Every finding on record at Heritage Manor West

Based on record review and interviews, the facility failed to ensure nursing staff provided nursing services to assure residents maintained the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by assessments and individual plans of care. The facility failed to complete a full body assessment for 1 (#1) of 3 sampled residents upon admission. Findings:Review of facility's Wound/Skin Documentation policy (latest revision date 4/25) revealed in part;Wound/skin evaluation is utilized to document and trend the status of pressure ulcers, other ulcers, (diabetic, arterial, and venous ulcers), surgical wounds, open lesions and other skin issues.Documentation shall occur on admission, on discovery, weekly and when significant changes to the wound occur. Review of Resident #1's MDS (Minimum Data Sets) assessment revealed Resident #1 was discharged to an acute hospital on [DATE] and returned to the facility on [DATE].Review of Resident #1's face sheet revealed the following diagnoses but not limited to acute non chronic diastolic (congestive) heart failure, cardiomegaly, peripheral vascular disease, primary generalized osteoarthritis, pain, non-ST elevation myocardial infarction, nonspecific intraventricular block, pressure ulcer of other site, unspecified stage, mild protein-calorie malnutrition, cellulitis, and anemiaReview of Resident #1's re-admission assessment completed by S3 ADON (Assistant Director of Nursing) dated 03/25/2026 revealed Resident #1 had a mepiplex in place to bilateral feet. Wound care nurse to do full body assessment. Further review of Resident #1's record failed to reveal wound care nurse completed a full body assessment when Resident #1 was readmitted to the facility. During an interview on 7/15/2026 at 10:00 a.m. S2 Treatment Nurse reported a full body assessment should be done when a resident is admitted to the facility. S2 Treatment Nurse reviewed Resident #1's record and confirmed there was no documentation a full body skin assessment was completed when Resident #1 was readmitted to the facility on [DATE]. During an interview on 07/15/2026 at 11:45 a.m. S1 DON (Director of Nursing) reported a full body assessment should be done when a resident is admitted to the facility. S1 DON reviewed Resident #1's record and confirmed there was no documentation a full body skin assessment was completed when Resident #1 was readmitted to the facility on [DATE].

Based on record review and interviews the facility failed to notify the resident's (RP) responsible party of a change in plan of care for 1 (#1) of 3 sampled residents.Findings:Review of facility's Change in Resident Medical Status Policy (latest revision date 9/17) revealed in part: A change in medical status is defined as any physical, psychological and/or medical deviation as compared to the resident's status as noted in the initial assessment.Facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s),A need to alter treatment significantly (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment).Review of Resident #1's face sheet revealed initial admission date of 03/03/2026 and a re-entry admission date of 03/25/2026 with the following diagnoses but no limited to acute on chronic diastolic (congestive) heart failure, cardiomegaly, peripheral vascular disease, primary generalized osteoarthritis, pain, unspecified, non-st elevation myocardial infarction, nonspecific intraventricular block, pressure ulcer of other site, unspecified stage, mild protein-calorie malnutrition, cellulitis, and anemia.Review of Resident #1's face sheet revealed Resident #1's family member was the responsible party, #1 emergency contact and Power of Attorney. Review of Resident #1's Part D Discharge form dated 04/02/2026 revealed start of care date for occupational therapy was 03/25/2026, last treatment date 04/06/2026, and discharge date [DATE]. During a telephone interview on 07/16/2026 at 2:35 p.m. Resident #1's RP (responsible party) reported not being notified when Resident #1 was discharged from occupational therapy. During an interview on 07/15/2026 at 3:00 p.m. S5 Therapy Care Navigator reported Resident #1 was evaluated for therapy on readmission to the facility on [DATE]. Resident #1 had medically declined and was discharged from therapy due to no progress. S5 Therapy Care Navigator reported the therapy department notified the facility, and the facility should have notified the resident's RP when Resident #1 was discharged from occupational therapy on 04/07/2026.During an interview on 07/15/2026 at 3:30 p.m. S1 DON (Director of Nursing) reviewed Resident #1's record and reported there was no documentation Resident #1's RP was notified when Resident #1's discharge from occupational therapy on 04/07/2026. During an interview on 07/16/2026 at 9:40 a.m. S4 Rehab Director reported there was no documentation Resident #1's RP was notified when Resident #1 was discharged from occupational therapy on 04/07/2026.

Based on record review, observations, and interviews the facility failed to follow physician orders for 1(#87) of 1 resident reviewed for tube feedings. The facility failed to administer medications to Resident #87 as ordered by physician prior to bolus feeding. Review of Resident #87's medical diagnoses revealed the following but not limited to moderate protein-calorie malnutrition, dysphagia, oropharyngeal phase, encounter for attention to gastrostomy, pneumonitis due to inhalation of other solids and liquidsReview of Resident #87's March 2026 Physician Orders revealed:11/05/2025: Carafate Oral Tablet 1 GM (Sucralfate); Give 1 tablet via PEG tube four times a day related to anemia; give down tube 30 minutes prior to bolus feeding. 09/15/2025: Tube feeding formula: Isosource 1.5 carton bolus. Give one carton (250 ml) bolus per PEG tube twice daily to deliver 750 calories, 34 gm protein and 500 ml total volume; two times a dayReview of Quarterly MDS (minimum data sets) dated 02/03/2026 revealed Resident #87 was assessed to have BIMS of 4 out of 15 indicating severely impaired cognition. Observation on 03/10/2026 at 11:10 a.m. of Resident #87's bolus feeding revealed S8 LPN administered Carafate 1gm at the time of Isosource 1.5 bolus feeding. During an interview on 03/10/2026 at 1:50 p.m. S8 LPN confirmed Resident #87's Carafate 1 gm was administered at the time of the Isosource 1.5 bolus feeding.

Based on record reviews and interviews, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#5) of 1 resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility. The facility failed to complete the dialysis communication sheet and monitor Resident #5 for complications after each dialysis treatment. Findings: Review of Resident #5's Medical Diagnoses revealed the following but not limited to end stage renal disease and dependence on renal dialysis.Review of Resident #5's March 2026 Physician Orders revealed an order dated 12/17/2025 for Hemodialysis on Monday, Wednesday, and Friday at 9:30 a.m. Review of Annual MDS (Minimum Data Sets) dated 12/09/2025 Resident #5 was assessed to have a BIMS of 04 out of 15 indicating severely impaired cognition. Review of facility's dialysis communication forms for February 2026 revealed: Review of Resident #5's Dialysis Communications forms were not completed at all on the following dates 02/04/2026, 02/06/2026, 02/09/2026, and 02/13/2026.Review of Resident #5's Dialysis Communication forms were not completed upon Resident #5 return from dialysis on the following dates 02/16/2026, 02/18/2026, 02/23/2026, and 02/25/2026. During an interview on 03/10/2026 at 4:00 p.m. S6 LPN (Licensed Practical Nurse) reviewed Resident #5's Dialysis Communication forms for February 2026 and confirmed Resident #5's Dialysis Communication forms should have been completed with each dialysis treatment and was not. During an interview on 03/11/2026 at 8:00 a.m. S2 DON (Director of Nursing) reviewed Resident #5's Dialysis Communications forms for February 2026 and confirmed Resident #5's Dialysis Communication forms should have been completed on each dialysis treatment and was not.

Based on record reviews, observations, and interview, the facility failed to ensure residents who were unable to complete their Activities of Daily Living received the necessary services to maintain grooming for 1 (Resident #91) of 1 resident reviewed for Activities of Daily Living. The facility failed to ensure nail care was provided for Resident #91. Findings:Review of Resident #91's Medical Diagnoses revealed the following but not limited to dysphagia following cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and dementia. Review of Resident #91's Quarterly MDS dated [DATE] was assessed to have a BIMS of 03 out of 15 indicating severely impaired cognition. Observation on 03/09/2026 at 1:00 p.m. revealed Resident #91's finger nails on the right hand had grown over the nail bed. Observation on 03/11/2026 at 3:00 p.m. with S3 ADON revealed Resident #91's finger nails on the left hand had grown over the nail bed. During an interview on 03/11/2026 at 3:00 p.m. S3 ADON confirmed Resident #91 finger nails had grown over the nail bed and needed to be trimmed.

Based on record review, observation, and interview, the facility failed to ensure a resident's narcotic record was maintained and reconciled for 1 (#30) of 1 resident individual narcotic record reviewed.Review of the facility's Drug-Controlled Substances Policy dated 09/2025 revealed the following: Controlled medications are to be signed out on Individual Resident Narcotics Record at the time they are administered.Observation on 03/11/2026 at 9:05 a.m. with S4 LPN revealed Resident #30's Individual Narcotic Record for Pregabalin 25 milligrams had a documented count of 47. Review of Resident #30's narcotic card of Pregabalin 25 milligrams revealed an actual count of 46. During an interview on 03/11/2026 at 9:05 a.m. S4 LPN reported she had given Resident #30's Pregabalin but failed to sign it out on Resident #30's Individual Narcotic Record. S4 LPN confirmed she should have signed the medication out at the time of administration.

Based on observations and interviews the facility failed to ensure all corridors were equipped with a complete and secure handrail. The facility failed to ensure handrails were complete and secure on 1(Hall A) of 6 resident hallways observed. Findings Observation on 03/09/3026 at 3:00 p.m. with S9 Service Tech, revealed the handrail on Hall A did not have an end cap, leaving a sharp metal piece exposed and was not secured to the wall. During an interview on 03/09/26 at 3:00 p.m., S9 Service Tech confirmed the handrail did not have an end cap and was unsecure. During an interview on 03/11/2026 at 3:56 p.m., S1Administrator confirmed Hall A handrail should have been repaired.

Based on observation, record review, and interview, the facility failed to revise the plan of care after a change in condition for 1(#14) of 3 (#13, #14, #18) residents reviewed for accidents. The facility failed to revise Resident #14's plan of care to reflect the removal of a wander/elopement alarm. Review of Resident #14's medical record revealed an admit date of 07/19/2022 with a diagnosis of but not limited to dementia in other diseases, unspecified anxiety disorder and Alzheimer's disease.Review of Resident #14's Quarterly Minimum Data Set revealed Resident #14 was assessed to have a Brief Mental Status Interview Score of 6 indicating severely impaired cognition. Review of Resident #14's comprehensive plan of care revealed Resident #14 had an intervention/approach of, wander/elopement alarm in place on left ankle.Observation on 03/11/2026 at 2:45 p.m. with S10 Licensed Practical Nurse, revealed Resident #14 did not have a wander/elopement alarm on her left ankle. During an interview on 03/11/2026 at 2:57 p.m. S5 Registered Nurse Medicare Case Manager reported that an elopement assessment had been completed on Resident #14 last week, which resulted in the removal of Resident #14's wander/elopement alarm. S5 Registered Nurse Medicare Case Manager confirmed she failed to revise/update Resident #14's plan of care to reflect this removal.During an interview on 03/11/2026 at 3:13 p.m. S2 DON confirmed Resident #14's plan of care should have been revised/updated to reflect the removal of Resident #14's wander/alert alarm.

Based on record review and interviews, the facility failed to ensure resident assessments were transmitted within the required timeframe for 1 (#48) of 1 resident reviewed for resident assessment. FindingsReview of Resident #48's medical record revealed an admission date of [DATE]. Further review revealed Resident #48 expired and was discharged on [DATE]. Review of Resident #48's MDS assessment revealed a discharge date of [DATE]. Further review of Resident #48's discharge MDS assessment revealed a signed date of [DATE]. During an interview on [DATE] at 8:10 a.m., S7MDS Nurse reported Resident #48 was discharged on [DATE]. S7MDS Nurse further reported Resident #48's discharge MDS assessment was not transmitted until [DATE]. During an interview on [DATE] at 8:10 a.m., S5RN, Medicare Case Manager confirmed Resident #48's discharge MDS assessment was not transmitted until [DATE]. S5RN, Medicare Case Manager further confirmed Resident #48's discharge MDS assessment should have been completed by [DATE].

Based on record reviews and interview the facility failed to provide the resident and the resident's representative with the facility bed hold policy at the time of transfer as required for 1(#16) of 2 residents reviewed for hospitalization. Findings:Review of facility's Bed Hold Policy with a revision date 12/24 revealed in part:2. When a resident is transferred to the hospital, or goes out on therapeutic leave, bed hold notice information is provided to the resident, specifying the duration of the bed-hold according to the state plan, and the facility's policy regarding bed-hold periods. In case of emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. Review of Resident #16's face sheet revealed an initial admission date of 09/04/2025 and a re-entry date of 10/20/2025 with the following medical diagnoses but not limited to non-ruptured cerebral aneurysm, gastrointestinal hemorrhage, iron deficiency anemia, chronic obstructive pulmonary disease, acute pulmonary edema, and chronic systolic (congestive) heart failure. Review of Resident #16's MDS (Minimum Data Sets) revealed February 2026 discharges to an acute hospital on [DATE] and 02/19/2026. During an interview on 3/11/2026 at 12:30 p.m. S2 DON (Director of Nursing) reviewed Resident #16's medical record and confirmed there was no documentation Resident #16 or Resident #16's responsible party was informed of the facility's bed hold policy at time of transfer to the hospital on [DATE] and 02/19/2026.

Based on observations and interviews the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#15, #80) of 2 (#15, #80) residents' rooms observed for environment. The facility failed to ensure: 1. Resident #15's wheelchair was clean and sanitary 2. Resident #80's restroom was clean and sanitary. Findings: Resident #15 Review of Resident #15's medical record revealed an admitted [DATE] with diagnoses, of but not limited to, Alzheimer's disease, moderate protein calorie malnutrition, gastric reflux disease, dermatitis, dysphagia, vascular dementia, lack of coordination, cognitive communication deficit, and hypertension. Review of Resident #15's MDS (Minimum Data Set) for 11/12/2024, revealed Resident #15 was assessed as rarely understood. Observation on 01/06/2025 at 8:00 a.m. with S4 ADON (Assistant Director of Nurses) revealed Resident #15's wheelchair had dried white colored food residue on the seat, armrest and the right wheel. During an interview 01/06/2025 at 8:00 a.m. S4 ADON confirmed the white food residue on Resident #15's wheelchair was build up from Resident #15 spitting and reported the certified nursing assistants on the night shift should have cleaned Resident #15's wheelchair. Resident #80 Review of Resident #80's medical record revealed an admitted [DATE] with a diagnoses, of but not limited to atrial fib, chronic kidney disease, mild protein calorie malnutrition, osteoarthritis, hypertension, gastric reflux disease and type 2 diabetes. Review of Resident #80's Quarterly MDS dated [DATE] revealed Resident #80 had a BIMS (Brief Interview Mental Status) Score of 15 indicating intact cognition. Observation on 01/06/2025 at 8:15 a.m. revealed brown colored splash spots on the wall next to and behind Resident #80's toilet. Further observation revealed Resident #80's toilet had brown stains on the seat and inside of the toilet. Observation on 01/07/2025 at 8:00 a.m. with S5 Housekeeper revealed brown colored splash spots on the wall next to and behind Resident #80's toilet. Further observation revealed Resident #80's toilet had brown stains on the seat and inside of the toilet. During an interview on 01/07/2025 at 8:00 a.m. S5 Housekeeper reported Resident #80's restroom was supposed to be cleaned daily and confirmed it had not been cleaned. During an interview on 01/08/2025 at 8:00 a.m. S6 Housekeeping Supervisor confirmed Resident #80's restroom was not cleaned daily and should have been.

Based on record review and interview the facility failed to ensure a resident's plan of care was implemented for 1 (#15) of 1(#15) resident out of total of 34 sampled residents. The facility failed to ensure Resident #15's lab work was done as ordered. Findings: Review of Resident #15's medical record revealed an admitted [DATE] with diagnosis of but not limited to; Alzheimer's disease, moderate protein calorie malnutrition, gastric reflux disease, dermatitis, dysphagia, vascular dementia, lack of coordination, cognitive communication deficit, and hypertension. Review of Resident #15's MDS (Minimum Data Set) for 11/12/2024, revealed Resident #15 was assessed as rarely understood. Review of Resident #15's December 2024 Physician's orders revealed an order for a CBC (Complete Blood Count) dated 12/13/2024 one time for dementia until 12/16/2024. Review of Resident #15's medical record failed to reveal lab results from the CBC ordered on 12/13/2024. During an interview on 01/08/2025 at 12:48 p.m. S2 DON (Director of Nurses) reported the facility did not have the results of Resident #15's CBC because the specimen had clotted and the facility failed to follow-up and ensure the lab was re-drawn. S2 DON confirmed Resident #15's lab work was not done as ordered.

Based on observation, interviews, and record reviews the facility failed to ensure each resident received the care and services in accordance with professional standards of practice for 1 (#2) of 1 sample resident reviewed for skin conditions (non-pressure). The facility failed to ensure resident #2, with a diagnosis of diabetes was provided necessary care and services for her feet. Findings: Review of resident #2's records revealed diagnoses of diabetes type 2, peripheral vascular disease, chronic kidney disease, dependence on dialysis, chronic obstructive pulmonary disease, and congestive heart failure. Review of resident #2's Annual Minimum Data Set assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating intact cognition. During an interview on 01/07/2025 at 09:20 a.m. resident #2 reported she had a black spot on her right foot. Resident #2 reported she had reported this to S8 Wound Care Nurse multiple times and nothing had been done. Resident #2 reported nothing had been done for her foot and she did not want to lose her foot. Observation made on 01/07/2025 at 09:30 a.m. of resident #2's right foot with S7 LPN (License Practical Nurse) revealed resident #2 had a black spot on top of her right great toe. During an interview on 01/07/2025 at 09:30 a.m. S7 LPN reported there is a foot doctor that comes to the facility that could see resident #2. S7 LPN reported she was not aware resident #2 had a black spot on her foot. During an interview on 01/08/2025 at 2:20 p.m. S9 CNA (Certified Nursing Assistant) reported she had worked with resident #2 bathing her at times. S9 CNA reported she had noticed resident #2's right toe being black yesterday and she reported it to the S8 Wound Care Nurse. During an interview at 01/08/2025 at 2:30 p.m. S10 SSD (Social Service Director) reported S11 APRN (Advanced Practice Registered Nurse) podiatrist sees all the resident at the facility for foot care. S10 SSD reported none of the facility's nurses had asked her to put resident #2 on S11 APRN podiatrist schedule. Review of S12 NP (Nurse Practitioner) notes dated 01/07/2025 revealed resident #2 had a toenail injury with toenail fungus.

Based on observations, interviews and record review the facility failed to provide preventive care, and treatment consistent with professional standards of practice, for 1 (#151) of 3 (#15. #35 and #151) residents reviewed for positioning/mobility. The facility failed to ensure residents who were at risk for development of pressure injuries was provided necessary care to avoid a pressure injury. Findings: Review of resident #151's records revealed diagnoses of non-traumatic intracerebral hemorrhage unspecified, benign neoplasm of cerebral meninges, other seizures. type 2 diabetes with hyperglycemia, diabetic polyneuropathy and essential hypertension. Review of resident #151's admit note dated 12/02/2024 S3 RN (Registered Nurse) reads in part, resident admitted to skilled facility after hospital or treatment for intracranial hemorrhaged. Resident #151 was independent prior to recent illness and did not need any assist from anyone. Resident #151 at the time of admit is total assist feeding, bed mobility, incontinent care, transfers. Review of the Skin and Wound Evaluation dated 01/01/2025 revealed resident #151's initial admitted was 12/04/2024. In facility acquired pressure ulcer to his right gluteus. Stage 2, partial-thickness skin loss with exposed dermis. Review of resident #151's MDS (Minimum Data Set) failed to reveal the entries were completed except for the entry on 12/04/2024. All other MDS entries were in progress. Review of resident #151's Plan of Care revealed the following problems and interventions: 1. Resident lifting plan Goal: Resident will have no injury/complication due to use of lift through need review. Interventions: Lift assessment quarterly and prn. 2. Resident has a stage 2 pressure ulcer to right gluteal. Goal: Pressure ulcer will heal without complication through next review. Interventions: Observe daily for sign and symptoms of infection. Observe for pain and medicate per order. Pressure relieving mattress and pressure relieving cushion to chair. Treatment to area per order. Weekly evaluation of wound healing. 3. Resident needs assist with ADL's (Activity of Daily Living) and late loss ADL's. Resident requires extensive assist with repositioning and bed mobility. Chair/Bed to chair transfer. Resident is dependent on staff to transfer to and from a bed to a chair/wheelchair. Roll left to right: Resident needs substantial/maximal assist to roll left to right. Observation on 01/06/2025 at 09:30 a.m. resident #151 awake and alert positioned on his back with his head elevated. Further observation revealed a turning schedule a clock posted on the wall at the head of the bed to be turned every 2 hours to the door, window, and ceiling. Observation on 01/06/2025 at 12:15 p.m. resident #151 was still positioned on his back in bed Observation on 01/06/2025 at 2:00 p.m. resident #151 was still in the same position in bed. During an interview at this time resident #151 reported he had not been out of bed, he had not been turning or repositioned Observation on 01/07/2024 at 8:18 a.m. resident #151 in bed at this time positioned on his back. Observation on 01/07/2024 at 2:15 p.m. revealed resident #151 in bed asleep. Resident #151 easily aroused, he reported he had not been out of bed today. During an interview on 01/06/2025 at 9:30 a.m. resident #151 reported he had been at the facility for a month and had never been gotten out of bed. Resident further reported he was unable to turn or reposition himself and unable to get out of bed without assistance. During an interview on 01/07/2024 at 2:35 p.m. S8 Wound Care Nurse reported there is no reason resident #151 should not be up and out of bed. S8 Wound Care Nurse reported resident #151 has very little control of his upper body and can get up with 2 person assist by a lift to a Geri chair. S8 Wound Care Nurse reported resident #151's had a stage 2 pressure ulcer that occurred in the facility. During an interview on 01/08/2025 at 10:00 a.m. S7 LPN reported resident #151 had not been up and out of bed. Review of resident #151's records failed to reveal any documentation he had refused to be turned or repositioned or got up out of bed. . .

Based on record review and interview, the facility failed to ensure each resident's MDS (Minimum Data Set) assessment was transmitted to CMS (Centers for Medicare and Medicaid Services) within the required timeframe for 1 (#74 ) of 1 (#74 ) resident who was reviewed for Resident Assessment. Findings: Review of Resident #74's MDS assessments revealed a discharge MDS dated [DATE] with a status of in progress. During an interview on 01/07/2025 at 4:30 p.m., S3 Nurse Case Manager confirmed resident #74's discharge MDS had not been transmitted to CMS and should have been.

Based on record reviews, observations, and interviews, and the facility failed to ensure appropriate treatment and services to prevent potential complications from enteral feeding for 3 (#2, #4, #5) out of 6 (#1, #2, #3, #4, #5) residents reviewed. The facility failed to change enteral feeding bags at appropriate interval and label the enteral feeding bag and syringe. Findings: Review of Facility's Tube Feedings Policy (12/15) revealed: 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders . 3. Procedures for administering tube feedings are in place and address: e. labeling of container Resident #2 Review of Resident #2's medical records revealed an admitted [DATE] with the following diagnoses, in part: mild protein calorie malnutrition and gastrostomy status. Review of Resident #2's Physician's Orders revealed an order dated 09/24/2024 - off at 5a.m./on at 9a.m. tube feeding formula: Isosource 1.5 at 70ml/hr (milliliter/hour) x 20 hours. Observation on 12/09/2024 at 9:30 a.m. failed to reveal Resident #2's enteral feeding bag labeled with resident name, date, time, formula and nurse initials. During an interview on 12/09/2024 at 9:30 a.m. S1 LPN (Licensed Practical Nurse) acknowledged the enteral feeding bag had no label and should. Resident #4 Review of Resident #4's medical records revealed an admitted [DATE] with the following diagnoses, in part: dysphagia oropharyngeal phase, moderate protein-calorie malnutrition, and gastrostomy status. Review of Resident #4's Physician's Orders revealed an order dated 11/15/2024 for tube feeding formula: Peptamen 1.5 bolus/carton daily at 1p.m and an order dated 10/16/2024 for on at 7p.m./off at 9a.m. tube feeding formula: Peptamen 1.5 at 50ml/hr for 14 hours. Observation on 12/09/2024 at 9:40 a.m. revealed Resident #4's enteral feeding bag with a torn label showing a date of 12/06/2024 and a date of 12/07/2024 written on bag. Further observation revealed enteral feeding bag was not labeled with resident name, formula, time, nurse initials. During an interview on 12/09/2024 at 9:40 a.m. S2 LPN acknowledged the enteral tube feeding bag had been reused and not been changed since 12/07/2024 and should have. S2 LPN further acknowledged there was no label with resident name, date, time, formula and nurse initials. Resident #5 Review of Resident #5's medical records revealed an admitted [DATE] with the following diagnoses, in part: dysphagia following unspecified cerebrovascular disease, moderate protein-calorie malnutrition, and gastrostomy status. Review of Resident #5's Physician's Orders revealed an order dated 09/24/24 for on at 7p.m./off at 9a.m. tube feeding formula: Nutren 2.0 at 50ml/hr for 14 hours and tube feeding formula: Nutren 2.0 bolus give one carton per PEG (Percutaneous Endoscopic Gastrostomy) tube twice daily. Observation on 12/09/2024 at 9:00 a.m. failed to reveal Resident #5's enteral feeding bag labeled with resident name, date, time, formula and nurse initials. During an interview on 12/09/2024 at 9:00 a.m. S3 LPN acknowledged the enteral feeding bag was not labeled with resident name, time, and nurse initials and should be.

Based on observations and interviews, the facility failed to ensure dependent residents were provided Activities of Daily Living for 2 (#2, #5) out of 5 (#2, #3, #4, #5, #6) residents observed. The facility failed to trim Resident #2 and Resident #5's fingernails. Findings: Review of Resident #2's medical records revealed an admitted [DATE] with the following diagnoses, in part: cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of persistent vegetative state/no discernible consciousness. Further review of functional status revealed Resident #2 requires total assistance. Observation on 12/09/2024 at 9:30 a.m. revealed Resident #2's fingernails were long on both hands. During an interview on 12/09/2024 at 9:30 a.m. S1 LPN (Licensed Practical Nurse) acknowledged Resident #2's fingernails were long and should be trimmed. Review of Resident #5's medical records revealed an admitted [DATE] with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and cognitive communication deficit. Observation on 12/09/2024 at 9:00 a.m. revealed Resident #5's fingernails long on both hands. During an interview on 12/09/2024 at 9:00 a.m. S3 LPN acknowledged Resident 5's fingernails were long and should be trimmed.

Based on record reviews and interviews, the facility failed to ensure residents on dialysis received services consistent with professional standards of practice for 1 (#62) of 3 (#44, #55, #62) sampled residents receiving dialysis. The facility failed to monitor dialysis access site for Resident #62. Findings: Review of Facility's Hemodialysis - Care of Resident Policy revealed: Document the following: 2. Condition of cannula site. Review of Resident #62's Medical Record revealed an admitted [DATE] with the following diagnoses, in part: end stage renal disease, dependence on renal dialysis, essential (primary) hypertension and type 2 diabetes mellitus with hyperglycemia. Review of Resident #62's Comprehensive Care Plan revealed included the problem of receives dialysis with approaches that included check shunt site daily bruit or thrill, pain, swelling, redness, warmth, drainage .notify MD (Medical Director) of any complications. Review of Resident #62's December 2023 and January 2024 MAR (Medication Administration Record)/TAR (Treatment Administration Record) failed to reveal left chest wall dialysis access site was monitored. During an interview on 01/10/2024 at 2:20 p.m. S1 DON (Director of Nursing) reviewed Resident #62's December 2023 and January 2024 MARs (Medication Administration Records)/TARs (Treatment Administration Records) and acknowledged they failed to reveal documentation of left chest wall dialysis access site monitoring

Based on record reviews, observations, and interviews the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practiced for 2 (#14, #55) of 3 (# 14, #55, #62) residents reviewed for respiratory care. The facility failed to ensure the oxygen tubing and humidification bottles were changed and dated weekly and oxygen and nebulizer tubings were bagged when not in use. Findings: Review of the facility Infection Control Oxygen Equipment Cleaning policy dated 03/2018 revealed in part: 6. Refillable humidifiers should be washed and refilled every 72 hours with distilled or sterile water and dated. 7. Tubing should be replaced every 7 days 8. Masks should be replaced every 7 days 9. Cannulas should be replaced every 7 days 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Resident #14 Observation on 01/08/2024 at 8:22 a.m. revealed resident #14's oxygen tubing dated 12/15/2023 and humidification bottle dated 07/02/2023. Observation on 01/09/2024 at 3:00 p.m. revealed resident #14's nasal cannula tubing on the floor unbagged dated 12/15/2023, and humidification bottle with no date. Review of resident #14's record revealed an admitted [DATE] with diagnoses that include in part chronic obstructive pulmonary disease, chronic pulmonary edema, and anxiety. Review of resident #14's January 2024 Physician orders revealed an order dated 07/20/2023 for oxygen at 2 liters/minute per nasal cannula continuously. Review of resident #14's MDS (minimum data set) dated 11/14/2023 revealed in part: Health Conditions: Shortness of breath/trouble breathing. Special treatments: Oxygen therapy Resident #55 Observation on 01/08/2024 at 9:30 a.m. revealed resident #55's nasal cannula on the floor unbagged and no date, and nebulizer mask dated 12/09/2023. Observation on 01/09/2024 at 3:45 p.m. revealed resident #55's nasal cannula on the floor unbagged and no date, and nebulizer mask dated 12/09/2023. Review of resident #55's record revealed an admitted [DATE] with diagnoses that include in part supraventricular tachycardia, acute and chronic respiratory failure, chronic systolic congestive heart failure, and obstructive sleep apnea. Review of resident #55's January 2024 Physician orders dated: 12/19/2023 Iprat-Albut 0.5-3 (2.5) milligram/3 milliliters. Give one unit dose via inhalation per nebulizer every 6 hours as needed for shortness of breath/wheezing 12/19/2023 Change oxygen & nebulizer tubing weekly. 12/19/2023 Oxygen at 3 liters via nasal cannula at night. Review of resident #55's MDS dated [DATE] revealed in part: Health Conditions: Shortness of breath/trouble breathing. Special treatment: Oxygen therapy During an interview on 01/09/2024 at 3:48 p.m. S3 LPN (Licensed Practical Nurse) reported the evening shift should change the tubing out for oxygen and nebulizers weekly and the tubing and mask should be bagged. S3 LPN acknowledged it had not been done and should have been.

Based on record reviews, the facility failed to ensure documentation of resident rights regarding Advance Directives had been presented and/or explained to the residents or their responsible party for 2 (#3, #17) of 33 sample residents. Findings: Review of resident #17's revealed admitted [DATE]. Review of resident #17's clinical records failed to reveal an Advanced Directive Acknowledgement form. 40193 Resident #3 Review of resident #3's revealed admitted [DATE]. Review of resident #3's clinical records failed to reveal an Advanced Directive Acknowledgement form.

Based on interviews, record reviews and facility policy review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#5) of 3 (#1, #2, #5) residents reviewed for quality of care out of 5 total sampled residents. The facility failed to ensure a resident's (#5) positive urine culture and sensitivity was reviewed and the facility failed to ensure a resident (#5) received treatment for [REDACTED]. This deficient practice resulted in an actual harm for Resident #5 on 12/1/2018 when the nursing staff failed to review and act upon the final results (Escherichia coli) of an urine C&S (culture and sensitivity) which had been collected on 11/28/2018. On 12/8/2018, the resident was observed to be lethargic with a blood pressure of 87/39 and a pulse of 108. The resident was transferred to a local hospital and diagnosed with [REDACTED]. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of Resident # 5's medical record revealed an admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident # 5's comprehensive care plan dated 8/21/18 revealed the following: - Indwelling catheter with approaches including intake and output, change catheter every month and prn (as needed), position urine catheter bag below bladder, encourage fluid intake and observe for signs of infection such as changes in mental status, increased temperature, decreased output. -Alteration in elimination pattern incontinent of bowel/bladder with approaches including use incontinent briefs as needed, incontinent care q (every) 2 hours and prn, report signs and symptoms of UTI (urinary tract infection) to MD (physician). -[DIAGNOSES REDACTED]. Review of Resident # 5's nurse practitioner's progress note dated 11/28/18 revealed: Chief Complaint: decline in urine quality History of present illness: Resident is an [AGE] year old female with chronic Foley catheter reported to have a decline in urine quality since yesterday. Resident typically has clear yellow urine however noted to have amber colored urine with increased sediment today on exam. Review of systems: [MEDICAL CONDITION] - Foley catheter with darkened yellow urine/sediment. Physical exam: [MEDICAL CONDITION] - No suprapubic tenderness or bladder distention. Foley catheter with amber urine/sediment. [DIAGNOSES REDACTED]. Plan: Change Foley catheter. Obtain UA (urinalysis) with C&S. Review of Resident # 5's urinalysis with microscopic laboratory results revealed: Collection date: 11/28/18, 5:00am Received in lab: 11/28/18, 6:36pm Printed: 11/28/18, 7:08pm Abnormal values: bilirubin 1+ (reference range Negative); blood trace-intact (reference range Negative); pH 8.5 (reference range 5.0-7.5); protein 2+ (reference range Negative); leukocyte esterase 2+ (reference range Negative). Handwritten notation on printed lab results: Wait on Cx (culture) results. Further review of Resident # 5's urinalysis results printed on 11/29/18 at 9:01pm revealed same results as above with the addition of: Urine WBC (white blood cell) 30-40; Urine RBC (red blood cell) 5-8; Renal cells few; Triple [MEDICATION NAME] Moderate. Handwritten notation on printed lab results: Waiting for C&S (culture and sensitivity), signed 11/30/18 by APRN (advanced practice registered nurse). Review of Resident # 5's Urine C&S results dated 12/1/18 at 2:20pm revealed Final Result of Escherichia coli. Further review of the report revealed no facility notation of acknowledgement on the report. Further review revealed the urine C&S was printed on 12/9/18 at 11:36am. Review of facility's policy on Laboratory Services revealed in part: 4. The attending physician, physician assistant, nurse practitioner, or clinical nurse specialist will be notified of abnormal laboratory results promptly after the facility has been advised of the results. Guidelines for Reporting Abnormal Test Results to Physicians may be used when determining physician next office day notification. The notification of the physician will be documented in the medical record. Review of Resident # 5's nurses notes revealed: 11/28/18, 8:15am: Late entry for 0500. Resident observed with decreased output. Informed by nursing assistant that resident adult depend slightly wet. Resident 16Fr (French) catheter removed with tip intact. Replaced with 16Fr catheter using sterile technique. Inflated with 10 ml (milliliters) of sterile water, urine return of 800 ml of urine. Urine cloudy with brown sand like sediment, foul purulent odor, resident abdomen non-distended and soft. Urine collected for urinalysis with culture and sensitivity. 12/8/18, 5:34pm: Lethargic, increased weakness, BP (blood pressure) 87/39, pulse 108, respirations 22, temperature 98.1. 12/8/18, 10:36pm: Late entry for 4pm. Unnamed CNA (certified nursing assistant) spoke with writer at nurse's station and stated, can you come and check on Resident # 5, I can't wake her up. Resident # 5 observed in room lying in bed with eyes closed. No signs of respiratory distress noted. Skin warm and dry, lethargic, respond to verbal/tactile stimuli by groaning, BP 87/39, pulse 108, respirations 22, temperature 98.1 Axillary, O2sat (oxygen saturation) 97% RA (room air). Family at bedside and notified resident will be transferred out to local hospital per ambulance services. Ambulance services notified. Resident transferred out to local hospital via stretcher at 418pm. Report called in to nurse at local hospital emergency room at 9PM. Writer called local hospital for follow up. Spoke to nurse. He stated resident is admitted for septic shock, [MEDICAL CONDITION]. 12/9/18, 6:39am: Addendum: Prior being transferred out to local hospital, resident noted with 16Fr Foley catheter in place draining brownish discolored urine, 150 ml urine observed in Foley catheter drainage bag. 12/9/18, 6:51am: Clarification: On 12/8/18 at 530pm 400 hall CNA spoke with writer at nurse's station and requested writer to check on resident. Resident assessed per writer, spoke with family/daughter at bedside and informed them resident will be transferred out to local hospital. Resident transferred out facility at 6PM per stretcher via ambulance services. Review of Resident # 5's (MONTH) and (MONTH) (YEAR) physician's orders [REDACTED].>Review of Resident # 5's medical record from local hospital revealed: Admission history and physical dated 12/8/18 with Assessment - [MEDICAL CONDITION], possibly septic shock secondary to hemorrhagic [MEDICATION NAME]/possible [MEDICAL CONDITION]; severe lactic acidosis; [DIAGNOSES REDACTED]; [MEDICAL CONDITION] secondary to volume depletion; acute [MEDICAL CONDITION], suspected prerenal; severe leukocytosis with left shift; normocytic [MEDICAL CONDITION]; severe dementia. Plan - admit to ICU (intensive care unit). Urinalysis results dated 12/8/18 - 4+ bacteria, many white blood cells clump, worried for maybe [MEDICAL CONDITION], 1+ blood, 2+ leukocytes, very turbid. Frank pus is visualized throughout the Foley tube. Review of Resident # 5's urinalysis and urine culture and sensitivity results from 11/28/18 with S2 DON (Director of Nurses) on 4/9/19 at 2:00pm revealed a notation on urinalysis results of awaiting C&S results and lack of notation on the C&S results of physician notification. During an interview on 4/9/19 at 2:00pm S2 DON stated the facility dropped the ball on following up on Resident # 5's pending urine C&S results and there were no procedures in place to trigger the follow up of a pending urine C&S result. S2 DON stated she was informed by the laboratory that the urine C&S results were faxed to the facility on [DATE]. S2 DON stated Resident # 5's urine C&S results were not reviewed and the physician was not notified. S2 DON further stated Resident # 5 was not treated for [REDACTED]. S2 DON stated Resident #5's condition worsened and subsequently had to be admitted to a local hospital for treatment on 12/8/18. During an interview on 4/9/19 at 2:00pm S1 Administrator stated S2 DON had taken full responsibility for failure to follow up on Resident # 5's urine C&S results. Review of Resident # 5's Intake and Output Roster for urine output from 11/1/18 to 12/31/18 revealed a decrease in urine output as evidenced by the following dates and urine outputs: 12/1/18 = 1400 cc (cubic centimeters), 12/2/18 = 1700 cc, 12/3/18 = 2025 cc, 12/4/18 =1030 cc, 12/5/18 = 830 cc, 12/6/18 = 500 cc, 12/7/18 = 520 cc, 12/8/18 = 500 cc. Review of Resident # 5's Intake and Output Roster with S2 DON for urine output from 11/1/18 to 12/31/18 revealed Resident # 5 had a decrease in urine output from 12/4/18 to 12/8/18. During an interview on 4/9/19 at 2:35pm S2 DON stated the decrease in urine output from 12/4/18 to 12/28/18 for Resident # 5 was not reported to the physician representative. During a telephone interview on 4/10/19 at 3:40pm S5 LPN (Licensed Practical Nurse) stated Resident # 5 was in her room on 11/28/18 when the CNA reported to LPN of decreased urine output for Resident # 5. LPN stated she checked on Resident # 5 and found her catheter bag with cloudy urine with sediment and collected a urine sample. LPN stated she changed Resident # 5's Foley and residual of 800 ml of urine was collected. LPN stated she worked nights. When surveyor asked if LPN made a notation of the urine specimen sent out to the lab on 11/28/18 in the 24 Hour Report book, LPN stated she could not recall if she had done so. During a telephone interview on 4/10/19 at 3:33pm S4 LPN stated Resident # 5 was in her room on 12/8/18 when the CNA asked LPN to check on Resident # 5 because Resident # 5 wasn't responding. LPN went to Resident # 5's room and found her to be breathing without respiratory distress but not responding to verbal stimuli. LPN reviewed Resident # 5's BP of 87/39 and brownish colored urine in catheter bag. LPN stated she did not collect a urine specimen from Resident # 5. LPN stated she initiated Resident # 5 being sent to local emergency room . LPN only worked weekends and stated the weekend prior Resident # 5 was her usual self. When asked by the surveyor if LPN was aware of a urine specimen drawn on Resident # 5 on 11/28/18, LPN responded that she was not aware of a previous urine specimen. During an interview on 4/9/19 at 3:35pm S2 DON stated she in-serviced the staff on 12/10/18 regarding following up on laboratory results, to place notifications of pending laboratory results in the staff 24 Hour Report book reviewed by staff daily so that other staff and shifts would be aware of pending laboratory results. During an interview on 4/10/19 at 10:50am S3 LPN stated the staff utilizes the 24 Hour Report book to communicate with other shifts any pending lab results, new lab draws expected, or resident events. During a telephone interview on 4/10/19 at 3:33pm S4 LPN further stated she attended an in-service presented by DON regarding follow up of lab results. LPN stated a notation of lab specimen submissions should be made in the 24 Hour Report book to alert other shifts of pending lab results. LPN stated she would check the 24 Hour Report book at the beginning of her shift for any pending lab or new resident events. During a telephone interview on 4/10/19 at 3:40pm S5 LPN further stated she attended an in-service presented by DON in (MONTH) (YEAR) regarding follow up of lab results. LPN stated a notation of lab specimen submissions should be made in the 24 Hour Report book to alert other shifts of pending lab results. LPN stated she would check the 24 Hour Report book at the beginning of her shift. Review of Resident # 5's medical record revealed Resident # 5 was discharged to the community on 3/22/19 and was not in the facility at the time of the survey. Review of the facility's Corrective Action Plan dated 12/10/18 revealed: Problem Identified: Facility failed to notify MD timely of results of a UA with C&S indicating resident was + (positive) for UTI with Escherichia coli. The nurse that collected the urine failed to document an order for [REDACTED].>Plan of Action: Audit of comparison of nurses notes against MD orders to note any lab that is obtained requiring MD notification. In-service Provided - Nursing in-serviced on timely follow up for all lab results. Monitoring (who, what, when): DON or designee will review lab results daily for results that require MD notification for change in treatment/orders. DON or designee will review MD orders and nurse's notes to ensure lab results are followed up on. Follow-up for Effectiveness: Current plan of action effective: yes, date 1/11/19. Resolved Date: 1/11/19. The facility has implemented the following actions to correct the deficient practice from 11/28/18: 1. Facility in-serviced the staff on utilizing the 24 Hour Report book to communicate with other staff and shifts any pending lab results, new lab draws expected, or resident events or upcoming appointments. 2. During the survey, staff indicated they had been in-serviced on utilizing the 24 Hour Report book to document and review for pending lab results. 3. During the survey, staff indicated they utilize the 24 Hour Report book to document pending lab results and review the 24 Hour Report book at the beginning of their shift for knowledge of pending lab results.

Based on record reviews and interviews the facility failed to provide the necessary care and services for 1(#) of 5 (#2, #3, #4, #5) residents out of a total census of 120 (according to the resident Census and Conditions record provided by the facility ' s staff) residents to attain or maintain their highest practical well-being by: 1. Failing to ensure Resident #1 ' s Physician was immediately informed of a change in condition related to a resident ' s fall. 2. Failing to assess Resident #1 for pain after the resident fell from the wheelchair to the floor of the van. Resident #1 had severe cognitive impairment. The deficient practice resulted in actual harm for Resident #1 on February 29, 2016 when the resident fell from the wheelchair while being transported in the facility ' s van. The van driver stopped the van in a convenience store parking lot as instructed by the Administrator until the Administrator, Maintenance Man and a CNA arrived to help the van driver place the resident back in the wheelchair without the resident being assessed by medical personnel. The resident was taken to the facility and placed in her bed. The resident was transported to a local hospital on March 1, 2016 where X-rays revealed acute, non-displaced supracondylar [MEDICAL CONDITION] femur just above the knee prosthesis. Anterior dislocation of the right knee arthroplasty. Findings: During an interview on 3/7/2016 at 2:00 PM S3 Van Driver stated on 2/29/2016 he had picked resident #1 up from the [MEDICAL TREATMENT] Center. S3 Van Driver stated he was returning to the facility with 2 residents when he had to slam on his brakes to keep from having a wreck. S3 Van Driver stated when he looked to the back of the van he only saw one person sitting. Resident #1 had slide out of her wheelchair onto the van floor. S3 Van Driver stated he phoned the Administrator from the van to report what had happened. S3 Van Driver stated he was told by S1 Administrator to go to the parking lot of a convenience store and she and other staff would come and help get resident #1 off the floor of the van. S3 Van Driver stated he had been taught to call 911 if something like this happened. S3 Van Driver stated S1 Administrator, 2 CNAs and the maintenance supervisor came to help get resident #1 off the van floor. S3 Van driver stated the facility did not send a nurse or a medically trained person to the accident site to evaluate resident #1 following the accident or prior to the return to the facility. Review of the facility ' s Policy and Procedure regarding Medical Emergency for the company/facility vehicle. Any time there is an emergency or safety issue, the driver of the facility owned vehicle must. Call 911-follow instructions as advised by the 911 responder. (Examples: resident falls from seat or wheelchair; Look for heavy bleeding and report to the EMT or 911 Responder. Reassure Resident. Stay with Resident. During an interview on 3/9/2016 at 10:00 AM S1 Administrator acknowledged the facility failed to follow their Policy and Procedure when resident #1 fell to the floor of the van. S1 Administrator stated we were wrong in that we did not call 911. During an interview on 3/9/2016 at 10:00 AM S2 DON stated resident #1 returned to the facility following an accident on the van between 4:30 and 5:00 PM on 2/29/2016. She stated the initially assessed Resident #1 when the resident returned to the building. She stated she did not document the assessment and ask the charge nurse to write down her assessment. Further review of the clinical record revealed no assessments of resident #1's injuries on return to the facility. During the course of the survey, the facility did not provide the post assessment completed by the DON. Review of the clinical records failed to reveal the physician was notified of resident #1's accident. During an interview on 3/14/16 at 9:15 AM S4 Maintenance Supervisor stated he was aware of the Policy and Procedure for obtaining emergency care when a resident is involved in an accident during transport. S4 Maintenance Supervisor stated he had trained the Van driver on Policy and Procedure regarding a medical emergency with the van and calling 911 responders in the event of a van accident. He stated he followed the directions from Administrator and did not follow the facility's Policy and Procedure. Review of Resident #1's 14 Day MDS (Minimum data Set) revealed a cognitive score of 6, which indicates severe impairment. Review of a Nurse's Note dated 2/29/2016 at 9:41 PM revealed a mobile x-ray was completed at the bedside of resident #1. Further review of the clinical record failed to reveal an X-ray order for Resident #1. Review of a Nurse's Note dated 3/1/2016 12:23 AM revealed a late entry nurse's note for 10:00 PM: resident up in bed resting with eyes open. No needs /concerns voiced at this time. O2 sat 96% RA (room air). Resident noted whimpering and complaint of pain, but denied PRN (as necessary) pain medication being administer for pain. Purplish bruising note to bilateral legs, minimal redness noted intact to right lower leg, X-ray results in progress due to fall incident. Will continue to monitor. Review of a Nurse ' s Note dated 3/1/2016 at 12:46 AM X-ray results received per mobile X-ray. Significant findings are pelvis and right hip negative. Acute, no displaced supracondylar [MEDICAL CONDITION] femur just above the knee prosthesis, anterior dislocation of the right knee arthroplasty. Nurse Practitioner notified at this time. New order to send resident out first thing in the AM. Review of a telephone Physician order [REDACTED]. Review of resident #1 mobile x-ray results revealed the date of the exam 2/29/2016; history of fall, and pain. IMPRESSION: Acute, non-displaced supracondylar [MEDICAL CONDITION] femur just above the knee prosthesis. Anterior dislocation of the right knee arthroplasty. Review of February 2016 Physician order [REDACTED]. Review of resident #1 ' s February 2016 MAR (Medication Administration Record) revealed on 2/29/2016 at 5:49 PM [MEDICATION NAME] HCL 50 mg tablet was administrated for relief of pain. Review of the clinical record revealed the physician was not notified for re-evaluation/adjustments of pain medication needs following Resident #1 ' s accident. Review of resident #1 ' s triage assessment on arrival to a local hospital emergency roiagnom on [DATE] at 8:37 AM revealed the following: appears in no apparent distress, behavior is appropriate for age. Pain: Complains of pain in right leg. Pain does not radiate, currently is 8 out of 10 on a pain scale. Quality of pain is described as aching. Pain began 1 day ago is continuous.