Every finding on record at Hillview Community Living Center

Based on policy review, review of Center for Disease Control (CDC) guidelines, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection during wound care and tracheostomy care for 2 of 2 (Resident #4 and #7) sampled residents. The findings include: 1. Review of the facility policy titled, Hand Hygiene Policy and Procedure, dated 4/11/2023, revealed .Hand hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination.The Centers for Disease Control and Prevention (CDC) defines hand hygiene as cleaning your hands by using either handwashing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated August 2009, revealed .Resident-care equipment, including reusable items .will be cleaned and disinfected according to CDC [Centers for Disease Control] recommendations for disinfection .Reusable items are cleaned and disinfected or sterilized between residents . Review of the CDC website article titled About Handwashing, dated 2/16/2024 revealed .Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs.Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.Scrub your hands for at least 20 seconds.Rinse your hands well under clean, running water.Dry your hands using a clean towel or an air dryer. 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated she was cognitively intact. Resident #4 had a Stage 3 pressure ulcer. Review of the Physician's Orders dated 12/10/2025, revealed Clean buttocks sacral wound with wound cleanser, pack sacrum with .iodoform [used during wound care to promote healing] strip.one time a day for wound care. Observation during wound care on 12/16/2025 at 1:20 PM, revealed Licensed Practical Nurse (LPN) C obtained wound care supplies and scissors from the treatment cart and cut the packing strip with the scissors, without disinfecting them prior to use. LPN C entered Resident #4's room, washed her hands for 4-5 seconds, donned her gloves, and placed the supplies on the over the bed table without a barrier. LPN C returned to the treatment cart, obtained 4x4 gauze from cart, sprayed wound cleanser on the gauze, and placed the 4x4 gauze on the top of the treatment cart without a barrier. LPN C entered the resident's room with gauze in her hand and turned to administer wound care with the contaminated gauze and was stopped by the surveyor and was asked if she was going to use the gauze that was placed on the treatment cart without a barrier. LPN C did not verbally respond but discarded the gauze. LPN C removed her gloves and returned to the treatment cart for a clean supply of 4x4 gauze. LPN C performed hand hygiene in the bathroom for 4-5 seconds, donned gloves, removed the soiled dressing from the resident's left hip, removed her gloves, and stated I'm changing gloves since I removed the soiled dressing. LPN C donned gloves and performed wound care to the left hip. LPN C removed her gloves, performed hand hygiene at the bathroom sink for 4-5 seconds, donned gloves, and performed wound care to the sacral wound. LPN C removed gown and gloves, and performed hand hygiene at the bathroom sink for 4-5 seconds. LPN C failed to disinfect the scissors, failed to sanitize or utilize a barrier on the top of the treatment cart and the over the bed table prior to use, failed to perform hand hygiene for the recommended length of time, and failed to perform hand hygiene after the removal of gloves. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Traumatic Brain Injury, and Tracheostomy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS assessment was not completed due to Resident #7 was rarely understood. Resident #7 received tracheostomy care. Review of the Physician's Order dated 12/10/2025, revealed Trach [tracheostomy] care Q [every] shift and prn [as needed]. During an observation and interview in Resident #7's room on 12/16/2025 at 10:55 AM, revealed LPN C donned a gown and gloves, performed hand hygiene at the bathroom sink, and turned the faucet off with her barehand. LPN C dried her hands with a paper towel, placed supplies on a barrier on the over the bed table, donned gloves, opened sterile saline, removed a 4x4 drain gauze from around the trach and discarded soiled gauze, removed her gloves, and donned new gloves without performing hand hygiene. LPN C dipped a cotton tip applicator in saline and cleansed the stoma site, removed the inner canula, removed her gloves, donned clean gloves without performing hand hygiene, cleaned the outer canula with a cotton tip applicator, inserted a new inner canula, removed her gloves, and donned clean gloves without performing hand hygiene,. LPN C placed a 4x4 drainage sponge around the trach site, removed gloves, and donned clean gloves without performing hand hygiene. LPN C lifted the gauze from around the peg tube site, removed her gloves, entered the bathroom and performed hand hygiene. LPN C removed her gown, exited the resident's room to take soiled trash to the biohazard room and failed to perform hand hygiene. LPN C returned to the nurses' station and was asked when performing hand hygiene how she should turn off the faucet. LPN C stated, with a paper towel and I didn't do that. LPN C was asked if hand hygiene should be performed after removing gloves and prior to donning a clean pair of gloves. LPN C stated, Yes. LPN C was asked if she did that. LPN C stated, No, but I should have. During an interview on 12/16/2025 at 3:09 PM, the Assistant Director of Nursing (ADON) was asked when staff are expected to perform hand hygiene. The ADON stated, Before and after the removal of gloves, and before and after any kind of patient care. The ADON was asked if wound care supplies should be placed on a soiled surface. The ADON stated, Supplies should not be placed on a soiled surface without a barrier during care. The ADON was asked the appropriate length of time for hand washing. The ADON stated, 30 seconds. During an interview on 12/16/2025 at 4:29 PM, the Director of Nursing (DON) was asked when staff should perform hand hygiene. The DON stated, Before touching the resident, before putting on gloves and changing gloves, and after leaving a resident's room. The DON was asked how long should staff wash their hands when performing hand hygiene. The DON stated, .60 seconds or [length of] happy birthday song .

Based on policy review, the facility's smoking list review, medical record review, observation, and interview, the facility failed to provide a safe environment for smoking when staff failed to provide a smoking apron for 1 of 3 (Resident #12) sampled residents reviewed for smoking. The findings include: 1. Review of the undated facility policy titled, Smoking and Tobacco Use Policy and Procedure, revealed .Provide a safe environment for those residents who choose to smoke. Review of the undated facility policy titled, Accidents and Incidents, revealed .It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible.Residents are to be routinely evaluated for individual risk factors in areas to include.smoking. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Convulsions, Major Depressive Disorder, Cognitive Communication Deficit, and Anxiety. Review of the Care Plan dated 7/18/2024, revealed .The resident requires a smoking apron while smoking. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 5 on the Brief Interview for Mental Status (BIMS), which indicated the resident was severely cognitively impaired. Review of Resident #12's Smoking and Tobacco Evaluation dated 10/21/2025, revealed .Resident need for adaptive equipment.Smoking apron. Review of the undated facility's Smoking List revealed Resident #12 was on the list. Review of the undated facility Smoking Apron List revealed Resident #12 was not on the list of residents for the use of a smoking apron on every smoke break. During an observation in the designated smoking area on 12/15/2025 at 10:13 AM, Resident #12 was observed smoking without an apron. During an observation in the designated smoking area on 12/16/2025 at 10:03 AM, Resident #12 was observed smoking without an apron. During an interview on 12/16/2025 at 10:13 AM, LPN D was asked how staff knew who needed a smoking apron. LPN D stated, The admitting nurse completes a smoking assessment on the residents, and the list is updated if they need an apron. During an interview on 12/16/2025 at 10:37 AM, the MDS Coordinator was asked when Resident #12 was care planned for the use of a smoking apron. The MDS Coordinator stated, On 7/18/2024 .she should be on the smoking apron list, but she's not on the list given to me this morning. The MDS Coordinator was asked if Resident #12 should have been on the smoking apron list. The MDS Coordinator stated, Yes, she should have.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain emergency supplies at the bedside, failed to change oxygen tubing weekly, and failed to document oxygen use for 1 of 1 (Resident #7) sampled residents reviewed for tracheostomy care. The findings include: 1. Review of the undated facility policy titled, Tracheostomy Care and Suctioning Policy, revealed .maintain a patent airway, to evacuate secretions, to prevent and/or reduce infection. 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Traumatic Brain Injury, and Tracheostomy (artificial airway opening in the trachea). Review of the Care Plan dated 7/24/2024, revealed .Change humidified bottle and O2 [Oxygen] tubing weekly and prn [as needed].Suction as necessary. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not completed due to Resident #7 was rarely understood. Resident #7 received tracheostomy care and oxygen therapy. Review of the Physician's Orders dated 12/10/2025, revealed the following: a. Supplemental oxygen at 4L [liters] as needed for sats [saturation] [checking for the amount of oxygen in the blood stream] below 91% [percent] every 12 hours. b. Suction PRN as needed for increased secretions. c. Change nebulizer mask/pipe and tubing weekly and prn every night shift. d. Trach [tracheostomy] care Q [every] shift and prn. Review of the Medication Administration Record (MAR) dated 12/2025, revealed .Supplemental oxygen at 4L as needed . was not documented as being administered on 12/15/2025 and 12/16/2025. Observations in Resident #7's room on 12/15/2025 at 8:55 AM, 11:06 AM, 2:14 PM, and 4:36 PM, revealed the resident was in bed with oxygen at 4L via (by way of) tracheostomy with the oxygen tubing dated 11/28 [2025]. A suction machine was at the bedside without a canister, and an Ambu bag (a device used to provide ventilation) was not readily accessible at the bedside. Observation in Resident #7's room on 12/16/2025 at 7:56 AM, revealed Resident #7 in bed with O2 at 4L via tracheostomy with O2 tubing still dated 11/28, the suction machine did not have a canister, and there was not an Ambu bag readily accessible at the bedside. During an observation and interview in Resident #7's room on 12/16/2025 at 10:55 AM, Licensed Practical Nurse (LPN) D performed tracheostomy care. LPN D was asked if Resident #7 was on oxygen. LPN D stated, Yes, she's always on oxygen. LPN D was asked the date on the oxygen tubing. LPN D stated, 11/28. LPN D was asked how often the tubing should be changed. LPN D stated, Weekly on night shift. LPN D was asked if it had been changed weekly based on the date of the tubing. LPN D stated, No. LPN D was asked if there should be a canister in the suction machine. LPN D stated, Yes. LPN D was asked if there was an Ambu bag readily accessible in the resident's room. LPN D looked in the dresser drawers and storage unit drawers for an Ambu bag, and LPN D stated, I know they are on the crash carts out on the hall, but I am not sure. During an interview on 12/16/2025 at 4:29 PM, the Director of Nursing (DON) was asked if emergency equipment such as a suction canister and an Ambu bag should be readily accessible for tracheostomy residents. The DON stated, Yes. The DON was asked how often oxygen tubing should be changed. The DON stated, Once a week. The DON was asked if oxygen should be signed out on the MAR if it is administered to the resident. The DON stated, Yes, it should be signed out.

Based on policy review, medical record review, and interview, the facility failed to conduct a care plan conference with the resident and/or family representative for 2 of 18 (Resident #12 and #19) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, Care Plan Policy and Procedure, revealed .The Resident's care plan will be reviewed with the resident, responsible party and interdisciplinary team quarterly and as needed during the care plan meeting as requested. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Convulsions, and Cognitive Communication Deficit. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was severely cognitively impaired. Review of the Care Conference notification form revealed Resident #12 was invited to attend a Care Conference on 7/30/2025 at 10:00 AM. The section of the form that states plan to attend or not to attend was not addressed. The form was not signed or dated. Review of the quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 5 on the BIMS assessment, which indicated the resident was severely cognitively impaired. Review of the Care Conference notification form revealed Resident #12 was invited to attend a Care Conference on 10/29/2025 at 10:10 AM. I do not plan to attend was marked, with Resident #12's signature and dated 10/24/2025. During a telephone interview on 12/15/2025 at 1:51 PM, Resident #12's responsible party stated that the facility had not invited him to attend any care plan meetings. During an interview on 12/16/2025 at 8:50 AM, the Social Services Director (SSD) was asked who was invited to attend Care Conference meetings. The SSD stated, The residents are invited or family members. The SSD was asked, who was invited if the resident was cognitively impaired. The SSD stated, the family should be. The SSD was asked if Resident #12 had impaired cognition. The SSD stated, Yes and her family should have been invited instead of her. 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Convulsions, Anxiety, Insomnia, and Gastro-Esophageal Reflux Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment, which indicated Resident #19 was cognitively intact. Review of the Care Conference notification form revealed Resident #19 was invited to attend a Care Conference on 10/29/2025 at 10:20 AM. The section of the form that stated plan to attend or not to attend was not addressed. The form was not signed. Review of the facility Care Conference Sign-In Sheet dated 10/29/2025, revealed Resident #19 was not in attendance and had not signed the designated space for declination to attend. During an interview on 12/15/2025 at 1:40 PM, Resident #19 was asked if they are invited to attend their Care Plan meetings. Resident #19 stated, I don't know anything about those. During an interview on 12/16/2025 at 8:16 AM, the MDS Coordinator was asked for documentation related to Resident #19's attendance or invitation to care plan meetings. The MDS Coordinator stated, He did not attend.There's a place at the bottom where he should have signed that he refused to attend but Social Services didn't have him sign the refusal.The last signed refusal was for May 2025. During an interview on 12/16/2025 at 8:23 AM, the SSD was asked if there were any notes or signatures that indicate Resident #19's attendance or declination to attend care plan meetings. The SSD stated, I did not get a signature of refusal to attend. The SSD was asked if there should be a signature or a note that indicates a resident's attendance, refusal, or when they are made aware of care plan meetings. The SSD stated, Yes, there should be. I just didn't get him to sign it. During an interview on 12/17/2025 at 8:43 AM, the Director of Nursing (DON) was asked if residents should be invited to participate in their care plan meetings. The DON stated, Yes. The DON was asked should their attendance or declination be documented. The DON stated, Yes.

Based on the facility Delegation of Responsibility for the Management of Personal Funds form, medical record review, Trial Balance form, and interview, the facility failed to provide quarterly statements for resident accounts for 2 of 42 (Resident #1, #19) sampled for personal funds. The findings include: 1. Review of the facility form titled, Delegation of Responsibility for the Management of Personal Funds, dated 1/20/2009, revealed .I understand that I shall receive an accounting of the financial transactions to these funds no less than quarterly. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Viral Hepatitis C, and Seizures. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was severely cognitively impaired. During a telephone interview on 12/15/2025 at 3:25 PM, Family Member F, Resident #1's Responsible Party, was asked who manages Resident #1's funds. Family Member F stated, The facility. Family Member F was asked if they received quarterly statements related to Resident #1's funds. Family Member F stated, No .I have asked for statements. Review of the Trail Balance form dated 12/17/2025, revealed Resident #1 had a balance of $989.32. 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Convulsions, Anxiety, Insomnia, and Gastro-Esophageal Reflux Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #19 scored a 15 on the BIMS assessment, which indicated Resident #19 was cognitively intact. During an interview on 12/15/2025 at 1:39 PM, Resident #19, who is his own Responsible Party, was asked who manages his funds. Resident #19 stated, It goes to the facility. Resident #19 was asked if he received quarterly statements related to those funds. Resident #19 stated, I don't know how much money I get really.No, I don't get statements. Review of the Trail Balance form dated 12/17/2025, revealed Resident #1 had a balance of $2420.30. During an interview on 12/16/2025 at 10:19 AM, The Business Office Manager (BOM) was asked when the last quarterly statements for resident funds was provided to the Residents and Resident Representatives. The BOM stated I mailed them out in October [2025] to the addresses on file.I do not have a note or anything to show who all I sent out. The BOM was asked if there would be a reason anyone may not have gotten a statement. The BOM stated, No. The BOM was asked if Resident #1 and Resident #19 were sent a statement at that time, and who the statement was sent to. The BOM looked up the addresses on file and stated, [Resident #19's] went to [Resident #19's home address] and was addressed to [Resident #19].[Resident #1's] went to [Family Member F] .I didn't keep anything related to who I sent the statements to. During an interview on 12/17/2025 at 8:43 AM, the Director of Nursing (DON) was asked if a resident had a resident fund should the resident or their representative receive statements quarterly and upon request regarding their account balance/transactions. The DON stated, Yes. The DON was asked if a resident resides in the facility long term and is their own Responsible Party, should they also receive a statement quarterly and upon request, and should it be provided to them at the facility where they reside. The DON stated, I would think they should receive their own statements here.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when medications were found in a resident's room for 1 of 45 (Resident #19) sampled residents. The findings include: Review of the undated facility policy titled, Medications Storage Policy and Procedure, revealed .Medications and biologicals will be maintained in a secured location only accessible to designated staff. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Convulsions, Anxiety, Insomnia, and Gastro-Esophageal Reflux Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #19 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #19 was cognitively intact. Review of the Physician Orders dated 12/10/2025, revealed no active order for antacids tablets. During an observation and interview in Resident #19's room on 12/15/2025 at 9:19 AM, 3 large pink tablets were observed in a small clear medicine cup, on the windowsill beside the resident's bed. Resident #19 was asked what the pills were. Resident #19 stated, They are antacids. Observation in Resident #19's room on 12/15/2025 at 10:12 AM, revealed the 3 pink tablets in a small clear medicine cup remained in the windowsill beside bed. During an observation and interview in Resident #19's room on 12/15/2025 at 10:40 AM, Licensed Practical Nurse (LPN) E was asked if medications should be left unattended and unsecured in a resident's room. LPN E stated, No, they should not be. LPN E was asked if he could confirm that the pills in the small clear medication cup on Resident #19's windowsill were antacids. LPN E stated Yes, they are. During an interview on 12/16/2025 at 8:05 AM, LPN E was asked where Resident #19 had gotten the antacids found in the resident's room on 12/15/2025. LPN E stated, His family has a history of bringing in items, there is a chance he got them from his family, or possibly the facility. I'm not certain. During an interview on 12/17/2025 at 8:43 AM, the Director of Nursing (DON) was asked if medication should be left unattended and unsecured in a resident's room. The DON stated, No.

Based on review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, medical record review, and interview, the facility failed to ensure residents were accurately assessed for weight loss and Activities of Daily Living (ADL) for 2 of 16 sampled residents (Resident #9 and #15) sampled residents reviewed. The findings include: Review of the CMS LTC Facility RAI 3.0 User's Manual Version 1.17.1 dated October 2019, pages G-24 and K-4 revealed, .Address the resident's unique needs for bathing .should be periodically evaluated .Weight loss can result in debility and adversely affect health, safety, and quality of life .Weight loss may be an important indicator of a change in the resident's status or environment . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Registered Dietician notes dated 10/21/2021, revealed Resident #9 had significant weight loss of 12.3 % in 6 months. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 was coded as weighing 199 pounds and having no weight loss. During an interview on 3/2/2022 at 6:11 PM, the MDS Coordinator confirmed the MDS should have been coded for a significant weight loss. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS dated [DATE], revealed Resident #15 was coded as bathing activity did not occur. Review of the quarterly MDS dated [DATE], revealed Resident #15 was coded as bathing activity did not occur. During an interview on 3/1/2022 at 11:50 AM, Certified Nurses Assistant (CNA) #1 confirmed Resident #15 received showers on Wednesday and Saturdays. CNA #1 confirmed Resident #15 enjoyed her showers and does not refuse them. During an interview on 3/1/2022 at 6:25 PM, The MDS Coordinator stated, .I do not honestly feel Resident #15 did not receive a shower . The MDS Coordinator confirmed she should have questioned the staff further related to bathing.

Based on policy review, medical record review, observation, and interview, the facility failed to follow its policy for weighing residents for 2 of 3 sampled residents (Resident #9 and #16) reviewed for nutritional status. The findings include: Review of the facility's policy titled, WEIGHTS: OBTAINING AND DOCUMENTING, dated 12/27/2017, revealed .Weights will also be taken upon admission .The DON or designee, the Dietary Manager, and the RD will review the weights for the current month and compare the current weight to the 30 and 180 day weights to determine significant weight losses and variances .Weekly: Admissions, readmissions, and residents .should be weighed weekly for 4 weeks or until stable .Reweighs will be done if there is a 3% [percent] or greater change from the last documented weight . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE], discharged to the hospital on 9/26/2021, and readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the entry MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #9 returned from a hospital stay on 9/28/2021. Review of the Weights and Vitals Summary for Resident #9, revealed .8/2/2021 224.9 lbs, 9/1/2021 210 lbs, 10/4/2021 205 lbs, 10/18/2021 198.8 lbs, 10/25/2021 200.6 lbs . The facility failed to obtain Resident #9's weight upon readmission from the hospital on 9/28/2021 and obtain a weekly weight for the week of 10/11/2021. During an interview on 3/2/2022 at 9:47 AM, the Registered Dietician (RD) confirmed Resident #9 had a hospitalization from [DATE] to 9/28/2021 and should have been weighed upon readmission to the facility and a weekly weight should have been obtained for the week of 10/11/2021. During an interview on 3/2/2022 at 6:26 PM, the Director of Nursing confirmed Resident #9 should have had a weight upon readmission from the hospital on 9/28/2021 and a weekly weight should have been obtained for the week of 10/11/2021. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Progress Notes revealed Resident #16 was re-hospitalized on [DATE] and returned to the facility on [DATE]. Review of the Weights and Vitals Summary revealed Resident #16 weighed 104 pounds on 10/18/2021 and 97.4 pounds on 11/15/2021. Review of the Weights and Vitals Summary revealed Resident #16 was not weighed when she returned from the hospital until 11/2/2021, 4 days later. During a telephone interview on 3/2/2022 at 12:20 PM, the RD confirmed Resident #16 should have been weighed when she returned from the hospital. During an interview on 3/2/2022 at 6:28 PM, the Director of Nursing (DON) confirmed Resident #16 went to the hospital on 10/21/2021 and returned to the facility on [DATE]. The DON confirmed Resident #16 was not weighed when she returned from the hospital until 11/2/2021.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly when opened multidose bottles without an opened date and expired medications were observed in 2 of 4 medication storage areas (West Hall Medication Cart and the Treatment Cart). The findings include: Review of the facility's policy titled, Storage of Medications, dated 9/5/2012, revealed .Medications and biologicals are stored safely, securely, and properly .Outdated, contaminated, or deteriorated medications .are removed from stock, disposed of according to procedures for medication disposal . Observation of the West Hall Medication Cart on 3/2/22 at 8:00 AM and at 5:13 PM, revealed an opened multidose bottle of Multivitamin with minerals without an opened date. Observation of the West Hall Medication Cart on 3/2/2022 at 5:16 PM, revealed an opened multidose bottle of Loratadine (an Antihistamine) without an opened date. Observation of the Treatment Cart on 3/2/2022 at 5:23 PM, revealed an expired tube of Moisturizing Hydrogel (a medication for dressing and management of wounds) with an expiration date of 6/2020. During an interview on 3/2/2022 at 8:07 AM, Licensed Practical Nurse #1 confirmed opened bottles of multidose medications should be labeled with an opened date. During an interview on 3/2/2022 at 5:25 PM, the Director of Nursing confirmed that opened multidose vials should be labeled with an opened date and expired medications should be discarded.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when food was thawed using improper procedures, 1 of 4 (Dietary Aide #1) staff members failed to perform hand hygiene, and unlabeled and undated food items were stored in 1 of 2 (Break Room) nourishment refrigerators. The facility had a census of 28 residents, with 27 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's undated Safe Food Preparation policy documented, .Many steps in safe food preparation must be controlled and monitored to prevent foodborne illness .Recommended methods to safely thaw frozen foods include .Thawing in the refrigerator .Completely submerging the item under cold water .that is running fast enough to agitate and float off loose ice particles .Thawing the item in a microwave oven, then cooking and serving it immediately .Thawing as part of a continuous cooking process . Observations in the Kitchen on 8/12/19 at 8:40 AM, revealed 3 packages of bologna thawing in a pan of standing water. Interview with the Dietary Manager on 8/12/19 at 8:50 AM, in the Kitchen, the Dietary Manager was asked about the bologna thawing in the water. The Dietary Manager stated, .they told me I could thaw it like that. 2. The facility's undated HANDWASHING PR[NAME]EDURE FOR DINING SERVICES policy documented, .Hand hygiene continues to be primary means of preventing the transmission of infection .some situations that require hand hygiene .After handling dirty dishes . Observations in the Kitchen on 8/13/19 at 1:35 PM, revealed Dietary Aide #1 rinsed dirty dishes using her bare hands, placed the dirty dishes on the dish ware rack, and into the dish ware washer. Dietary Aide #1 pulled out the clean dishes with her bare hands without washing her hands. Dietary Aide #1 removed a large container from the clean rack and placed it onto the drying rack using her bare hands, and then continued to rinse the dirty dishes. Interview with Dietary Aide #1 on 8/13/19 at 1:45 PM, in the Kitchen, Dietary Aide #1 was asked if she should have washed her hands between clean and dirty dishes. Dietary Aide #1 stated, Yes. Interview with the Dietary Manager on 8/13/19 at 2:00 PM, in the West Hall, the Dietary Manager was asked what staff should do between loading the dish ware washer with dirty dishes and handling clean dishes. The Dietary Manager stated, Wash their hands . 3. The facility's Food Storage policy dated 8/18/11 documented, .All foods stored in refrigerators and freezers that have been opened, will be .labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame . Observations in the Break Room refrigerator on 8/13/19 at 1:56 PM, revealed 24 Boost Plus supplements, 3 Boost supplements, and 3 Nephro supplements stored in this refrigerator. There was 1 half-full gallon container of whole milk with no opened date, 1 half-full gallon container of orange juice with no opened date, 1 pitcher with a small amount of orange liquid with no label or date. Interview with the Dietary Manager on 8/13/19 at 2:00 PM, in the West Hall, the Dietary Manager stated, We don't take care of those refrigerators. Interview with the Director of Nursing (DON) on 8/13/19 at 4:39 PM, in the Conference Room, the DON was asked where resident supplements and snacks were stored. The DON stated, We have some in the Break Room, and then in the med (medication) room, we have a mini (miniature) refrigerator that also has puddings that we use for med administration. It's not like a snack refrigerator. The DON was asked who was responsible for maintaining the refrigerators. The DON stated, I need to check on that. The DON was asked if she expected food items to be labeled and dated when opened. The DON stated, Resident items, yes for sure.

Based on observation and interview, the facility failed to maintain clean equipment in 1 of 25 (room [ROOM NUMBER]) resident rooms. The findings include: Observations in room [ROOM NUMBER]B on 8/12/19 at 8:55 AM, 9:51 AM, 11:45 AM, 2:20 PM, and 4:42 PM, and on 8/13/19 at 7:49 AM, revealed Resident #5 had a [MEDICAL CONDITION] (trach) (a tube placed through a hole and directly into the windpipe to assist breathing) and the bottom of the dressing to [MEDICAL CONDITION] unsecured. A stand up fan with a dirty, dusty outer grid was at the foot of the bed blowing air directly toward Resident #5's [MEDICAL CONDITION]. Observations in room [ROOM NUMBER]B on 8/13/19 at 10:55 AM, revealed Registered Nurse (RN) #1 performed [MEDICAL CONDITION] change. A stand up fan with a dirty dusty outer grid was at the foot of the bed blowing air directly toward Resident #5 during [MEDICAL CONDITION]. Interview with RN #1 on 8/14/19 at 11:02 AM, in Resident #5's room, RN #1 was asked if the outer grid of the fan was dirty and dusty. RN #1 stated, Yes, ma'am. RN #1 was asked if the fan should have been blowing directly toward Resident #5. RN #1 stated, No, ma'am.

Based on National Pressure Ulcer Advisory Panel guidelines, policy review, medical record review, observations and interview the facility failed to provide care and services to promote healing of pressure ulcers for 1 of 2 (Resident #3) sampled residents reviewed for pressure ulcers. The findings include: 1. The NATIONAL PRESSURE ULCER ADVISORY PANEL dated (MONTH) (YEAR) documented partial-thickness loss of skin with exposed dermis .should not be used to describe moisture associated skin damage (MASD) .MASD basic guidelines: No slough or eschar . 2. The facility's SKIN CARE PR[NAME]ESS policy dated 1/17/18 documented, .It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .Process Guidelines .4. If a wound is not showing signs of improvement within 2 weeks of treatment, a re-evaluation of the wound and change in treatment should be considered . 3. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].cleanse stage 3 pressure injury to right buttock with wound cleanser or NS (normal saline), pat dry with gauze, apply collagen powder to wound bed, cover with foam dressing and secure with transparent dressing every day shift for pressure injury . The Physician Telephone Order dated 5/16/19 documented, .clean MASD to right buttock with wound cleanser and dry, apply skin prep around edges and allow to dry, apply [MEDICATION NAME] dressing q (every) 3 days and prn (as needed) soilage, every 24 hours as needed for skin care . The Physician Telephone Order dated 6/5/19 documented, .Santyl Ointment 250 unit/GM (gram) ([MEDICATION NAME]) Apply to right buttock topically one time a day . Review of the Pressure Injury Report dated 5/13/19 documented, .right buttock Stage 3 wound with 75% (percent) slough-white . Review of the Wound Care Skin Integrity Evaluation completed by the Wound Care Consultant dated 5/16/19 documented, . RIGHT BUTT[NAME]K .MASD .Wound Bed .yellow 75%, Adherent Fibrous Slough . Review of the Non-Pressure Skin Report dated 5/21/19 documented, .right buttock wound as MASD with UTD (unable to determine) . Review of the Non-Pressure Skin Report dated 5/29/19 documented, .right buttock wound as MASD . Review of the Pressure Injury Report dated 6/5/19 documented, .right buttock wound as Unstageable Pressure Injury with 25% slough, 75% gran (granulation) . Medical record review revealed Resident #3 received [MEDICAL TREATMENT] 3 days a week on Tuesday, Thursday, and Saturday and a hospitalization for a [MEDICAL CONDITION] from 5/13/19 through 5/15/19. 4. Observations of Resident #3 in room [ROOM NUMBER] B on 6/4/19 at 2:10 PM revealed right buttock wound with an open circular wound with 25% white to pale yellow slough in the center of the wound with a slight amount of serosanguinous drainage. Interview with the Director of Nursing (DON) in room [ROOM NUMBER] B on 6/4/19 at 2:10 PM, the DON was asked if the wound to the right buttock was a pressure injury. The DON stated .I thought it was pressure when it was first identified, we called (Named Wound Consultant) and she thought it was MASD and we changed it (wound description). Interview with the DON in the Conference Room on 6/5/19 at 4:17 PM, the DON was asked would MASD have slough. The DON stated, No, never had experience with MASD, should have researched it . The DON was asked if she consulted with the physician after the consultant changed the treatment. The DON stated, Probably should have . Telephone interview with the Medical Director on 6/5/19 at 6:50 PM, the Medical Director was asked if MASD would have slough and the Medical Director stated, No. It would be superficial, possibly a scattered area .

Based on medical record review, observation, and interview, 2 of 2 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to ensure a gastrostomy (a tube inserted through the abdomen that delivers nutrition directly to the stomach) tube was flushed according to facility policy and physician's orders [REDACTED]. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Crush each med (medication) and give individually flushing with 5ml (milliliters) H2O (water) between each med (medication) .Flush with 60ml before and after med pass .[MEDICATION NAME] Tablet 20 MG (milligram) Give 1 tablet via (by way of) PEG (Percutaneous Endoscopic Gastrostomy)-Tube three times a day . Observations in Resident #9's room on 8/28/18 at 2:29 PM, revealed LPN #1 administered medications though Resident #9's feeding tube. LPN #1 flushed the tube with 5 ml of water by gravity, administered [MEDICATION NAME], flushed the tube with 5 ml of water, removed her gloves, washed her hands, and exited the room. LPN #1 stated, .it says to flush with 5 ml before and after meds . LPN #1 did not flush the PEG with 60 ml before and after the medication as ordered by the physician. Observations in Resident #9's room on 8/29/18 at 1:06 PM, revealed LPN #2 administered medications through Resident #9's feeding tube. LPN #2 flushed the tube with 30 ml of water, administered [MEDICATION NAME], flushed the tube with water, removed his gloves, washed his hands, and exited the room. LPN #2 did not flush the PEG with 60 ml before and after the medication as ordered by the physician. Interview with the Director of Nursing (DON) on 8/29/18 at 1:42 PM in the conference room, the DON was asked how much water should be used to flush Resident #9's gastrostomy tube prior to and after administering medications through the PEG. The DON stated, .It looks like, based on this, we need clarification (of the order) for either of them (LPN #1 and #2) to get it right .

Based on policy review, medical record review, and interview, the facility failed to ensure services were provided to attain pain relief and in accordance with physician prescribed orders for 1 of 5 (Resident #56) sampled residents reviewed for medication administration of the 29 residents included in the stage 2 review, and the facility failed to ensure communication between the facility and the [MEDICAL TREATMENT] clinic for 1 of 1 (Resident #33) sampled residents receiving [MEDICAL TREATMENT]. The failure to administer pain relieving treatment to a resident in pain and in accordance with physician's orders [REDACTED]. The findings included: 1. Review of the facility's Pain Management policy documented, .Every resident has the right to be as comfortable and pain free as possible .Pain control is essential to the continued quality and dignity of life as well as the maintenance of each resident's current level of function .2. When pain is identified, either acute or chronic, a more comprehensive assessment will be performed and pain management implemented in the resident's interdisciplinary plan of care. 3. The resident's attending physician will be informed when appropriate, and orders for [MEDICATION NAME] will be obtained to promote resident comfort .4. The resident's pain management will be evaluated. Any changes in pain management will be discussed with the attending physician and appropriate orders obtained. 5. Pain intensity will be measured with appropriate measurement tool .a pain scale of 0-10 (0 = no pain, 10 = worst pain) will be utilized for the adult patient . 2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medication Review report revealed a physician's orders [REDACTED].Give 1 tablet by mouth every 8 hours as needed for pain. A quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The MDS pain assessment interview revealed Resident #56 had pain occasionally over the last 5 days with a numeric rating scale of 5 on a pain scale of 0 to 10. The resident's revised plan of care dated 3/18/16 revealed the resident has potential for pain related to chronic pain, poor mobility, history of muscle spasms. The resident's plan of care goal was to be in less pain with a pain scale of 3/10 or below. The plan to reach the goal of less pain included the following interventions: .Administer [MEDICATION NAME] as per orders . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care . There was no documentation the resident's pain was monitored and treated to relieve the resident's pain on 5/31/15. The Medication Review report revealed a physician's orders [REDACTED].Give 1 tablet by mouth every 6 hours as needed for pain. The Medication Review report and the May 2016 Medication Administration Record (MAR) documented on 5/13/16 the physician increased the pain medication to regularly scheduled .[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) Tablet 10-325 MG (Milligrams) .Give 1 tablet by mouth every 6 hours for Pain . Review of the MAR dated May, 2016, revealed Resident #56 received a [MEDICATION NAME] 10-325 mg tablet on May 31 at 2 AM, 8 AM and 2 PM as prescribed. Review of the CONTROLLED DRUG RECORD documentation was contradictory of the May 2016 MAR and revealed the [MEDICATION NAME]-APAP 10/325 mg tablet was not signed for 2 AM, 8 AM and 2 PM on 5/31/16. The Rx Solutions Individual Patient Control Administration Record dated 5/31/16 revealed only 1 (one) tablet was signed out for administration on 5/31/16 for 8:00 PM. In an interview with Resident #56 on 5/31/16 at 3:51 PM, in Resident #56's room, the resident was asked do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? Resident #56 stated, My back. she was asked if they give her pain medication to relieve the pain. Resident #56 stated, They have me on scheduled pain medicine, and they ran out of it today, so they went to (Named Physician), and then to fill the prescription, and it should be here tomorrow. In an interview with Licensed Practical Nurse (LPN) #1 on 6/2/16 at 8:45 AM, in the medication room, LPN #1 was asked to see the [MEDICATION NAME] punch cards for Resident #56. LPN #1 stated, We had to get some from (Named Pharmacy), and there was 1 left in that bottle, so I gave her (Resident #56) that one (tablet) this morning. I turned that sheet in to (Named Director of Nursing (DON)). The card with 1 pain pill missing was given to (Named Resident #56) by (Named LPN #2) at 8 PM on 6/1/16. Observations in the medication room on 6/2/16 at 8:45 AM, revealed 1 punch card for Resident #56 with 60 tablets of [MEDICATION NAME]-APAP 10/325 mg, and 1 punch card for Resident #56 with 59 [MEDICATION NAME]-APAP 10/325 mg tablets. In an interview with Resident #56 on 6/2/16 at 1:50 PM, Resident #56 was asked about her pain. Resident #56 stated, .my upper back is where I have the pain .(Named Physician) has me on 10 mg of [MEDICATION NAME] every 6 hours. I can't wait to go to the doctor, because I get no breakthrough pain medicine. If I ask them (for pain medication) they (nurses) tell me it's not time yet. Resident #56 was asked about her pain the day she did not get pain meds. Resident #56 stated, My back was killing me .I had sharp achy pains in my upper back. I tried to get involved with activities to get my mind off of things but I finally had to lay down, I was in so much pain . Telephone interview with LPN #1 on 6/2/16 at 2:48 PM in the medical record office, LPN #1 was asked about administering the [MEDICATION NAME] to Resident #56 on May 31st at 8 AM and 2 PM. The narcotic sign out sheet and the Rx (Prescription) Solutions Individual Patient Control Administration Record were read to her. She stated, .I remember (Named LPN #3) told me we were out. (of pain medication). It may have been unavailable. I should have marked a no on the 31st. She said she used the last one on the card . LPN #1 was asked what should have been documented on the MAR for the 31st (May). She stated, I should have marked it unavailable. She was asked if she did any non-pharmacological interventions when a resident has increased pain between scheduled medications or when the pain medications are not available. LPN #1 stated, It depends on where the pain is . In an interview with the DON on 6/2/16 at 2:54 PM, in the medical records office, the DON was asked what do you expect the nurses to document on the MAR when the facility runs out of a scheduled medication for a resident. The DON stated, I expect them to get a script (prescription) from the doctor and get it filled, and they will have to document that it is not available on the MAR .they would have to get another script for a refill. The DON was asked if she expects the staff to try non-pharmacological interventions for residents with pain between medications or when they are not available. The DON stated, They need to try repositioning, breathing techniques, quiet places, darkened places. In an interview with Registered Nurse (RN) #1 on 6/3/16 at 7:40 AM, at the nurses desk, RN #1 was asked if residents run out of pain medicine and what is the process to get more. RN #1 stated, Once in a blue moon residents run out of meds (medication) .the pharmacy, they don't deliver on Sundays or Mondays, so we have a back up pharmacy . If it's Monday through Friday, we run to the doctor's office or we meet the providers to get the script. RN #1 was asked how they manage the inventory of drugs for the residents. RN #1 stated, Usually it's the full time nurse on the cart .you watch the card, when they get down to 10 (pills), we order them . In an interview with Certified Nursing Assistant (CNA) #1 on 6/3/16 at 7:43 AM, at the nurses desk, CNA #1 was asked if Resident #56 displayed any signs of being in pain, or did she mention that she was in pain on Tuesday, May 31. CNA #1 stated, I did not notice and there was no conversation from the resident that she was in pain. In an interview with CNA #2 on 6/3/16 at 7:50 AM, at the nurses desk, CNA #2 was asked if Resident #56 displayed any signs of being in pain or did she mention that she was in pain on Tuesday May 31. CNA #2 stated, She didn't mention pain but she said she was short of breath. Since she has been smoking she has had that more. She didn't eat her breakfast, when I went in to pick up her tray, she asked for hot coffee, because hers had gotten cold. CNA #2 was asked if that was that normal for her not to eat her breakfast. She stated, No ma'am. CNA #2 was asked did you ask her if she was in any pain. CNA #2 stated, No, not with her being in her right mind. I did ask if she wanted something else to eat. She said no. In an interview with Resident #56 on 6/3/16 at 7:46 AM, in the front of the nurses desk, Resident #56 was asked if she told anyone she was in pain during the time she was without her pain medication. Resident #56 stated, It is scheduled now so I don't have to ask for it, but that day, I asked (Named LPN #1), when was the last time I got my pain medicine, my back is hurting. (Named LPN #1) said they ran out of my medicine and I said to her, (emphatic) YOU have GOT to be kidding me, I said it just like that In an interview with LPN #2, on 6/3/16 at 8:00 AM, at the nurses desk, LPN #2 was asked what did she do on May 31 when Resident #56's medicine ran out. LPN #2 stated, (Named LPN #3) told me in report that she had given her (Resident #56) her last pain pill. I told my RN supervisor, (Named RN #2). She said she knew it and we wouldn't get them (pain pills) that day. She said they sent over a script to be signed, what ever (Named RN #2) does with them. LPN #2 was asked if she told Resident #56 she was out of pain medicine. LPN #2 stated, I never tell them because it causes them to worry. LPN #2 was asked if she assessed the resident for pain since she knew there was no pain medicine for her on May 31st. LPN #2 stated, In the morning, when I gave her her medicine, I asked her if she was in pain and she (Resident #56) said not at that time. LPN #2 was asked if she assessed her for pain throughout that day. LPN stated, Yes, I asked her and she said no, not at this time. LPN #2 was asked if she documented the pain assessment and responses. LPN #2 stated, I did not make a note on her that day about assessing for pain or that the meds were out . In an interview with LPN #2 on 6/3/16 at 9:48 AM, at the nurses desk, LPN #2 was asked why did the pain meds continue to be increased because they went from every 8 hours as needed, to every 6 hours as needed, and now every 6 hours scheduled. LPN #2 stated, I don't know if the doctor was here and she asked him to increase it .I don't know if she mentioned it to another nurse or if she talked to the doctor, She (Resident #56) may have mentioned it to (Named Physician Assistant (PA)), the PA for (Named Physician). she comes here once a month anyway, and if we call her she will stop in for a visit. LPN #2 was asked if she notified the doctor that Resident #56 had not received any pain medicine and she was not in pain to see if he might re-evaluate her pain management. LPN #2 stated, I did not call him that day, no ma'am. I did not call him about that. In an interview the DON on 6/3/16 at 9:55 AM, in the DON's office, she was asked how she expects the staff to manage pain for residents. The DON stated, Our patients that are on scheduled pain meds, they (nurses) are required to ask about pain intensity at each administration, and it is on the MARs. The DON and LPN #4 were unable to show the pain scale documented in June for Resident #56. LPN #4 stated, .That is just another glitch in the system. It (pain scale assessment) didn't pull over. The system sets it up, and it didn't pull right . The DON was then asked if she would expect the staff to do any additional pain assessments on residents that run out of pain medications. The DON stated, I would have expected them to call and get something, an order for [REDACTED]. In an interview with the DON and LPN #4 on 6/3/16 at 10:20 AM, in the DON office, the DON was asked if Resident could have received Tylenol listed on the standing order. The DON stated, Yes, ma'am The DON was asked when she became aware that Resident #56 was out of pain medications on May 31. The DON stated, Yesterday. LPN #4 stated, not until the script came over (on the fax machine) Tuesday morning. The pharmacy sends us the script. then it is hand delivered to the doctor. I wait while he signs it and you have to fax it back from their clinic to our pharmacy. LPN #4 was asked how the pharmacy knows to send the script over, what is the process. LPN #4 stated, (Named LPN #1) came back here and said I just reordered the medicine, did you get the script. I told her that I just got it off the fax machine, is she out (of medication)? LPN #1 said yes, I said ok, call (Named Physician's) office and tell them we need a hard script to take to back. (Named RN #2 took it to the pharmacy and got it filled. It was after about 9:30 am to 10 am. after everything got called in to his office, it was lunch time. so as soon as the clinic opened back she went and got it, took it to the pharmacy and got it filled and brought it back to the facility. The DON was asked what she expected her staff to do if a resident runs out of pain medication. The DON stated, .I expect them to write a 1 time order to give an off cycle dose or what ever the case may be, then call the doctor and say we need to go ahead and give this. The DON was asked if she expected her staff to call the physician and let him know if a resident who is not getting scheduled pain medication, and does not complain of pain during the time of no pain medicine to evaluate the pain management. The DON stated, I expect them to recognize that, but this resident has had this doctor a long time, and he knows her history. For them to call him and say she no longer needs the meds, i don't know that that would be the best case scenario either. The failure of the facility to administer scheduled pain medication or provide pain relief interventions for Resident #56, who was in pain, resulted in actual harm. 3. The facility's Clinical Practice Guideline, [MEDICAL TREATMENT]-[MEDICAL TREATMENT] policy documented 1. The physician's orders [REDACTED]. and care of access device. Assessments/Observations .3. Observations of the resident's . [MEDICAL TREATMENT] access, body/skin . should be done pre and post [MEDICAL TREATMENT]. A form is available to complete this documentation .Care Planning 1). The plan of care should include .The type of access .The care and assessment of the access device .Resident specific complications .Nutrition/Hydration .Weight should be obtained weekly or as ordered by the physician. Pre and post [MEDICAL TREATMENT] weights will be obtained from the [MEDICAL TREATMENT] provider by the facility for inclusion in the medical record . 4. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].In case of right [MEDICATION NAME] access hemorrhage or dislodgement apply direct pressure, call 911, and refer to clinical guideline for [MEDICAL TREATMENT] until EMS (Emergency Medical Services) arrives every shift . Review of the resident's plan of care dated 5/16/16 documented, .DAILY WEIGHT or as ordered .monitor right [MEDICATION NAME] access site, dressing and apply immediate pressure if bleeding, call 911 .Monitor/document/report for s/sx (signs and symptoms) of acute failure . Record review revealed there was was no documentation the facility obtained the facility [MEDICAL TREATMENT] communication form to ensure the resident was monitored by the facility on the [MEDICAL TREATMENT] days of 5/23/16, 5/27/16, 5/30/16 and 6/1/16. In an interview with the DON on 6/2/16 at 3:50 PM, in the conference room, the DON was asked how the facility and [MEDICAL TREATMENT] unit communicated to obtain the information for monitoring in accordance with the plan of care. The DON stated there is a [MEDICAL TREATMENT] Treatment Form sent with the resident, some we get back and some we don't. I can only produce four of the forms. The facility failed to provide evidence that Resident # 33's [MEDICAL CONDITION], [MEDICAL TREATMENT] and [MEDICATION NAME] access were assessed and monitored in accordance with the facility policy, physican's orders and the resident's plan of care to prevent complications.

Based on policy review, medical record review, and interview, the facility failed to ensure pain management was provided and interventions were implemented in accordance with the written plan of care for 1 of 5 (Resident #56) sampled residents reviewed for medication administration of the 29 residents included in the stage 2 review, and the facility failed to provide care and services in accordance with the resident's written plan of care for checking [MEDICATION NAME] access site for bleeding every shift for 1 of 1 (Resident #33) sampled residents receiving [MEDICAL TREATMENT]. The failure to administer pain management to a resident in pain during a 24 hour period resulted in actual harm. The findings included: 1. Review of the facility's Pain Management policy documented, .Every resident has the right to be as comfortable and pain free as possible .Pain control is essential to the continued quality and dignity of life as well as the maintenance of each resident's current level of function .3. The resident's attending physician will be informed when appropriate, and orders for [MEDICATION NAME] will be obtained to promote resident comfort .5. Pain intensity will be measured with appropriate measurement tool. A pain scale of 0-10 (0 = no pain, 10 = worst pain) will be utilized for the adult patient . 2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The MDS pain assessment interview revealed Resident #56 had pain occasionally over the last 5 days with a numeric rating scale of 5 on a pain scale of 0 to 10. The resident's plan of care revised on 3/18/16 revealed the resident has potential for pain related to chronic pain, poor mobility, history of muscle spasms. The resident's goal was to be in less pain with a 3/10 or below. The plan to reach the goal of less pain included the following interventions: .Administer [MEDICATION NAME] as per orders . Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment . Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care . There was no documentation the resident's pain was monitored in accordance with the written plan of care. The Medication Review report and the May 2016 Medication Administration Record (MAR) documented on 5/13/16 the physician increased the pain medication to regularly scheduled .[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) Tablet 10-325 MG (Milligrams) .Give 1 tablet by mouth every 6 hours for Pain . Record review revealed the following medication discrepancies for 5/31/16: The May 2016 MAR revealed Resident #56 received a [MEDICATION NAME] 10-325 mg tablet on May 31 at 2 AM, 8 AM, 2 PM and 8PM as prescribed. Review of the CONTROLLED DRUG RECORD (CDR) revealed a [MEDICATION NAME]-APAP ([MEDICATION NAME]) 10/325 mg tablet was last signed out at 8 PM on 5/30/16. There was no documentation on the CDR the [MEDICATION NAME]-APAP 10/325 mg tablets were signed out to be administered to be administered to the resident again until 8 PM on 5/31/16, 24 hours after the last administration and not the every 6 hours as scheduled. In a telephone interview with LPN #1 on 6/2/16 at 2:48 PM in the medical record office, LPN #1 was asked about administering the [MEDICATION NAME] to Resident #56 on 5/31/16 as documented on the MAR. LPN #1 stated, .I should have marked No .it ([MEDICATION NAME]) was unavailable . on 5/31/16, instead of signing as if it was administered to the resident. In an interview with Resident #56 on 5/31/16 at 3:51 PM, in Resident #56's room, she was asked do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? Resident #56 stated, My back. she was asked if they give her pain medication to relieve the pain. Resident #56 stated, They have me on scheduled pain medicine, and they ran out of it today .and it should be here tomorrow. In a telephone interview with Licensed Practical Nurse (LPN) #1 on 6/2/16 at 2:48 PM in the medical record office, LPN #1 was asked about administering the [MEDICATION NAME] to Resident #56 on May 31st at 8 AM and 2 PM. The narcotic sign out sheet and the Rx (Prescription) Solutions Individual Patient Control Administration Record were read to her. She stated, .I remember (Named LPN #3) told me we were out. (of pain medication) . In an interview with the Director of Nursing (DON) on 6/2/16 at 2:54 PM, in the medical records office, the DON was asked what do you expect your nurses to document on the MAR when the facility runs out of a scheduled medication for a resident. The DON stated, .I expect them to document that it is not available on the MAR .they would have to get another script for a refill. In an interview with LPN #2, on 6/3/16 at 8:00 AM, at the nurses desk, LPN #2 was asked if she documented the pain assessment and responses. LPN #2 stated, I did not make a note on her that day about assessing for pain or that the meds were out . In an interview with LPN #2 on 6/3/16 at 9:48 AM, at the nurses desk, LPN #2 was asked if she notified the doctor that Resident #56 had not received any pain medicine and she was not in pain to see if he might re-evaluate her pain management. LPN #2 stated, I did not call him that day, no ma'am. I did not call him about that. In an interview the DON on 6/3/16 at 9:55 AM, in the DON's office, she was asked how she expects the staff to manage pain for residents. The DON stated, Our patients that are on scheduled pain meds, they (nurses) are required to ask about pain intensity at each administration, and it is on the MARs. The DON and LPN #4 were unable to show the pain scale documented in June for Resident #56. LPN #4 stated, .That is just another glitch in the system. It (pain scale assessment) didn't pull over. The system sets it up, and it didn't pull right . The DON was then asked if she would expect the staff to do any additional pain assessments on residents that run out of pain medications. The DON stated, I would have expected them to call and get something, an order for [REDACTED]. In an interview with the DON and LPN #4 on 6/3/16 at 10:20 AM, in the DON office, the DON was asked if Resident could have received Tylenol listed on the standing order. The DON stated, Yes, ma'am. There was no documentation the Tylenol was administered. The failure of the facility to provide pain relief measures and monitor/record/report pain in accordance with the plan of care for Resident #56, a resident that experienced pain on 5/31/16, resulted in actual harm. 3. The facility's Clinical Practice Guideline, [MEDICAL TREATMENT]-[MEDICAL TREATMENT] policy documented 1. The physician's orders [REDACTED]. and care of access device. Assessments/Observations .3. Observations of the resident's . [MEDICAL TREATMENT] access, body/skin . should be done pre and post [MEDICAL TREATMENT]. A form is available to complete this documentation .Care Planning 1). The plan of care should include .The type of access .The care and assessment of the access device .Resident specific complications .Nutrition/Hydration .Weight should be obtained weekly or as ordered by the physician. Pre and post [MEDICAL TREATMENT] weights will be obtained from the [MEDICAL TREATMENT] provider by the facility for inclusion in the medical record . 4. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].In case of right [MEDICATION NAME] access hemorrhage or dislodgement apply direct pressure, call 911, and refer to clinical guideline for [MEDICAL TREATMENT] until EMS (Emergency Medical Services) arrives every shift . Review of the resident's plan of care dated 5/16/16 documented, .DAILY WEIGHT or as ordered .monitor right [MEDICATION NAME] access site, dressing and apply immediate pressure if bleeding, call 911 .Monitor/document/report for s/sx (signs and symptoms) of acute failure . Record review revealed there was was no documentation the facility had the facility [MEDICAL TREATMENT] communication form to ensure the resident was monitored by the facility on the [MEDICAL TREATMENT] days of 5/23/16, 5/27/16, 5/30/16 and 6/1/16. In an interview with the DON on 6/2/16 at 3:50 PM, in the conference room, the DON was asked how the facility and [MEDICAL TREATMENT] unit communicated to obtain the information for monitoring in accordance with the plan of care. The DON stated there is a [MEDICAL TREATMENT] Treatment Form sent with the resident, some we get back and some we don't. I can only produce four of the forms. The facility failed to provide [MEDICAL TREATMENT] monitoring for Resident # 33 in accordance with the resident's plan of care. Refer to F309

Based on facility policy, medical record review, and interview, the facility failed to ensure staff immediately notified the physician of unmanaged pain for 1 of 2 (Resident #56) sampled residents reviewed for pain management. The failure of the facility to notify the physician that Resident #56's scheduled pain medication was unavailable and the resident's pain was not treated resulted in actual harm. The findings included: 1. Review of the facility's Pain Management policy documented, .Pain control is essential to the continued quality of life as well as the maintenance of each resident's level of function .Any changes in pain management will be discussed with the attending physician and appropriate orders obtained . 2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status summary score was 13. Review of the MDS dated [DATE] documented the resident's Brief Interview for Mental Status summary score was 15, which indicated no cognitive impairment. Review of the resident's plan of care plan dated 3/18/16 documented, .potential for pain r/t (related to) chronic pain, poor mobility, hx (history of) muscle spasms .resident to be in less pain . The Medication Review report revealed a physician's orders [REDACTED].Give 1 tablet by mouth every 8 hours as needed for pain. Record review revealed on 5/2/16 the pain medication was increased to [MEDICATION NAME] 10-325 mg .Give 1 tablet by mouth every 6 hours as needed for pain. The Medication Review report and the May 2016 Medication Administration Record (MAR) documented on 5/13/16 the physician increased the pain medication from as needed to regularly scheduled .[MEDICATION NAME] ([MEDICATION NAME] -[MEDICATION NAME]) Tablet 10-325 MG (Milligrams) .Give 1 tablet by mouth every 6 hours for Pain . Record review revealed the following medication discrepancies for 5/31/16: The May 2016 MAR revealed Resident #56 received a [MEDICATION NAME] 10-325 mg tablet on May 31 at 2 AM, 8 AM, 2 PM and 8PM as prescribed. The CONTROLLED DRUG RECORD (CDR) documented a [MEDICATION NAME]-APAP ([MEDICATION NAME]) 10/325 mg tablet was signed out for 8 PM on 5/30/16. There was no documentation on the CDR that another [MEDICATION NAME]-APAP 10/325 mg tablet was signed out to be administered until 8 PM on 5/31/16, 24 hours after the last administration and not the every 6 hours as prescribed. The Rx (prescription) Solutions Individual Patient Control Administration Record dated 5/31/16 revealed only 1 [MEDICATION NAME]-APAP 10/325 mg tablet was signed out for the day of 5/31/16. In a telephone interview with LPN #1 on 6/2/16 at 2:48 PM in the medical record office, LPN #1 was asked about administering the [MEDICATION NAME] to Resident #56 on 5/31/16 as documented on the MAR. LPN #1 stated, .I should have marked No .it ([MEDICATION NAME]) was unavailable . on 5/31/16, instead of signing as if it was administered to the resident. Review of the progress notes dated 5/25/16 to 6/2/16 revealed there was no documentation during these dates. In an interview with Resident #56 on 5/31/16 at 3:51 PM, in Resident #56's room, she was asked do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief? Resident #56 stated, My back. she was asked if they give her pain medication to relieve the pain. Resident #56 stated, They have me on scheduled pain medicine, and they ran out of it today .and it should be here tomorrow. In a telephone interview with LPN #1 on 6/2/16 at 2:48 PM in the medical record office, LPN #1 was asked about administering the [MEDICATION NAME] to Resident #56. LPN #1 stated, .I remember (Named LPN #3) told me we were out. (of pain medication). It may have been unavailable . LPN #1 stated, .I should have marked No .it ([MEDICATION NAME]) was unavailable . on 5/31/16. In an interview with Resident #56 on 6/3/16 at 7:46 AM, in the front of the nurses desk, Resident #56 was asked if she told anyone she was in pain during the time she was without her pain medication. Resident #56 stated, It is scheduled now so I don't have to ask for it, but that day, I asked (Named LPN #1), when was the last time I got my pain medicine, my back is hurting. (Named LPN #1) said they ran out of my medicine and I said to her, (emphatic) YOU have GOT to be kidding me, I said it just like that. In an interview with LPN #2, on 6/3/16 at 8:00 AM, at the nurses desk, LPN #2 was asked what did she do on May 31 when Resident #56's medicine ran out. LPN #2 stated, (Named LPN #3) told me in report that she had given her (Resident #56) her last pain pill. I told my RN supervisor, (Named RN #2). She said she knew it and we wouldn't get them (pain pills) that day. She said they sent over a script to be signed . In an interview with the Director of Nursing (DON) on 6/3/16 at 9:55 AM, in the DON's office, The DON was asked if she would expect the staff to do any additional pain assessments on residents that run out of pain medications. The DON stated, I would have expected them to call and get something, an order for [REDACTED]. The failure of the facility to immediately notify the physician of Resident #56s unmanaged pain resulted in actual harm.

Based on observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by opened and undated foods, inadequate sanitizer levels in the dishwasher and foods not being served at an appropriate temperature. The facility had a census of 37, with 36 of those residents receiving a meal tray from the kitchen. The findings included: 1. Observations in the kitchen on 5/31/16 at 9:24 AM, revealed a 5 pound tub of sour cream that was approximately half full but it did not have an open date or use by date, and an opened box of individual butter pats without an open or use by date. In an interview with the Dietary Manager (DM) on 5/31/16 at 9:35 AM, in the kitchen, the DM was asked if open food should have an opened dated on the box. The DM stated, yes ma'am. 2. Observations in the kitchen on 5/31/16 at 9:36 AM, revealed the dishwasher sanitizer to measure 0 PPM (parts per million). Observations in the kitchen on 5/31/16 at 9:42 AM, revealed the dishwasher sanitizer to measure less than 150 PPM. Observations in the kitchen on 5/31/16 at 9:47 AM, revealed the dishwasher sanitizer to measure less than 150 PPM. In an interview with the DM in the kitchen on 5/31/16 at 9:47 AM the DM stated, we will have to do the sink thing (pointing to the 3 compartment sink). In an interview with the DM on 5/31/16 at 5:30 PM, in the kitchen, the DM was asked about sanitizer repair. The DM stated, .the maintenance fixed it a little bit ago. He found a little hole in the tube . 3. Observations in the kitchen on 6/1/16 at 5:15 PM, revealed the Salisbury steak to be 100 degrees, the cheesy mashed potatoes to be 122 degrees, the gravy to be 130 degrees, and the mechanical soft Salisbury steak to be 118 degrees. In an interview with the Registered Dietitian (RD) on 6/1/16 at 5:25 PM, in the kitchen, the RD was asked what should the temperatures be on the tray line. The RD stated, .140 (degrees Fahrenheit) . In an interview with the DM on 6/1/16 at 5:35 PM, in the kitchen, the DM was asked if the food temperatures she was about to serve to the residents was acceptable. The DM stated, No, ma'am.

Based on observation, and interview, the facility failed to ensure complete staffing information was posted for 3 of 4 (6/1/16, 6/2/16, 6/3/16) days of the survey. The findings included: Observations at the employee time clock on 6/1/16 at 2:55 PM, 6/2/16 at 5:00 PM, and 6/3/16 at 9:00 AM, revealed the staff posting did not document number of staff hours. In an interview with the Director of Nursing (DON) on 6/3/15 at 10:25 AM, in the DON office, the DON was asked who is responsible for posting the daily staffing by the time clock. The DON stated, The night shift nurse does it.

Based on observation, and interview, the facility failed to maintain resident dignity and respect during dining when 1 of 21 (Resident #10) sampled residents was not served a meal at the same time with the others seated at the same table. The findings included: Observations in the dining room on 5/31/16 at 11:30 AM, revealed 4 residents at a dining table and 3 had been served their meal and had begun to eat in front of Resident #10. Observations in the dining room on 5/31/16 at 11:41 AM, revealed Resident #10 had not been served her meal tray. Registered Nurse (RN) #3 was asked by the resident in a loud voice where her tray was. RN #3 did not respond. Observations on 5/31/16 at 11:42 AM, revealed Resident #10 had not yet been served a meal tray. Resident #10 stated, Ask em' where mines at? as the administrator passed by her. Observations on 5/31/16 at 11:43 AM, revealed Resident #10 received her meal tray, 13 minutes after the other residents at the table had been served. The 3 residents at that table had almost completed their meals. In an interview with the Administrator on 06/02/16 at 9:10 AM, in the business office, the Administrator was asked how she expected residents to be served at multiple tables in the dining room. She stated, .I expect them to be served a table at a time.

Based on medical record review, review of activity calendars, and interview, the facility failed to provide an ongoing program designed to meet the interest and the physical, mental, and psychosocial well-being for 2 of 16 (Residents #20 and 56) sampled residents interviewed the stage 1 review. The findings included: 1. Medical record review revealed Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], and [MEDICAL CONDITION]. The quarterly Minimum Data Set ((MDS) dated [DATE] documented Resident #20 was cognitively intact. The care plan dated 10/20/15 documented Resident #20 was very social and attends several activities and attends smoke breaks. In an interview with Resident #20 on the back patio on 6/2/16 at 9:30 AM, Resident #20 was asked if there were activities at night and on the weekends. Resident #56 stated, no . 2. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] documented a BIMS of 13 which indicated no cognitive impairment. Interview for activity preference revealed the following: How important is it to you to participate in religious services or practices? Resident #56 answered Very important. In an interview with Resident #56 on 5/31/16 at 3:33 PM, in Resident #56's room, she was asked are the activities provided as often as you would like, including on weekends and evenings. Resident #56 stated, They don't do anything on the evenings or the weekends. There is singing but no preaching. I would love to have preaching every Sunday. Review of the monthly activity calendars revealed no structured group activities lead by a staff member on Saturdays and Sundays. In an interview with the Activities Director (AD) on 6/3/16 at 8:30 AM, in room [ROOM NUMBER], the AD was asked if there were activities scheduled in the evenings and on the weekends. The AD stated, .Sunday mornings we have someone that does a Sunday school type devotional and then there is singing afterwards .There's nothing else scheduled on Sundays .

Based on policy review, medical record review and interview, the facility failed to ensure care plan interventions were followed for administering pain medication for 2 of 35 (Residents #61 and 62) sampled residents of the 35 residents included in the stage 2 review. The failure to administer pain medication when Resident #61 complained of pain on the pain scale as a 9, resulted in actual harm. The findings included: 1. The facility's Pain Management Policy & (and) Procedure documented, .Every resident has the right to be comfortable and pain free as possible. Pain control is essential to the continued quality and dignity of life as well as the maintenance of each resident's current level of function. A resident receiving scheduled medications for pain, will have their pain assessed at least daily pain assessed using a scale of 1 - (to) 10 and recorded on the medication administration record. 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED] The interim/acute care plan dated 1/15/15 documented, .Diagnosis. Rt (right) hip FX (fracture). Pain. Goal: Will be reduced to an acceptable level - less than 2/10. Assess for pain on each contact. [MEDICATION NAME]/narcotic per MD (medical doctor) order. The care plan was not followed for administering pain medication. The nurses' notes for Resident #61 documented the following: a.Admission Nurse's Note. 1-15-15 1700 (5:00 PM) Arrived to facility. by stretcher. Discoloration from Rt upper side to Rt knee from surgical site (with) 26 staples noted. c/o (complains of) R hip pain upon arrival. b.1-15-15. SKILLED DAILY NURSES NOTE. Pain. Rt hip. 5 (5/10 on pain scale). E (evening shift). c.1-16-15. 0700 (7:00 AM). c/o pain level 9 (9/10 on pain scale) at his Right hip. Staples in-tact, Bruising from achilles to upper hip rt side purple/Blue in color. Review of the medication administration record (MAR) revealed Resident #61 received only 1 dose of Tylenol on 1/16/15 at 4:00 AM, and did not receive any doses of [MEDICATION NAME] during his stay at the facility. Interview with the Director of Nursing (DON) on 5/20/15 at 11:40 AM, at the nurses station, the DON was asked what pain scale is used at the facility. The DON confirmed that the 1-10 numerical pain scale is used. The DON was asked what is considered mild pain. DON stated 3 or 4. The DON was asked what is considered moderate pain. The DON stated 7, 8, or 9. The DON was asked if a resident complains of a pain level of 9, should pain medication be given if ordered. The DON stated, Absolutely. The DON was asked whether Resident #61 should have been given pain medication when he reported a pain level of 9 on 1/16/15 at 7:00 AM. The DON stated, Yes. He just got Tylenol at 4:00 (AM). That looks like the only one he got. I assessed him at 7 (AM) with the level of 9. He could have had the Tylenol again at 11. He should have had the [MEDICATION NAME] at 7 o'clock. I should have followed through on the pain relief. Well, I hate that, but no, he didn't (get pain medication at 7 AM). 3. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/14 section J was coded for receiving PRN medications, for the presence of pain almost constantly with an intensity of 8 on a scale of 0-10. A physician's orders [REDACTED].@ (at) 6 A (AM) & 6 P (PM). Review of the care plan dated 9/22/14 and updated 10/1/14 documented, .Problem/Need. RESIDENT IS AT RISK FOR PAIN AND DISCOMFORT R/T (related to) HAVING A [DIAGNOSES REDACTED]. Review of the September 2014 MAR revealed the 6 PM dosage of [MEDICATION NAME] on 9/30/14 was not documented. Review of the October 2014 MAR revealed the 6 PM dosage of [MEDICATION NAME] on 10/3/14 was circled. Interview with the DON on 5/19/15 at 3:37 PM, in the DON's office, the DON was asked about medications not being given with no explanation. The DON stated, They have got to circle when a med (medication) is not given and document why it wasn't given.

Based on policy review, medical record review and interview, the facility failed to ensure pain medications were administered as ordered by the physician for 2 of 35 (Residents #61 and 62) sampled residents of the 35 residents included in the stage 2 review. The failure to administer pain medication when Resident #61 complained of pain on the pain scale as a 9, resulted in actual harm. The findings included: 1. The facility's Pain Management Policy & (and) Procedure documented, .Every resident has the right to be comfortable and pain free as possible. Pain control is essential to the continued quality and dignity of life as well as the maintenance of each resident's current level of function. A resident receiving scheduled medications for pain, will have their pain assessed at least daily pain assessed using a scale of 1 - (to) 10 and recorded on the medication administration record. 2. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED] The nurses' notes for Resident #61 documented the following: a.Admission Nurse's Note. 1-15-15 1700 (5:00 PM) Arrived to facility. by stretcher. Discoloration from Rt (right) upper side to Rt knee from surgical site (with) 26 staples noted. c/o (complains of) R (right) hip pain upon arrival. b.1-15-15. SKILLED DAILY NURSES NOTE. Pain. Rt hip. 5 (5/10 on pain scale). E (evening shift). c.1-16-15. 0700 (7:00 AM). c/o pain level 9 (9/10 on pain scale) at his Right hip. Staples in-tact, Bruising from achilles to upper hip rt side purple/Blue in color. Review of the medication administration record (MAR) revealed Resident #61 received only 1 dose of Tylenol on 1/16/15 at 4:00 AM, and did not receive any doses of [MEDICATION NAME] during his stay at the facility. Interview with the Director of Nursing (DON) on 5/20/15 at 11:40 AM, at the nurses station, the DON was asked what pain scale is used at the facility. The DON confirmed that the 1-10 numerical pain scale is used. The DON was asked what is considered mild pain. DON stated 3 or 4. The DON was asked what is considered moderate pain. The DON stated 7, 8, or 9. The DON was asked if a resident complains of a pain level of 9, should pain medication be given if ordered. The DON stated, Absolutely. The DON was asked whether Resident #61 should have been given pain medication when he reported a pain level of 9 on 1/16/15 at 7:00 AM. The DON stated, Yes. He just got Tylenol at 4:00 (AM). That looks like the only one he got. I assessed him at 7 (AM) with the level of 9. He could have had the Tylenol again at 11. He should have had the [MEDICATION NAME] at 7 o'clock. I should have followed through on the pain relief. Well, I hate that, but no, he didn't (receive pain medication). 3. Medical record review revealed Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/14 section J was coded for receiving PRN medications, for the presence of pain almost constantly with an intensity of 8 on a scale of 0-10. A physician's orders [REDACTED].@ (at) 6 A (AM) & 6 P (PM). Review of the September 2014 MAR revealed the 6 PM dosage of [MEDICATION NAME] on 9/30/14 was not documented. Review of the October 2014 MAR revealed the 6 PM dosage of [MEDICATION NAME] on 10/3/14 was circled. Interview with the DON on 5/19/15 at 3:37 PM, in the DON's office, the DON was asked about medications not being given with no explanation. The DON stated, They have got to circle when a med (medication) is not given and document why it wasn't given. Meds must be given they are part of the treatment.