS pointed to her under the dishwasher and the steamtable sink. During an observation of the dry storage area with the DSS on February 20, 2020 at 1:39 PM, in between the salt tank for the water softener and the corner of the wall, the surveyor observed a black small egg-shaped object. When it was being swept out from that corner with a plastic broom, the egg shape object disintegrated. A black-brown liquid came out of the egg shape object with a stench originating from it. During an observation of the space between the reach-in freezer and the wall adjacent to the DSS's office on February 20, 2020 at 1:46 PM, one dead cockroach was found. During a concurrent re-observation and interview of the shelf under the steamtable, with Cook 1, on February 20, 2020 at 1:57 PM, a live cockroach (German cockroach) crawled out on the metal pipe from a hole on the shelf under the steamtable. The metal pipe came from under the floor through the hole on the shelf under the steamtable. Cook 1 stated one live was cockroach found on the metal pipe crawling out from the hole. Cook 1 raised her voice in surprise to confirm the live roach. During a further observation of the metal pipe under the steamtable on February 20, 2020 at 2:05 PM with Cook 1 and the Dietary Aide (DA) 1, DA 1 pointed a live cockroach crawling between the feet of the surveyor. The surveyor called the DSS to show the live cockroach. The DSS stepped on the live cockroach to crush it. During a follow up interview with the DSS on February 20, 2020 at 4:05 PM, the DSS said she met the EHS in the kitchen at around 10:30 AM. The EHS started banging on the sink near the dishwasher and found the cockroach problem. DSS stated when EHS informed her of the cockroach infestation, lunch was prepared and ready for tray line (serving the cooked food on trays for distribution to the residents). The DSS stated the cockroach infestation made the facility's kitchen unsanitary. The DSS stated the food prepared in the unsanitary kitchen was considered contaminated. The DSS further said she (DSS) still decided to serve the contaminated food for lunch for the 67 vulnerable residents. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation, retrieved on February 26, 2020 at http://publichealth.lacounty.gov/eh/docs/Specialized/Vector_Management/cockroachMgmt.pdf, indicated the cockroaches may become pests in a structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that love outdoors come into contact with human excrement in sewers or with per dropping, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Center for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on July 2019 and retrieved on February 26, 2020 at https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in healthcare facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as vector (carrier that transfer an infectious organism from one host to another).

Based on observation, interview, and record review, the facility failed to maintain an air temperature range of 71 to 81-degree Fahrenheit ((°F) a unit of measure) for 11 of the 88 resident rooms and ensure the heater, which provided warmth to 28 of 28 residents who occupied these 11 rooms, was functioning. One of the 28 sampled residents (Resident 1) had an asthma attack or exacerbation (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus (a slimy substance) which makes it difficult to breathe) due to the cold temperature. Three of the 28 sampled residents (Resident 2, 3, and 4) complained their respective rooms were cold, especially at night, and they required extra blankets to keep them warm. According to an online article by the Mayo Clinic titled, Asthma-[DIAGNOSES REDACTED]. The article indicated wintertime was an especially hard with people with asthma, as studies have indicated asthma hospital admission increases during the winter months. The article indicated cold air increases mucus production, which triggers asthma attacks and allergy attack. Cold dry air was listed as an asthma trigger. This deficient practice resulted in Resident 1 being transferred via 911 (an emergency service) to the general acute care hospital (GACH) and admitted to GACH's telemetry unit (a unit in with several patient rooms with vital sign monitors that continuously transmit data, such as your heart rate, breathing, and blood pressure, to a nearby location) due to difficulty breathing; and Resident 2, 3, and 4 to live and sleep in a cold environment. This deficient practice had the potential for Resident 1 to experience complications from an asthma attack, which included cessation (to stop) of breathing and death. Findings: A review of the air temperatures from a weather website (weather.com) for the city in which the facility was located indicated from 12/13/19 through 12/19/19, the air temperature ranged from 64 °F to 70 °F during the day and 44 °F to 55 °F during the night. The highest air temperature during the day on 12/19/19 for the city in which the facility was located was 66 °F. On 12/19/19 at 7:56 a.m., during an interview with Resident 1's family member (FM 1), FM 1 stated that the facility was always cold every time she visited the resident (no date specified). FM 1 stated she complained to the management (no name or title specified) about the resident's room being cold but nothing was done about it. FM 1 stated that on one of her visits (on 12/16/19), she noticed that Resident 1 was shaking (in the resident's room), the staff could not get the resident's vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function), and the resident had to be sent to the hospital by 911. On 12/19/19 at 9 a.m., during an observation while conducting a tour of the facility and a concurrent interview with the Maintenance Supervisor (MS), the MS measured the air temperatures of the resident rooms, Rooms 2 to 11, and stated the room temperatures were as follows: rooms [ROOM NUMBERS] were 67°F Rooms 2, 5, 7, 8, and 10 were 68°F Rooms 6, 9 and 11 were 69°F The MS adjusted the thermostats (a device that automatically regulates temperature, or that activates a device when the temperature reaches a certain point) in the residents' rooms but the air temperatures did not change. The MS stated he needed to go to the roof to check the heater. On 12/19/19 at 10:55 a.m., during an interview, the MS stated he checked the residents' room air temperatures daily and he maintained a temperature log. The MS stated his routine inspection entailed checking the air temperatures in the hallways and one or two resident rooms. The surveyor asked the MS to review with him the temperature log for the facility's hallway and resident rooms. The MS provided air temperature logs with readings for March, April, July, August, September, and (MONTH) but without a year indicated. The MS stated he had not checked the temperatures in the resident rooms recently (time period not specified) so he could not tell how long the air temperatures in the resident rooms had been low (cold). On 12/19/19 at 12:15 p.m., during the interview, the Administrator stated she had not received any complaints from any residents or visitors regarding the air temperature in the facility. The Administrator stated the facility's goal was to provide residents with a comfortable and home-like environment. The Administrator stated residents' room air temperature should be maintained within an acceptable range of 71 to 81°F. On 12/19/19 at 1 p.m., during an interview with the Administrator and the MS, the MS stated the heater was not functioning due to loosened and old wires. 1. A review of Resident 1's Admission Face Sheet indicated the facility admitted Resident 1 on 5/15/18 with a [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), Resident Assessment and Care Screening, dated 12/23/19, indicated the resident cognitive (thought process) skills for decision-making were severely impaired. A review of the History and Physical record, dated 12/20/19, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's nurse's note, dated 12/16/19 and timed at 10:48 a.m., indicated a licensed nurse documented Resident 1 was transferred to GACH's Emergency Department (ED) due to a pronounced cough, twitching episode, shaking, congestion and body pains. A review of GACH's ED note, dated 12/16/19 and timed at 9:21 p.m., indicated the facility sent Resident 1 to ED due to a productive cough with thick yellow sputum (mixture of saliva (watery liquid secreted into the mouth by glands) and mucus) coughed up from the respiratory tract (the passage formed by the mouth, nose, throat, and lungs, through which air passes during breathing)), and an apparent difficulty in breathing. The ED note indicated Resident 1 was admitted to the telemetry unit for further observation and work up. A review of Resident 1's Medication Administration Record [REDACTED] 2. On 12/19/19 at 11:10 a.m., during an interview, Resident 2 stated it was cold the night before (12/18/19) and it was still cold in the building that morning. A review of Resident 2's MDS, dated [DATE], indicated the resident's cognitive skills for decision-making were moderately impaired and the resident was able to make self-understood and understand others. 3. On 12/19/19 at 11:20 a.m., during an interview, Resident 3 stated the facility was always cold especially in her room. Resident 3 stated she had to use two blankets at night. A review of Resident 3's MDS, dated [DATE], indicated the resident's cognitive skills for decision-making were intact and the resident was able to make self-understood and understand others. 4. On 12/19/19 at 11:40 a.m., during an interview, Resident 4 stated he was cold all the time in the facility, but especially at night. Resident 4 stated he would ask the staff for extra blankets (at night). A review of Resident 4's MDS, dated [DATE], indicated the resident's cognitive skills for decision-making were moderately impaired and the resident was able to make self-understood and understand others. A review of the facility's policy and procedure titled, Resident Rooms and Environment, with a revised dated of 1/1/2012 indicated the facility would provide residents with a safe, clean, comfortable and homelike environment with close attention to comfortable temperature.

Based on interview and record review, the facility failed to follow its policy for fall management, provide necessary supervision and implement resident's care plans for fall prevention for two of three sampled residents (Residents 1 and 2). Residents 1 and 2 were assessed as a high risk for falls, had a history of [REDACTED]. This deficient practice resulted in Residents 1 and 2 falling sustaining injuries that required a transfer to general acute care hospitals (GACH), undergoing surgeries and receiving strong narcotic pain medications. Resident 1 sustained a right femur (thigh bone) fracture (broken bone) and had an ORIF surgery (a surgery to repair a broken bone with screws, plates, rods, or pins to hold the broken bones together), and Resident 2 had a right femur fracture and underwent a surgical repair with an intramedullary rod placement (a metal rod used for the treatment of [REDACTED]. Findings: a. A review of Resident 1's Admission Record indicated that Resident 1 was initially admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 1' [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Sets (MDS), a standardized assessment and care-screening tool, dated 6/18/18 and 12/17/18, indicated Resident 1's Brief Interview for Mental Status ((BIMS) a screening tool to assess cognition (thought process)) was severely impaired with a score of 01, had an unsteady gait (walking) and was only able to stabilize with staff assistance and required a one-person physical assist with transferring and utilized a wheelchair as a mobility device. The MDS indicated Resident 1 was incontinent (inability to control) of bladder and bowel function. A review of Resident 1's Fall Risk Assessment, dated 6/18/18 indicated the resident had total score of 11. According to the Fall Risk Assessment, a total score of 10 or more represents a high risk. A review of Resident 1's history and physical (H/P), dated 7/17/18, indicated Resident 1 did not have the capacity to understand and make decisions. A review of a Change of Condition (C[NAME]) note, dated 9/13/18, indicated at 8 a.m., on the same day ,Resident 1 was observed with a right lateral lower leg skin tear. The C[NAME] note indicated when Resident 1 was asked how did she sustained a skin tear, Resident 1 could not answer. A review of an Interdisciplinary Team ((IDT) a meeting with multi-disciplines to develop care that meets the patient needs and goals) Conference Record, dated 9/14/18, indicated Resident 1 was confused, but could understand and be understood at times. The IDT note indicated Resident 1's right lower leg skin tear was due to hitting the wheelchair footrest, which had Resident 1's leg caught up. The IDT's plan included removing the foot pedals from Resident 1's wheelchair. A review of Resident 1's Fall Assessment, dated 10/24/18, four months later, had improved which indicated Resident 1 had a score of 9. A review of Resident 1's Admission Assessment, dated 10/24/18, after the resident was readmitted , indicated the resident was assessed as being unsteady while standing and required total assistance from the staff with transferring and bed mobility. A review of Resident 1's Side Rail Evaluation, dated 10/24/18, indicated the resident required assistance with transferring, ambulation, and bed mobility. A review of Resident 1's plan of care, dated 10/24/18 and titled, Falls Risk Prevention and Management, Patient at risk for falls related to limited mobility, due to lack of awareness, cognitive (thought process) deficit, and unsteady gait. The staff's interventions included for the staff to provide Resident 1 with an environment that minimized hazards over which the facility had control; the bed in a low position and frequent visual checks as often as needed. The care plan also had the use of floor mats as an option, but had a line drawn through it to indicate it was not being implemented. A review of the Situation, Background, Appearance and Review ((SBAR) an internal communication tool) dated 12/20/18, indicated at 8:30 a.m., Resident 1 fell , an assessment was completed and Resident 1 was assisted back to bed and was observed with internal rotation of the right leg. A review of Resident 1's Post Fall Assessment, dated 12/20/18, indicated the resident's right leg was shorter than the left, it was immobilized (unable to move) and Resident 1 had pain to the right leg of 8 on a pain scale with 10 being the worse pain. The Post Fall Assessment indicated the [MEDICATION NAME] (natural) factors that determined the fall occurrence was Resident 1's balance and/or strength and the extrinsic (external) factors indicated falling during a transfer from the wheelchair to the bed. A review of Resident 1's Medication Administration Record [REDACTED] A review of Resident 1's Transfer Record, dated 12/20/18, indicated Resident 1 was transported to the GACH for further evaluation and treatment due to right leg pain with an internal rotation ((out of alignment)arms or legs moved toward the center of the body) post fall. A review of the GACH's Nurses' Note, dated 12/20/18 and timed at 4:12 p.m., indicated Resident 1 was admitted to a Medical-Surgical unit from the Emergency Department (ED). A review of the GACH's history and physical (H/P) for Resident 1, dated 12/22/18, indicated Resident 1 underwent an open reduction internal fixation (ORIF) of the right femur (a surgery to repair a broken bone with screws, plates, rods, or pins to hold the broken bones together), as a result of the fall. Resident 1 was hospitalized for [REDACTED]. A review of the GACH's MAR indicated [REDACTED]. On 5/17/19 at 10:15 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), stated residents who had an unwitnessed fall and constantly gets out of bed or the wheelchair, required safety measures. LVN 1 stated the safety measures included the bed being in the lowest position, fall mats on both sides of the bed, and for the staff to keep an eye on the residents who were at risk for falls. LVN 1 was asked how are the residents who were at risk for falls supervised, LVN 1 stated frequent supervision should be performed by all staff, especially the LVNs and Certified Nursing Assistants (CNAs). LVN 1 further stated when a resident falls continuously, a review of the resident's medications would be required, as well as an IDT meeting. At 12:27 p.m., on 5/17/18, during an interview, the Director of Nursing (DON) stated the facility did not have a fall program. The DON was asked how were resident falls prevented, the DON stated by placing the beds in the lowest position, and conducting one hour to two (2) hour visual checks on the residents, the DON was unable to indicate the amount of residents who required visual monitoring. The DON stated the visual monitoring log was implemented in 4/2019. During a concurrent interview and record review of the facility's hourly visual monitoring log, dated for the month of 4/2019, the DON stated the visual monitoring log did not indicate any residents' names or room numbers. The DON was asked what fall prevention measures did the facility have in place prior to 4/2019, the DON stated placing residents back to bed after breakfast for napping purposes, changing and checking residents. On 5/17/19 at 12:55 p.m., LVN 2 stated for residents who were at risk for falls and had an unwitnessed, a safe environment was provided by supervision with visual monitoring, a low bed and floor mats to prevent an additional fall. LVN 2 stated Resident 1 had an unsteady gait and required staff assistance and did not have any floor mats prior to falling. On 5/17/19 at 1:45 p.m., during an interview, the DON was asked how did the facility prevent residents from falling and when the facility did not have a fall prevention program, the DON stated the residents who were at risk for falling were transferred to a wheelchair during the day, placed close to the nurses' station and/or in activities. The DON further stated residents who were constantly walking unattended would be placed on one-on-one monitoring. b. A review of the Resident 2's Admission Record indicated the resident was initially admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident 2's [DIAGNOSES REDACTED]. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 10 with a moderately impaired cognition, an unsteady gait with only the ability to stabilize with staff assistance. According to the MDS, Resident 2 required a one-person physical assist with transferring and walking with an assistive device. The MDS indicated Resident 2 had a fall within a month prior to admission to the facility. A review of Resident 2's Admission Assessment, dated 10/28/18, indicated the resident was assessed as having a history of falls within the past six (6) months, having poor safety judgement and required limited assistance with transferring, ambulating and bed mobility. A review of Resident 2's Fall Assessment, dated 10/28/18, indicated Resident 2 had a total score of 14. According to the Fall Assessment, a total score of 10 or more represents a high risk. A review of Resident 2's care plan, dated 10/28/18 and titled, Fall Risk Prevention and Management for poor balance, lack of awareness, unsteady gait, engages in independent transfer/ambulation despite of explanation of risk and a history of falls. The staff interventions included for the staff to provide an environment that supports minimized hazards, which included low bed, call light in reach, remind the resident to use the call light and monitor for side effects of medications. A review of Resident 2's Weekly Summary, dated 1/18/19, indicated the resident was assessed as requiring a one-person physical assist with transferring. A review of Resident 2's Post Fall Assessment, dated 1/22/19, indicated The resident (Resident 2) was unable to indicate a level of pain and move extremities without pain and first aid was not provided (sic). A review of Resident 2's untimed SBAR note, dated 1/22/19, indicated the resident was found on the floor after losing his balance while attempting to go to the bathroom. According to the SBAR, the physician was notified at 7:40 p.m. and gave an order to transfer Resident 2 to the GACH and administer [MEDICATION NAME] for pain. A review of the Resident Transfer Record, dated 1/22/19, indicated Resident 2 had severe pain to the right leg and knee. The transfer record indicated Resident 2 was administered [MEDICATION NAME] 5/325 mg, one tablet orally, and was transferred to a GACH. A review of Resident 2's Therapy Post-Fall Screen, dated 1/23/19 and timed at 5:45 p.m., indicated Resident 2 did not have any root cause related to falling. A review of Resident 2's IDT Conference Note, dated 1/23/19, indicated Resident 2 ambulated independently unsupervised and lost his balance and fell while attempting to go to the bathroom. A review of the GACH's physicians' progress note, dated 1/23/19, indicated Resident 2 had x-rays of the right hip secondary to right hip pain. The x-ray report indicated a displaced intertrochanteric (where the thigh and hip connect) [MEDICAL CONDITION] (center) right femur. The physician's progress note indicated Resident 2 underwent surgery of a corrective surgery with an intramedullary rod placed into Resident 2's right femur and required a 7-day hospital stay. On 5/17/19 at 10:10 a.m., during an interview, LVN 3 stated Resident 2 ambulated slowly and possibly had some type of physical foot deformity (abnormality) and fell during the night. A review of the facility's revised policy, dated 11/7/18 and titled, Fall Management Program, indicated the resident's risk for fall was assessed by a Licensed Nurse by completing the Admission Assessment form and by the IDT utilizing the Resident Assessment Instrument (RAI) process quarterly, annually, and significant change in condition identification. According to the policy, indicated residents who sustains multiple falls as defined as more than one fall in a day, week, or month, will be considered a high risk and as a result may sustain a major injury, these residents may require more frequent observation of activities and whereabouts.

Based on interview and record review, the facility failed to provide the necessary care and services to ensure abnormal laboratory results were reported timely to the physician and physician's orders [REDACTED]. Resident 1 had abnormal critical laboratory results with an altered mental status (AMS) and the physician ordered a STAT (immediately) repeated platelet (component of blood whose function is to stop bleeding) count laboratory test that was not done as ordered. Resident 1 was sent for [MEDICAL TREATMENT] treatment (process of removing waste and excess water from the blood due to kidney failure) with a change in condition (C[NAME]). These deficient practices resulted in Resident 1's AMS worsening after being transported to a [MEDICAL TREATMENT] center. Upon arrival to the center, 911 was called due to the resident having an altered mental status (AMS) and was transported to general acute care hospital (GACH) where the resident expired due to cardiopulmonary arrest, two days after hospitalization . Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on (MONTH) 26, 2012 and last readmitted on (MONTH) 14, (YEAR). Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool and a care-screening tool, dated (MONTH) 13, (YEAR), indicated the resident's was cognition was intact (ability person to think, reason, and remember). According to the MDS, Resident 1 was highly involved in activity of daily living ((ADLs), eating, transferring, hygiene, and dressing), but required a one-person physical assist. A review a Change of Condition (C[NAME]) Note, dated (MONTH) 16, (YEAR) and timed at 6:30 a.m., indicated Resident 1's primary physician was called to inform of the resident's abnormal laboratory results, but the physician did not call back. The medical director was called and ordered Stat (immediate) platelet (component of the blood that helps to stop bleeding) count. A nurses' note, dated (MONTH) 16, (YEAR) and timed at 9:15 a.m., indicated Resident 1 was alert and verbally responsive, but refused to eat breakfast and take medications (7 a.m. and 9 a.m.) respectively. Resident 1's Primary Physician (PP 1) was notified with no new order (NNO). A review of a S[NAME] 341 (report of suspected dependent adult/elder abuse), dated (MONTH) 23, (YEAR), indicated 911 was called due to Resident 1 having an AMS. During an interview on (MONTH) 25, (YEAR), at 11:08 a.m., SW 1 stated Resident 1 was found alone and unsupervised in the lobby of the [MEDICAL TREATMENT] center, in a slumped position in the wheelchair, by the [MEDICAL TREATMENT] center's technician. SW 1 stated when she called the facility to inquire why the resident was transported in that condition, Registered Nurse 2 (RN 2) would not let her speak with the resident's charge nurse. SW 1 stated RN 2 stated the facility had received critical laboratory results of an elevated platelet count, for Resident 1 and PP 1 was not responding to the calls and the Medical Director (MD 1) was notified and ordered repeated Stat laboratory tests. SW 1 stated the facility did not send the critical laboratory results with Resident 1 to the [MEDICAL TREATMENT] center. SW 1 stated the resident died on (MONTH) 18, (YEAR) at the hospital. On (MONTH) 25, (YEAR), at 11:15 a.m., during an interview, the [MEDICAL TREATMENT] center's registered nurse (RN 1) stated on (MONTH) 16, (YEAR), the [MEDICAL TREATMENT] center technician informed her that Resident 1 looked bad. RN 1 stated upon assessment, the resident was lethargic (weak), not verbally responsive, and was just moaning. RN 1 stated they never transferred the resident to the [MEDICAL TREATMENT] chair to receive [MEDICAL TREATMENT], but called 911 to transport the resident to the GACH. During an interview on (MONTH) 25, (YEAR) at 2:30 p.m., Licensed Vocational Nurse 1 (LVN 1) from the facility stated someone from the GACH had contacted RN 2 and stated Resident 1 had expired. On (MONTH) 25, (YEAR) at 2:45 p.m., during an interview, Certified Nurse Assistant 1 (CNA 1) stated on (MONTH) 16, (YEAR), Resident 1 looked different and weak. CNA 1 stated the resident stated, I am okay, I am okay twice when CNA 1 asked the resident how he was doing. CNA 1 stated the resident's head was leaning to one side and had a spitting-like behavior. CNA 1 stated she informed LVN 1 of the resident's condition and behavior. CNA 1 stated Resident 1 would usually assist with transfers and ADLs. However, on that day ([DATE], (YEAR)), Restorative Nurse Assistant 1 (RNA 1) had to assist CNA 1 with transferring the resident from the bed to the chair, because the resident was weak and not able to assist. During an interview on (MONTH) 25, (YEAR) at 3 p.m., RNA 1 stated CNA 1 had requested her assistance to transfer Resident 1 from the bed to the wheelchair on (MONTH) 16, (YEAR). RNA 1 stated the resident looked a little sick, because the resident usually required a one-person physical assist, but that day the resident did not help at all. During an interview on (MONTH) 25, (YEAR) at 3:05 p.m., LVN 1 stated on (MONTH) 16, (YEAR), no one had reported to her that Resident 1 had C[NAME]. LVN 1 stated the resident did look a little different, not his usual, and had refused all morning medications and breakfast. LVN 1 stated she checked the resident's vital signs and they were normal. On (MONTH) 25, (YEAR) at 3:10 p.m., during an interview, RN 2 stated Resident 1's platelets count on (MONTH) 15, (YEAR), was critically low at 13,000 (normal reference range (NRR) is between 150,000 and 450,000 platelets per microliter (pm)) and the white blood cell count ((WBC), cells that help fight infections) were high at 14.28 (NRR is 4,500 and 10,000 cells pm), indicative of an infection and/or disease. RN 2 stated LVN 2 informed MD 1 about Resident 1's critical laboratory results on (MONTH) 16, (YEAR), at 7 a.m. and MD 1 ordered Stat repeated platelets count. RN 1 stated the resident told him I am okay during the assessment. RN 1 verified the critical laboratory results were faxed to the physician on (MONTH) 15, (YEAR) at 11:01 p.m., the day before the resident had a C[NAME] and went to [MEDICAL TREATMENT]. RN 1 was not able to state why there was a delay in communicating Resident 1's abnormal laboratory results to the physician. RN 2 stated he never communicated to LVN 1 about the residents' abnormal laboratory results and that the resident needed a repeated blood drawn for platelets count. RN 1 also stated when the phlebotomist (a health professional trained in drawing/collecting blood) came to draw the blood, Resident 1 had already been transported to the [MEDICAL TREATMENT] center. During an interview on (MONTH) 25, (YEAR) at 4:50 p.m., RN 3 stated she received a call from the laboratory and was informed that Resident 1's platelets were critically low at 13,000 microliters (mcL). RN 3 stated she forgot to document on the nurses notes about the critical laboratory results, but endorsed the critical laboratory results to LVN 2 during the shift change, but also forgot to document she had endorsed the information. On (MONTH) 25, (YEAR) at 5:10 p.m., during an interview, the Director of Nurses (DON) stated LVN 1 had informed the [MEDICAL TREATMENT] Transport Driver to check on Resident 1 because the resident did not look good. The DON stated which was unusual, because Resident 1 was always feisty (lively, determined, and courageous). During a telephone interview on (MONTH) 27, (YEAR) at 12 p.m., LVN 2 stated RN 3 never endorsed Resident 1's critical laboratory results to her at shift change. LVN 2 also stated it was the responsibility of the nurse, who received the critical laboratory results, to immediately contact the resident's attending physician. On (MONTH) 27, (YEAR) at 1:50 p.m., during an interview, the Transport Driver (TD) stated when he went to pick up Resident 1 on (MONTH) 16, (YEAR), the resident was not ready. The TD stated the resident had approximately six facility's employees attending to the resident when he arrived. The TD stated two employees were talking to the resident, but the resident was not responding back. The TD stated he walked back to the nurses' station and informed the resident's charge nurse that the resident did not look good and asked the resident's charge nurse if the resident was still okay to go for a [MEDICAL TREATMENT] treatment. The charge nurse stated it was the resident's [MEDICAL TREATMENT] day and that the resident needed to go to [MEDICAL TREATMENT]. A review of Resident 1's laboratory results, dated (MONTH) 15, (YEAR), indicated a laboratory employee had called RN 3 at 10:34 p.m., on (MONTH) 15, (YEAR), regarding the critical results of WBC count of 14.28 mcL and [DIAGNOSES REDACTED]s count of 10.19 mcL (NRR is 1.5 to 8.0 mcL). The document further indicated RN 3 read back and verified the critical laboratory results to the laboratory employee. A review of the facility's policy titled, Laboratory Critical Values dated (MONTH) 1, 2012, indicated that the licensed nurse would immediately call the attending physician with the laboratory results. A review of the GACH's Hospital course summary dictation undated note, indicated Resident 1 presented to the ER from the [MEDICAL TREATMENT] center with AMS. Resident 1 was identified to be hypoxic (deficiency in the amount of oxygen reaching the tissues) and lethargic (weak) with concerns for aspiration pneumonia (lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). Resident 1 was started on antibiotics (medications to treat infections) and was started back on [MEDICAL TREATMENT] due to a high potassium level of 5.4 (NRR 3.7 to 5.2 milliequivalent per liter (mEq/L)). Resident 1 had a cardiopulmonary arrest requiring resuscitation and intubation and was placed on a mechanical ventilator (a machine to assist in breathing). Despite aggressive ACLS (advanced cardiac life support) attempts, the resident expired on (MONTH) 18, (YEAR). A review of the facility's policy titled, [MEDICAL TREATMENT] Care, dated (MONTH) 1, 2012, indicated that nursing staff would communicate in writing to the [MEDICAL TREATMENT] staff any changes of conditions specific to the resident with each treatment. A review of the facility's policy titled, Change of Condition Notification, dated (MONTH) 1, (YEAR), indicated that change of condition is any sudden marked adverse change in the resident's condition which is manifested by signs and symptoms different than usual denote a new problem, complication, or permanent change in status and require a medical assessment, coordination, and consultation with the attending physician and a change in the treatment plan. A review of Resident 1's Certificate of Death, dated (MONTH) 26, (YEAR), listed the cause of death as cardiopulmonary arrest (sudden stop of heart beat and breathing),[MEDICAL CONDITION] (severe body infection), and pneumonia (a serious lung infection that makes it difficult to breathe).

Based on observation, interview, and record review, the facility failed to ensure five of 18 sampled residents (Residents 3, 6, 11, 15, 17) were provided with effective pain management, and prevention of constipation (a side effect of narcotic pain medication) by failing to: 1. Assess Resident 3, who was unable to express his needs, before, and during range of motion (ROM, the range through which a joint can be moved, usually its range of flexion and extension) exercises for non-verbal signs and symptom of pain, and promptly report the observation to a licensed nurse. The deficient practice resulted in Resident 3 suffering unnecessary pain during ROM exercises, and had a potential for further contractures (condition of shortening and hardening of muscles, tendons, tissue leading to deformity and rigidity of joints that can be very painful to exercise) of upper and lower extremities. 2. Promptly recognize non-verbal signs and symptom of pain for Resident 6, who had severely impaired cognition (a process of acquiring knowledge and understanding through thought, experience, and the senses),, and to evaluate the effectiveness of as needed pain medication, and a need for routine scheduled pain medication before the resident's routine wound treatment. This deficient practice resulted in Resident 6 not receiving wound treatment and was transferred to general acute care hospital due to uncontrolled pain. 3. Consistently assess the effectiveness of routine scheduled pain medication, and to intervene for Resident 11, who was admitted with chronic back pain, when the resident verbalized unrelieved pain. This deficient practice resulted in Resident 11 remaining in pain, refusing to move and participate in physical therapy treatment. In addition Resident 11 was not monitored for side effect of pain medication which resulted in constipation. 4. Ensure Resident 15, who had right above the knee amputation (AKA), gangrene (dead tissue) of a left great toe, and under Hospice care (a care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) would remain comfortable and/or free of pain as much as possible by consistently assessing and evaluating the pain characteristic, before and after the pain medication was administered, and was assessed for a need of routine scheduled pain medication. 5. Assess Resident 17, who had [MEDICAL CONDITION] (Skin infection) of the left stump (after amputation above the knee), and face, when the resident verbalized increased pain, and to administer as needed pain medication as ordered. Findings: a. On February 10, 2016 at 1:15 p.m., during observation of Resident 3's ROM exercises with restorative nursing assistant (RNA 1), the resident was observed lying in bed, on his back in a fetal position, arms bent, hands clenched, and balled into fists. During the ROM exercises of Resident 3's upper extremities, the resident was observed grimacing, frowned and had a furrowed brow when the RNA opened his left contracted hand. The resident grimaced with pain while kicking his left leg, rubbing his heel, digging it against the pillow as the RNA continued to flex (closing) and extend (opening) the resident's contracted right hands. The RNA did not ask the resident if he was experiencing pain and continued to perform the ROM. A review of Resident 3's admission records indicated the resident was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A Minimum Data Set (MDS, a resident assessment care and screening tool), dated May 19, 2015 indicated the resident's cognitive skills for daily decision-making were severely impaired, and was totally dependent on staff for his activities of daily living. The resident was assessed with [REDACTED]. There was a physician's order dated September 30, 2015, for Tylenol with [MEDICATION NAME] #3 (combination of [MEDICATION NAME] 300 milligrams (mg) and [MEDICATION NAME] 30 mg) two tablets via gastrostomy tube (GT, a small feeding tube surgically inserted directly into stomach) every six hours as needed (PRN)for pain, and [MEDICATION NAME] 2 milligrams per 1 milliliters via GT every four hours as needed for pain. The physician ordered to monitorthe resident pain every shift using the pain scale. Resident 3 had a physician's order dated October 1, 2015, for application of left and right hand roll, four to six hours daily with skin check, five times a week as tolerated, and RNA program for passive ROM to left and right upper extremities. On January 8, 2016 an order was received for RNA to perform passive ROM for right and left lower extremities daily five times a week or as tolerated. The care plan for mobility impaired, contracture dated February 5, 2016, the intervention included ROM exercises as ordered, to perform slow and gentle ROM exercises to allow maximum joint capacity as ordered, to monitor for pain, and stiffness, progress or lack of progresses, to notify medical doctor of any pain, stiffness, and deterioration of joint mobility. The Medication Administration Record [REDACTED]. During an interview with RNA 1 on February 11, 2016 at 8:46 a.m., he stated that he was assigned to Resident 3 for a month. RNA 1 stated that he was aware of the way the resident communicated his pain. The RNA stated that the resident felt more pain on his left hand because when he placed the hand roll, that he could not open or close resident's left hand. RNA 1 stated that he should anticipated that Resident 3 will experience pain during ROM and hand roll application. He further stated he should had stopped and reported to licensed nurses Resident 3' facial grimacing and kicking of his leg during ROM exercises. A review of the Restorative Nursing Weekly Summary of Range of Motion from December through February 10, 2016 indicated Resident 3 received the PROM exercises and hand roll application. There was no pain and discomfort documented in the resident's RNA weekly summary as indicated by RNA 1 during an interview. During an interview with the director of nurses (DON) on February 16, 2016 at 7:45 a.m., the DON stated that the RNA should first see if the resident is in pain, if so, communicate the pain to the licensed nurse. The DON added that CNAs and RNAs received in service training for pain, an online education was available for all line staff, as well as stand up meetings every morning prior to shift change. According to the facility's policy and procedure titled Pain Management Nursing Manual-Pain revised November 2015, indicated to monitor residents for symptoms of pain and when identified, provide a detailed pain assessment. If the resident cannot verbalize the intensity of pain, the licensed nurse will assess the resident's pain based on non-verbal cues such as facial expressions. If the licensed nurse is unable to determine if the resident's facial expressions are related to pain, the nurse will advise the attending physician and interdisciplinary team, so that the attending physician can consider ordering pain medication. Nursing staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain. b. During the initial tour of the facility on February 9, 2016 at 1:56 p.m., Resident 6 was heard moaning. On February 10, 2016 from 7 a.m., until 8:25 a.m., the resident was observed lying in bed moaning with facial grimacing. Certified Nursing Assistant (CNA 7) who was providing care to the resident's roommates did not acknowledge the resident's moaning. During an interview on February 10, 2016 at 8:25 a.m., CNA 7 stated I had not had him before so I do not know if this was normal for him. CNA 7 then left Resident 6's room and notified licensed vocational nurse 1 (LVN 1) of the resident's moaning. During observation on February 10, 2016 at 8:29 a.m., licensed vocational nurses (LVN 1 and LVN 2) were at Resident 6's bedside. LVN 2 asked Resident 6 if he was in pain. The resident moaned and stated yes. LVN 2 asked Resident 6 the location of his pain and he stated his back, and the pain intensity level was 8 out of 10 (a pain scale of 1 to 10, 10 being the worse pain a person can experience). LVN 1 administered a pain medication to Resident 6. According to the Admission Record, Resident 6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, an assessment care and screening tool) dated January 27, 2016, indicated resident's cognitive skills for daily decision-making were severely impaired and required extensive to totally dependent from the staff with all activities of daily living. The MDS indicated the resident received as needed pain medication, and not on a routine pain medication. The resident was assessed with [REDACTED]. Resident 6's care plan dated January 20, 2016, for at Risk for Pain related to general body pain as indicated by non-verbal sounds (e.g. crying, whining, grasping, groaning). The approaches included to monitor for non-verbal sounds, crying, whining, grasping and groaning, facial grimacing, wincing, clinch teeth, guarded movement, altered mood, and decrease social interaction, and to assess level of pain using the pain rating scale 1 to 10, to provide non-pharmacological such as repositioning, calming environment and reassurance. A review of Resident 6's physician's order dated January 20, 2016 indicated [MEDICATION NAME] 600 milligrams to be administered via gastrostomy tube (GT, a small tube surgically inserted directly into the stomach for nutrition and medication administration) every four hours as needed for moderate pain. Another physician's order on February 20, 2016, indicated [MEDICATION NAME] 5/325 milligrams (mg) (combination [MEDICATION NAME] 5 milligrams and [MEDICATION NAME] 325 mg) (control pain medication) to be administered via GT daily as needed (PRN) before wound care, and Tylenol 650 mg via GT every 6 hours PRN for mild pain. A review of the Medication Administration Record [REDACTED]. There was no documented evidence the resident was assessed after the pain medication was given. On February 10, 2016 at 5 a.m., the MAR indicated [REDACTED]. There was no documentation that the resident was assessed after the [MEDICATION NAME] was administered. A review of the physician's order the [MEDICATION NAME] was ordered for moderate pain. On February 10, 2016 at 8:50 a.m.,the MAR indicated [REDACTED]. At 9:20 a.m., the documentation indicated the resident pain scale was 5 (moderate pain) out of 10. At 10 a.m., a Tylenol 650 mg was administered, then at 10:50 a.m., the resident pain scale was 5 (moderate) out of 10 after the Tylenol was given. A review of Pain Flow Sheet for month of January 2016 indicated on January 23, 2016 at 8 p.m., Resident 6 complained of 8 out 10 generalized body pain. The documentation indicated after the pain medication was given the resident pain scale was 0 out 10, however, there was no documented time of assessment. Resident 6's clinical record indicated there was no Pain Assessment Flow Sheet for the month of February 2016. During an interview on February 10, 2016 at 2:00 p.m., CNA 8, (who had been assigned to Resident 6 for the past few days) stated she had notified the charge nurse about Resident 6, who was in more pain than usual lately. On February 10, 2016 at 9:45 a.m., Resident 6 was observed lying on his back, and was again observed moaning. LVN 2 (treatment nurse) asked the resident if he was in pain, and he stated yes. The LVN 2 was unable to turn Resident 6 for his wound care. LVN 2 then stated that he had to call the doctor to get an order for [REDACTED].> During an observation on February 10, 2016 at 1:50 p.m., Resident 6 was heard moaning while lying on his back. LVN 2 stated that he still was not able to perform the wound care because the resident was in so much pain. LVN 2 further stated that the resident received three different pain medications and his pain was not controlled. During an interview with LVN 2 on February 10, 2016 at 3:15 p.m., he stated that Resident 6 was being transferred out to a general acute hospital (GACH) for the uncontrolled pain. A review of Resident Transfer Record dated February 10, 2016, no time indicated the resident was transferred to GACH for intractable pain During an interview with the administrator on February 16, 2016 at 2:30 p.m., she stated that CNA 7 should have acknowledged the moaning of Resident 6 and non pharmacological intervention should have been done. A review of the facility policy and procedures titled Pain Management dated November 2015, indicated nursing staff will implement timely interventions to reduce the increase in severity of pain. Nursing staff will also utilize non-pharmacological interventions by adjusting the residents environment to reduce pain. c. On February 10, 2016 at 10:00 a.m., during a group interview of alert and oriented residents, one of 10 residents complained that the nurses did not respond when his roommate called for pain medication. During an observation on February 12, 2016 at 11:15 a.m., Resident 15 was observed moving his left lower extremity and right leg stump up and down, grabbing his inner left thigh. The resident was observed with a facial grimace and was attempting to sit up in bed. During an inquiry, the resident stated that he was in pain, when asked to point where the pain was, Resident 15 grabbed his left inner thigh. LVN 3 was informed about the resident's pain. A review of Resident 15's admission records indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, assessment and care screening tool) dated January 29, 2016, indicated Resident 15 had memory problems but was able to express his needs, and needed extensive assistance from staff for bed mobility, transferring, and dressing. The resident was incontinent (lose control) of bowel and bladder functions. The resident had a physician's order dated February 4, 2016 to be under Hospice care (Care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure). A plan of care for Hospice dated February 8, 2016, indicated that Resident 15 would remain at a comfortable level during care; the pain would be resolved with the medication ordered, and to monitor and assess the effectiveness of current and new medication/treatment. The resident had the following pain medication physician orders: 1. On January 22, 2016, for Tylenol 325 milligram (mg) two tablets by mouth every six hours as needed (PRN) for mild pain. 2. On February 4, 2016, for [MEDICATION NAME] (narcotic pain reliever) 5 milligrams (mg) by mouth (orally) and/or sublingually (under the tongue), PRN for pain and/or shortness of breath (SOB). 3. On February 4, 2016, for Tylenol 650 mg/suppositories per rectum every six hours PRN for mild pain. The Medication Administration Record [REDACTED]. There was no documented evidence that the resident was assessed for the location of pain, pain intensity and pain level before and after [MEDICATION NAME] was administered. On February 11, 2016, at 2:40 p.m., the MAR indicated [REDACTED]. The documentation indicated Resident 15 was reassessed after the Tylenol was administered and his pain scale was 0 out of 10, there was no time when the resident was reassessed after the pain medication was administered. During interview on February 16, 2016 10:10 a.m., licensed vocational nurse (LVN 3) was not able to provide documentation that Resident 15 was assessed for a need of routine pain medication due to gangrene of the left great toe. She stated that the resident should have been assessed one hour after the pain medication was administered. According to facility revised Pain Management policy and procedures dated November, 2015, indicated that after medication and interventions were implemented, the resident's pain level would be re-evaluated within one hour. d. During room observation on February 10, 2016, at 7:25 a.m., Resident 11 was observed with facial grimaces, squeezed his eyes tightly shut and held his breath as he was repositioned by staff members to receive his breakfast tray. The resident stated It hurts. During an inquiry, Resident 11 complained of back pain that radiated down to his right leg. The resident described the pain as 10/10 on the pain scale of 1 to 10 (10 being the worst pain a person can experience). Resident 11 stated he was more comfortable following repositioning but his back pain remained 8/10 (severe pain). During an observation on February 12, 2016 at 8:25 a.m., Resident 11 occasionally squeezed his eyes shut, his forehead creased, and he breathed rapidly. Resident 11 stated I have severe--10/10 pain. Resident 11 stated that in the last few days, between pain and constipation he had not slept well. According to the admission record, Resident 11was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a standardized assessment care and screening tool) dated December 30, 2015, indicated Resident 11's cognitive skills for daily decision-making were moderately impaired and required extensive assistance from staff with bed mobility, transfer, walking in the facility, toilet use and personal hygiene. The MDS indicated the resident had frequent pain with an intensity of 8/10 (severe pain). A review of Care Plan for Pain dated December 23, 2015, indicated the goals included for the resident to verbalize or show decreased signs and symptoms of pain, and to achieve self-reported pain goal of 0/10 (no pain). The approaches included assessment of pain medication and treatment for [REDACTED]. A review of the facility's pain scale used to assess resident's pain level indicated the following: 0/10, the resident experienced no pain; 1-4 mild pain; 5-7 moderate pain; 8-9 severe pain; and 10/10 very severe pain. Resident 11 had the following physician's orders for pain management: 1. On December 23, 2015, [MEDICATION NAME] (a narcotic pain medicine) administer 10 milligrams (mg) by mouth twice a day for pain management. 2. On December 23, 2015, Tylenol (an over-the-counter pain medicine) 325 mg administer two tablets by mouth as needed (PRN) for mild pain every six hours. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of Resident 11's clinical records indicated no documentation that the resident was assessed before and after the pain medication was administered. There was no Pain Assessment Flow Sheet found in the resident's clinical record from December to February 10, 2016. The Licensed Nurse Weekly Summaries from January 8, 2016 through February 3, 2016 indicated Resident 11 had no pain. The Weekly Summary dated February 10, 2016, indicated Resident 11 was on routine pain medications twice a day and that at the time of the summary the Resident's current pain level was 5-7/10 (moderate pain). During an interview on February 10, 2016 at 1:30 p.m., with licensed vocational nurse (LVN 3)/a medication nurse (main responsibility was to administer residents medication), in the presence of Resident 11. LVN 3 stated that the resident was receiving [MEDICATION NAME] twice a day for pain. LVN 3 stated that dose should be adequate. Resident 11 stated this was not sufficient to control his pain. When asked how LVN 3 planned to address resident's pain, LVN 3 stated she would call the doctor to get an order for [REDACTED].>During an interview on February 10, 2016 at 3:20 p.m., with LVN 5 (charge nurse) , she stated that she had talked to Resident 11 about pain. LVN 5 stated that Resident 11 remained in pain and the pain scale was 8/10 (severe pain). LVN 5 acknowledged that she should have a registered nurse (RN) reassess Resident 11 at that time. In an interview on February 12, 2016 at 8:10 a.m., certified nursing assistant (CNA 9) stated she had cared for Resident 11 for two to three days. CNA 9 stated that the resident had been in pain every day. CNA 9 further stated that she attempted to make him more comfortable by repositioning him but he continued to complain of pain. CNA 9 stated she reported Resident 11 complaint of pain to the licensed nurse. On February 12, 2016 at 10:20 a.m., during an interview with the director of rehabilitation (DR),she stated that on February 11, 2016, Resident 11 did not fully participate in therapy because of pain. The DR stated she had recently participated in an Interdisciplinary Team (IDT, a forum used to plan the resident's care including representatives from medicine, nursing, rehab, pharmacy and other departments as necessary). She stated that she was unsure if Resident 11's pain had been discussed in the recent IDT meeting. Review of an IDT Conference Record dated February 3, 2016 indicated that the team met with Resident 11 to discuss discharge planning. There was no documented evidence of discussion of pain management. The Licensed Nurses Progress Notes dated February 12, 2016 at indicated that arrangements were made to transfer Resident 11 to a general acute care hospital (GACH) for intractable (uncontrolled pain) severe pain. At 2:32 p.m., the documentation indicated Resident 11 was notified of the transfer and refused to go, there was no documentation indicating the reason for the resident's refusal. On February 16, 2016 from 7 a.m., to 3:30 p.m., Resident 11 was out of the facility and was not available for interview. According to the facility Pain Management Nursing Manual-Pain, policy and procedures revised November 2015 indicated the facility staff had responsibility for helping the residents attain or maintain their highest level of well-being while working to prevent or manage the resident's pain to the extent possible. The policy outlined that the nurse will assess the resident for pain on admission, develop a care plan for pain management and utilize the Pain Assessment Flow Sheet to assess effectiveness of medications/interventions, a Licensed Nurse will assess the resident if there is a new onset of pain or change in medication, and to document resident pain and intervention on a weekly basis. d2. During an observation on February 11, 2016 at 7:50 a.m., Resident 11 stated he was not feeling well because he was having a third day of constipation (a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces). A review Physician's Order dated December 23, 2015 indicated [MEDICATION NAME] (a stool softener) 100 mg by mouth twice a day as needed for constipation. The [MEDICATION NAME] order was discontinued January 28, 2016. There was a Physician's Order dated February 11, 2016 for [MEDICATION NAME] (a sugar that will not absorb in the intestine used to treat constipation) 30 cubic centimeters (ccs) by mouth at bedtime for constipation. The care plan dated February 11, 2016 for constipation risks indicated the goals included for the resident to have regular bowel movements. A review of Licensed Nurse Weekly Summary from February 3 to 10, 2016, indicated that Resident 11 had no signs and symptoms of constipation. The documentation indicated that the Resident was having a bowel movement every other day. The Activity of Daily Living Flow Record indicated Resident 11 last bowel movement was on February 7, 2016 at 11 p.m. to 7 a.m. shift. During an interview with LVN 3 on February 11, 2016 at 9:30 p.m., LVN 3 stated she will notify the resident's physician regarding resident constipation. e. During a room observation and interview on February 12, 2016, at 11:10 a.m., Resident 17 was observed sitting in his bed, rocking back and forth holding onto his left stump and rubbing it. Resident complained of 10 out of 10 pains (severe pain). He stated his pain was not only in the stump but also in his left face. The resident face was observed swollen and red around his left eye. At 11:15 a.m., Resident 17 transferred himself to his wheelchair and wheeled himself into the corridor, and approached LVN 3. Resident 17 was overheard complaining to LVN 3 regarding his pain to his left stump. LVN 3 told Resident 17 that he had a dose of [MEDICATION NAME] (a narcotic pain medicine) at 6 a.m., and Tylenol (an over-the-counter pain medicine) for his pain. LVN 3 told Resident 7 that this should help his pain. Resident 17 was observed and heard made unhappy remarks and wheeled himself rapidly away from LVN 3. According to Resident 17's admission record, the resident was admitted to facility on January 7, 2016 with [DIAGNOSES REDACTED]. A Change of Condition Notes dated February 10, 2016 indicated Resident 17 went to a general acute care hospital (GACH) emergency department for treatment of [REDACTED]. The resident returned to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a standardized assessment care and screening tool), dated December 9, 2015, indicated Resident 17's cognitive skills for daily decision-making were severely impaired and he required limited assistance from staff with bed mobility, transfer, and moving around the facility. He required extensive assistance from the staff with toilet use and was totally dependent on the staff for personal hygiene. The MDS indicated that Resident 17 had occasional pain with an intensity of 5/10 (mild pain). The care plan for chronic pain dated January 7, 2016, indicated approaches included that nursing would assess pain medication and treatments for effectiveness, to evaluate need for a routine pain medication, to monitor for verbal complain of pain and assesse level of pain using pain level scale. The resident had the following pain medication orders [REDACTED] 1. On January 7, 2016, for Tylenol 325 milligrams two tablets every four hours as needed for mild pain, not to exceed 3 grams per 24 hours. 2. On January 7, 2016, for [MEDICATION NAME] 5/325 mg one tablet by mouth every four hours as needed for moderate pain. 3. On February 11, 2016, for [MEDICATION NAME] 5/325 mg one tablet by mouth every six hours for pain management. The Pain Assessment Flow Sheet indicated the following: 1. On February 6, 2016, at 6 p.m., Resident 17 received [MEDICATION NAME] 5/325 mg for generalized body pain, for a pain scale of 8 (severe) out of 10. The resident was reassessed after the pain medication was given, and indicated the resident had no pain (0/10). However, there was no specific time when the resident was reassessed after the pain medication was given. 2. On February 10, 2016, at 11 a.m., Resident 17 received [MEDICATION NAME] 5/325 mg for left face pain, for a pain scale of 8 (severe) out of 10. The resident was reassessed after the pain medication was given, and the pain scale was 4 (mild pain) out of 10. There was no documentation that a Tylenol was administered as ordered by the physician, even though the resident was still complaining of mild pain. In addition, there was no specific time when the resident was reassessed. 3. On February 10, 2016 at 3:30 p.m., Resident 17 received [MEDICATION NAME] 5/325 mg for generalized body pain, for a pain scale of 8 (severe pain) out of 10. The resident was reassessed, no specific time of reassessment, as no pain after the pain medication was administered. 4. On February 11, 2016, from 12 noon indicated Resident 17 received [MEDICATION NAME] 5/325 mg one tablet every six hours. 5. On February12, 2016 at 6 a.m., indicated Resident 17 received [MEDICATION NAME] 5/325 mg and the Tylenol. However, Resident 17 was not given the [MEDICATION NAME] 5/325 mg ordered for every four hours as needed for pain when the resident was complaining of pain at 11:15 a.m. (five hours after the last pain medication. In addition, LVN 3 did not assess Resident 17 even though the resident complained of severe pain, and notify the physician.