Every finding on record at Jupiter Rehabilitation and Healthcare Center

*Based on observations, interviews and record reviews, the facility failed to provide food that was prepared, stored and served in a sanitary manner in accordance with standards for food safety professionals. The findings included: The facility's policy ‘Hand Hygiene' (no reference date) documented: Policy:All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and guidelines:6. Additional considerations:a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately removing gloves. 1. During the initial kitchen tour, on 07/07/25 at 9:11 AM, accompanied by the Food Service Director/Certified Dietary Manager (CDM), the following were noted:a. In the walk in cooler, a box containing raw shell eggs were stored directly over a box containing liquid pasteurized eggs.b. Cleaned and sanitized utensils were not stored inverted At the conclusion of the tour, the CDM acknowledged the concerns. 2. During a follow up visit to the kitchen, on 07/09/25 at 6:59 AM, accompanied by the CDM, Staff D, Cook, was asked about the food items that were in the steam table being served for breakfast. Staff D stated that she needed to change her gloves and walked away from the steam table. Staff D was observed going to a food preparation area where she took single use gloves from a box that was secured to the wall and returned to the steam table. During the observation, Staff D did not perform hand hygiene prior to getting and donning the gloves. The CDM acknowledged the concern and instructed Staff D to wash her hands and don a clean pair of gloves. 3. During a follow up tour of the kitchen, on 07/09/25 at 11:25 AM, accompanied by the CDM, the following were noted:a. There were several plates that were chipped in a manner that could cause skin tears to the residents. b. Staff E, Dietary Aide, was observed rinsing a knife in a food preparation sink and then placed the knife on a magnetic strip over the food prep table without properly cleaning and sanitizing the knife. When asked what the knife was used for, Staff E stated that she used it for cutting strawberries. When asked, Staff E acknowledged that she rinsed the knife and placed it back on the magnetic strip.c. Staff E was observed leaving the food preparation area through a door and returned to the food preparation area and took single use gloves from a box that was secured over the preparation table and sheets of parchment paper. Throughout the observation, Staff did not perform hand hygiene. Staff E acknowledged that she did not perform hand hygiene upon returning to the food preparation area and preparing for her next task by getting gloves and handling the parchment paper. The CDM acknowledged the concerns and instructed Staff E to wash her hands and don a clean pair of gloves.

Based on observations and interviews, the facility failed to provide maintenance and housekeeping services and linens in a manner to provide a clean, sanitary and homelike environment. The findings included:A. During an observation in the Main Dining Room, on 07/07/25, at the conclusion of the initial kitchen tour, at approximately 9:40 AM, there was a plastic folded table stored between a snack vending machine and the wall that had an accumulation of food residue and debris. The Food Services Director/Certified Dietary Manager (CDM) had the table removed by staff. B. During the initial pool process, beginning on 07/07/25 at approximately 9:45 AM, the following were noted: a. In room [ROOM NUMBER], there was a soiled gown that was left in the shower b. In room [ROOM NUMBER] there was an accumulation of debris on the floor at the hand washing sink, under the resident’s bed and on the fall mat for Resident #61’s bed (window bed). 3. In room [ROOM NUMBER], there was an accumulation of debris on the floor at the hand washing sink and under the resident’s bed. C. During an observation of the Main Dining Room, on 07/09/25 at 7:33 AM, the following were noted: a. A trash container by the entrance to a screened in patio was approximately 1/3 full of from the previous day and had an odor, The CDM agreed that the refuse container smelled foul. b. There were accumulations of food residue and stains on the tablecloths on 8 of the 18 tables. During an interview, at the time of the observation, the CDM stated that housekeeping was responsible for emptying the trash containers and the kitchen was responsible for changing the linens on the tables. On 07/10/25 at 12:35 PM, the Surveyor attempted to contact the pest control company that provided services to the facility and a voice message was left. There was no response from the pest control company D. Upon entering the room for Resident #37 and #39 on 07/07/25 at 10:50 AM, a strong urine odor was noted. The large room contained four beds. The urine odor became stronger near the two beds located at the back of the room, the beds belonging to these two residents. Resident #39 was not in the room during this observation, but the area near her bed revealed the strong odor. The bed for Resident #39 was a low bed with a specialty air mattress, that was flanked by two regular thick mattresses used as fall mats. Both Residents #37 and #39 were totally dependent upon staff for all care needs. During an interview on 07/07/25 at 11:27 AM, Resident #45 voiced a concern that there was less staff on the weekends. The resident explained that during the week there were four housekeepers, one for each unit, but on the weekends, there were only two. The resident voiced it took longer to get their rooms cleaned and they weren't cleaned as well as during the week. She voiced concerns with picking up germs and stated she had to be careful because it wasn't as clean as it could be. An observation on 07/08/25 at 3:46 PM revealed Resident #39 lying on the thick mattress on the floor to the left side of her bed. The resident was uncovered, wearing a top with an adult brief, moving about the mattress with involuntary jerky movements. A large wet spot was noted on the fitted sheet under the resident. The urine odor remained in the room. Staff B, Certified Nursing Assistant (CNA), was sitting in a chair watching her, as the resident had been put on one-to-one observation. Upon entering the room, the CNA stated, she's a tough one. On 07/09/25 at 9:59 AM, Staff A, CNA, was sitting with Resident #39. Staff A confirmed she smelled the urine odor. When asked why there was an odor in the room, the CNA stated they don't have any incontinent pads for the beds, so when the resident urinates, it goes through the fitted sheet and into the mattress. When asked if they had either the plastic or cloth pads the CNA stated they had none. An observation of all four laundry carts, one on each hall, on 07/09/25 at 10:12 AM, lacked any incontinence pads. During an interview at that time, the Housekeeping Director stated they do have the cloth incontinence pads, and that they were put out on the carts that morning. When told there was none available to staff at the present time, the Housekeeping Director stated they must be in the laundry. Observation in the laundry revealed a large bin of dried linens. Staff stated there were some incontinence pads in that bin. Only one was observed at that time, although staff did not dig into the pile of clean laundry. The Housekeeping Director explained the carts were restocked during lunch for linen use in the afternoon. Upon entering the room of Resident #39 on 07/09/25 at 12:24 PM, the urine odor was noted. Resident #39 had finished lunch, and a large puddle was noted under her Broda chair (a specialty recliner type wheelchair). When asked if the observed puddle was urine, Staff A confirmed it was and explained the resident's adult brief doesn't stay in place because of her movements. The CNA was placing fitted sheets on the resident's bed and mattress to the left. Observation revealed the sheets were threadbare in larges spots on one of the sheets, and over approximately a quarter of the second sheet. Photographic Evidence Obtained. During an interview on 07/10/25 at 11:35 AM, the Housekeeping Director explained there was a deep cleaning schedule so that all rooms were deep cleaned at least once a month. When asked about the process for odorous rooms and or mattresses, the Housekeeping Director explained they would clean the rooms as needed and the Maintenance Director, who was also present at that time, stated they would replace the mattresses as needed. When asked if he had changed out any mattresses that week, the Maintenance Director was not sure. When asked about the room for Resident #37 and #39, the Maintenance Director thought they had changed out the mattresses but was unsure when. The Directors were informed of the concerns observed and smelled throughout the week. An observation was made of the room at that time, with the two Directors, who both agreed with the findings. When shown the photo of the threadbare sheets that were used, the Housekeeping Director stated those sheets should never have made it back to the floor and the CNAs should not have used them. During an interview on 07/10/25 at 11:45 AM, the Administrator (NHA), stated the specialty air mattress used for Resident #39 was a rental mattress, and that it had not been changed out since arrival on 06/19/25. An observation on 07/10/25 at 12:56 PM of all four laundry carts on the four units lacked any incontinence pads. An observation in the laundry at that time revealed a total of 9 cloth incontinence pads available for staff use and being restocked on the carts. Photographic Evidence Obtained. Laundry staff said there are some in the one cart being folded, and in the dryer, although none were observed. During an interview at that time, the Director of Nursing stated the cloth incontinent pads were for use on all the beds, and the plastic ones were used during wound care. During a supplemental interview on 07/10/25 at 12:59 PM, the Housekeeping Director stated she always has a box of cloth incontinent pads available in storage so that she could replace them as needed. When asked why they are not available on the carts for the staff to use she currently, the Director stated, Just because I keep getting pulled in different directions. Class III

Based on facility policy review, observation and interviews, the facility failed to file a grievance in a timely manner, for 1 of 1 sampled resident reviewed for grievances. As evidenced by failure of staff to respond to Resident #46's grievance regarding her missing blankets for almost 2 weeks.The findings included:The facility policy titled, Resident and Family Grievances documented in part Grievances can be voiced in the following forums: a. Verbal complaint to a staff member or grievance official.Record review revealed Resident #46 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, on a 0 to 15 scale, indicating mild cognitive impairment.During an interview on 07/07/25 at 11:24 AM, Resident #46 stated, I'm missing my two blankets, The blue one my grandson got for me. I've been missing them for over 1 week. I have told several staff, but they do nothing. I even went out to the nurses' station and told them, but nothing happened.During an interview on 07/08/25 at 11:09 AM, when asked did you speak to anyone about your missing blankets. Resident #46 stated, Yes, I spoke to the person over housekeeping finally on yesterday afternoon after complaining to three or four other people.During an interview on 07/09/25 at 1:45 PM when asked did they find your blankets. Resident #46 stated No, the housekeeping director hasn't come back to talk to me about them.During an interview with the Social Worker (SW) on 07/10/25 11:56 AM she was asked are grievance forms available for staff to fill out when a resident has a complaint, she stated Yes, the forms are at the nurses station, in the conference room, and in my office. When asked, do you know anything about the missing blankets for Resident #46. The SW stated Housekeeping was given the grievance. I just found out yesterday. I have to call her family to see if maybe they took them home to wash. A copy of the grievance form was requested from SW. The grievance form was dated 07/08/25, the top portion of the form with the resident's information and complaint was filled out, there was no other documentation on the form. (photographic evidence obtained)During a conversation with the Housekeeping Director (HD) and the SW, The HD was asked by the SW if she had an update on Resident #46's missing blankets. The HD stated, no, after lunch I will show the resident all the blankets I have and maybe she can identify hers. The SW stated, I'm going to go call the family now. During a brief conversation with the SW on 07/10/25 at 2:01PM, she stated I spoke to Resident #46's son and he said the family does not have the blankets and the resident had been complaining to him that the blanket that her grandson got for her is missing. I didn't see a blanket listed on the resident's inventory.

Based on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 1 of 5 sampled residents, Resident #39, related to antipsychotic use, and for 1 of 10 sampled residents, Resident #37, related to weights.The findings included:1) Review of the record revealed Resident #39 was admitted to the facility on [DATE]. Review of the current comprehensive MDS assessment dated [DATE] documented the resident was taking an antipsychotic medication, and that a Gradual Dose Reduction (GDR) for the antipsychotic was both attempted on 01/14/25 and was contraindicated on 01/14/25.Further review of the record revealed Resident #39 was ordered Risperdal, an antipsychotic medication, since 08/11/22, and that the dose of the medication had not been changed. Further review of the psychiatric progress noted dated 01/14/25 documented the dosing of the Risperdal should be done by neurology as the medication was ordered for a neurological condition, Huntington's disease. This progress note lacked any contraindication to a GDR for the Risperdal.During a side-by-side record review and interview on 07/09/25 at 10:35 AM, the MDS Coordinator confirmed the findings, further stating the resident's Ativan, an antianxiety medication and classed as a psychotropic medication, not an antipsychotic medication, was discontinued at that time. The MDS Coordinator stated there had not been a change in the antipsychotic medication since 2022 and she was unable to locate any contraindication for a GDR on 01/14/25, as incorrectly documented on that MDS assessment.2) Review of the record revealed Resident #37 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE], documented in section K that the resident weighed 134 pounds.Further review of the electronic medical record revealed on 05/07/25, the most current weight prior to the assessment date, documented the resident weighed 132 pounds.During an interview on 07/09/25 at 1:11 PM, when asked how she obtained weights for section K of the MDS assessment, the Registered Dietician (RD) stated she gets the weights directly from the electronic medical record and uses the weight right before the assessment date. When told of the inconsistency between the weight in the assessment and the weight in the electronic medical record for Resident #37, the RD stated she would review the concern. During a supplemental interview on 07/09/25 at 1:25 PM, the RD agreed with the finding.

Based on observations, interviews and record reviews, the facility failed to develop and implement a care plan to address Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled resident reviewed for Behavior, Resident #61; The facility failed to develop and implement a care plan for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #63. The findings included: Resident #61 was admitted to the facility on [DATE]. According to the resident’s most recent complete assessment, an Annual Minimum Data Set (MDS) with a reference date of 05/31/25, Resident #61 had a Brief Interview for Mental Status (BIMS) score of 03, indicating a severe cognitive impairment. The assessment documented that the resident was dependent upon staff for all activities of daily living (ADLs). Resident #61’s diagnoses at the time of the assessment included: Non-Alzheimer's dementia, Anxiety disorder, Psychotic disorder, Post Traumatic Stress Disorder (PTSD). A review of Resident #61’s medical records revealed that there was no care plan to address the resident’s PTSD. During the survey process, it was determined that the resident was not interviewable due to multiple attempts to interact with the resident and the resident did not respond to being greeted by name on multiple occasions. During an interview, on 07/09/25 at 9:30 AM, with Resident #61’s Power of Attorney (POA), when asked about the resident's PTSD, Resident #61’s POA replied, he was in Vietnam. When asked about triggers and what should be avoided, Resident #61’s POA replied, loud noises, fireworks, things like that. During an interview, on 07/09/25 at 1:59 PM, with Staff F, RN, when asked about Resident #61's PTSD, Staff F replied, I am assuming he was in the military, I am not sure of the underlying reason.” When asked about triggers and what should be avoided, the RN replied, “Probably not getting what he wants, or forgetting his tray and he will feel like he is abandoned. They are very good with him and with getting him in his chair. I have only been here for about a month and a half.” During an interview, on 07/09/25 at approximately 2:30 PM, with Staff G, LPN, when asked about providing care to Resident #61, Staff G replied, he is okay, he is not violent. Sometimes when you provide care, he is combative and then you can talk to him, and he will calm down. When asked about Resident #61 having PTSD, Staff G replied, “they have a past history of anxiety, he had a stroke and has left sided weakness.” During an interview, on 07/09/25 at 3:50 PM, with Staff H, CNA, when asked about Resident having PTSD, Staff H replied, I did not know he had PTSD. During an interview, on 07/09/25 at 3:54 PM, with the MDS Coordinator, since 06/03/25, the MDS Coordinator acknowledged that there was no care plan to address Resident #61's PTSD prior to Surveyor intervention. During an interview, on 07/09/25 at 3:59 PM, with the Social Services Director (SSD), when asked about a care plan to address Resident #61’s PTSD, the SSD acknowledged that there was no care plan to address Resident #61's PTSD prior to the Surveyor bringing it to her attention. 2) A review of the clinical records indicated that Resident #63 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder. A physician's order dated 06/04/2025, revealed that the resident had been prescribed NovoLog Injection Solution 100 UNIT/ML (Insulin Aspart) 4 units to be injected subcutaneously before meals for diabetes. The order also stated that the medical doctor or nurse practitioner should be contacted if blood sugar levels exceed 300 mg/dL. On 06/26/2025, the interdisciplinary team reviewed the residents' care plans, but no specific care plans were developed for the diagnosis of diabetes or for the use of insulin. During an interview on 07/09/2025 at 2:14 PM, the MDS Coordinator confirmed that no active care plan addressing the resident's diabetes diagnosis or insulin usage.

Based on record review, the facility failed to update the care plan for 2 of 28 sampled residents, as evidenced by failure to ensure that the diet orders were care planned for Resident #50 and failure to ensure the antianxiety medication care plan for Resident #63 was updated.The findings included: 1) Record review revealed Resident #50 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not conducted, because the resident was rarely or never understood. Review of a physician order's dated 06/02/25 for Resident #50, indicated that the resident was prescribed a diet of regular, pureed (pudding like) texture, and nectar thickened fluid consistency. Review of the revised care dated 06/12/25, indicated that Resident #50 was on a regular, mechanically altered ground texture, and nectar thickened liquids consistency diet. 2) A review of the clinical records indicated that Resident #63 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder. A review of a physician's order dated 06/18/2025, revealed that Alprazolam 0.5 mg was prescribed to be given as one tablet by mouth every 12 hours as needed for anxiety for 7 days. Additionally, a review of the care plans, with a revision date of 06/26/2025, noted that Resident #63 uses anti-anxiety medications related to anxiety disorder. However, it was identified that there was no current order for anti-anxiety medication in place. The care plan was not updated to reflect the resident's current status. On 07/09/2025 at 2:14 PM, the MDS Coordinator was interviewed, who confirmed an active care plan for anti-anxiety medication. Still, no current order has been issued for it.

Based on observations, record review, and interviews, the facility failed to ensure that 1 of 1 sampled resident reviewed for skin rash received further treatment as evidenced by Resident #35 remained symptomatic after the initial treatment for a skin rash.The findings included:Record review revealed that Resident #35 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview Mental Status score of 07 on a 0-15 scale, indicating severe cognitive impairment.During an interview on 07/07/25 at 9:45 AM with Resident #35, she was observed scratching the left side of her face. A rash was noted to her left cheek area. When asked are the staff putting any medication on your face for the itching, she stated, I don't think so. Review of a physician progress note dated 07/05/25, revealed that the attending nurse practitioner (NP) visited Resident #35 on 07/04/25 due to a skin rash and the resident was noted to have a mild to moderate skin rash. The NP's plan was to prescribe Permethrin 5 % (for treatment of scabies) cream for a one-time dose and reevaluate the rash after treatment for effectiveness. During an interview with Resident #35 at 07/09/25 at 8:32 AM, when she was asked how the rash on her face is, the resident stated It itches and that's not the only area the rash is on, it's all on my neck. It feels like something is biting me. When asked had the staff applied any medication for the itching, Resident #35 stated, No.During a skin assessment on 07/09/25 at 1:30 PM with Staff I, Certified Nursing Assistant (CNA) at the bedside, Resident #35 was noted to have several scabbed and reddened areas to the skin on her neck, upper back, bilateral arms, chest area, and the left side of her (UM)face.During an interview on 07/09/25 at 1:38 PM with the Unit Manager, (UM) she was asked if Resident #35 had received any treatment for a skin rash. She looked in the resident's record and printed out a treatment record that indicated the resident had received a one-time treatment of Permethrin cream on 07/06/25. When asked if she knew if the resident had any other treatments for itching ordered or when will she be reassessed by the nurse practitioner (NP), she stated No, she doesn't have any other treatment ordered. The UM read the progress note in the resident's record written by the NP on 7/05/25. Suddenly, she placed a call to the NP and asked her when she will follow with Resident #35 for reassessment of the skin rash as stated in her note. The UM stated, The NP said she usually follows up with the resident seven days following treatment and the resident should be seen by dermatology. When asked if or when will Resident #35 be seen by dermatology, she stated I will have to let you know. The UM did not give any follow up information regarding the dermatologist. During an interview on 07/09/25 at 1: 58PM with the Medical Director of the facility, she was made aware of the NP's response to the UM stated that she will follow up with Resident #35 seven days after her prescribed treatment for a skin rash and the resident should be seen by dermatology. When asked what happens if the resident is still having symptoms of itching and when will dermatology see the resident, the Medical Director stated, We do have a dermatologist that comes to the facility, but the resident doesn't have to wait, I can see her.

Based on observation, record review and interview, the facility failed to follow physician orders for treatment of a facility acquired pressure ulcer for 1 of 3 sampled residents reviewed for pressure ulcers, as evidenced by not changing the dressing, as ordered for Resident #13 pressure ulcer.The findings included: Record review revealed Resident #13 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set assessment dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 02, on a 0-15 scale, indicating severe cognitive impairment. Review of a pressure injury investigation audit form dated 06/30/25, indicated that Resident #13 had a new left heel pressure ulcer (caused by unrelieved pressure). Review of a physician order dated 07/03/25 for Resident #13, instructed staff to cleanse the right achilles (heel) pressure wound with normal saline (salt solution), apply skin prep to the necrotic area and cover with a foam dressing every day shift (7 AM to 3 PM) on Monday, Wednesday, and Friday. A second order dated 07/03/25, instructed staff to cleanse the right achilles pressure wound with normal saline, apply skin prep to the necrotic area and cover with a foam dressing as needed for saturation or dislodgment of the dressing. During an observation on 07/08/25 at 3:30 PM, Resident #13 was sitting in her wheelchair with her right leg elevated, the tan foam dressing noted to her right achilles was partially hanging off and exposing the wound. (photographic evidence obtained)During an observation on 07/09/25 at 8:48 AM, Resident #13 was lying in her bed with a tan foam dressing dated 07/04/25 to her right achilles that was partially hanging off. (photographic evidence obtained)On 07/09/25 at 1:21 PM, Resident #13 was observed sitting in her wheelchair with tennis shoes on both feet. The foam dressing that should have covered the wound to her right achilles was above the back of the shoe. (photographic evidence obtained) Review of the Treatment Administration Record (TAR) for Resident 13, revealed that Staff L, Licensed Practical Nurse (LPN) had signed the TAR acknowledging that she had performed the wound care treatment to Resident #13 right achilles pressure wound, on 07/07/25 and 07/09/25. During an interview on 07/09/25 at 4:22PM, Resident # 13 was noted sitting on the edge of her wheelchair with her right leg elevated. She was wearing a tennis shoe to her right foot, but the shoe from the left foot was on the bed. The resident was mumbling trying to say something and grimacing as if she was having discomfort. When asked if she was having discomfort, Resident #13 pointed to her right foot and shook her head yes. Staff K, Licensed Practical Nurse (LPN) was made aware of the resident's complaint of discomfort to her right foot. She went into the resident's room. Staff K, LPN removed the foam dressing that was hanging off the resident's right achilles wound. The dressing that was removed had the date 7/4 and the initials { } written on it. There was some dark brownish drainage noted on the dressing and the dressing had a foul odor. The wound was noted to have eschar (dark color). Staff K, (LPN) stated I'm going to put on a new dressing and give you some pain medication. Resident #13 shook her head yes.

Based on policy review, observation, record review, and interview, the facility failed to ensure care and services, and supervision to prevent falls, for 1 of 4 sampled residents, as evidenced by Resident #39 having had eight falls since 05/01/25, with six being from her chair. The three most recent falls occurred while Resident #39 was in her Broda chair, the newest of intervention as of 06/19/25. The facility also failed to ensure the provision of two neurology consults for increased involuntary movements related to Huntington's Disease, which was care planned as part of the resident's risk for falls.The findings included:Review of the policy Fall Prevention Program (not dated), documented in part, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. 4. Risk Protocols: . g. Provide interventions that address unique risk factors: medications, psychological, cognitive status, or recent change in functional status. h. Provide additional interventions as directed by the resident's assessment, including but not limited to: . ii. Increased frequency of rounds iii. Sitter, if indicated . Review of the record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses to include Huntington's Disease, repeated falls, and abnormal involuntary movements. Review of the current Minimum Data Set (MDS) comprehensive assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 0, on a scale of 0 to 15, indicating severe cognitive impairment. This MDS assessment documented the resident was totally dependent upon staff for all Activities of Daily Living (ADLs) and had two or more falls since the prior assessment of 12/29/24.Review of the current physician orders include a neurology consult dated 10/29/24 for increased involuntary movements related to Huntington's Disease. The record lacked any evidence that the consult had been completed, and it remained an active order in the record at the time of the survey.A current care plan initiated on 09/09/20 documented in part that Resident #39 was at further high risk for falls with injury related to ongoing progressive loss of functional abilities. This care plan included an intervention dated 05/09/25 for a neurology consult.All Fall Risk Assessments in the medical record documented Resident #39 as a high risk for falls. The Risk Manager was asked to locate and provide evidence of the investigation for all falls from 05/01/25 to the present time.Review of progress notes and post-fall investigations revealed the following:a) On 05/09/25 at 2:45 PM Resident #39 was found on the floor, having slid off her chair. The root cause analysis was that the resident had Huntington's Disease with involuntary movements with an evaluation for a Geri-chair (a recliner-type wheelchair).b) On 05/12/25 at 11:00 AM Resident #39 was sitting on her bed and slipped off the bed onto the floor. The root cause analysis was documented as the resident had Huntington's Disease that caused her to roll off the floor mat and onto the floor. This contradicted the documented eyewitness statement by the Staff Developer who saw the resident slip off the bed and the mattress was in an upright position and not on the floor during the event. Therapy services were to evaluate for a Geri-chair.A physician's progress note dated 05/12/25 at 1:48 PM documented, in part, . Assessment/Plan: . Huntington's disease: . needs close supervision secondary to involuntary movements.c) A progress note dated 05/12/25 at 2:26 PM documented, Observed resident on floor next to bed. The facility did not provide any investigation for this event. A subsequent physician's progress note dated 05/13/25 at 12:03 PM documented the resident found to have 2 falls in the last 24 hours . Fall prevention protocols. Continue with nursing supervision. Follow neurology. Continue supportive treatment.d) On 05/20/25 at 8:35 AM, Resident #39 was sitting in her chair, waiting for breakfast, during meal tray pass. As per a witness statement, staff turned around and observed the resident on the floor. Resident #39 was placed on frequent checks of every 15 minutes, for 24 hours. A physician's progress note dated 05/20/25 at 2:55 PM documented the fall that morning with no injury. This note documented, in part, . Assessment/Plan: . Huntington's disease: . needs close supervision secondary to involuntary movements.e) On 05/27/25 at 11:55 AM Resident #39 was on the floor, having fallen out of the chair. The root cause analysis was that the resident kicked the footboard of the wheelchair and slid out of the chair. An intervention was again to evaluate for a Geri-chair.f) As per an invoice provided by the Administrator, Resident #39 was provided a new Broda chair (a specific recliner-type wheelchair) on 06/19/25. Note the evaluation for a new chair was made on 05/09/25.g) On 07/04/25 at 12:09 PM Resident #39 was found on the floor in the hallway, next to her chair. The root cause analysis was that the resident sat up and slid out of the chair, although the progress note revealed the resident had been seen in the chair, appropriately placed, and with the footrest up.h) On 07/08/25 at 7:50 AM Resident #39 was found on the floor in the hallway next to her chair. At the time of the survey, this fall was in the process of being investigated. The resident was placed on frequent checks of every 15 minutes.During an observation on 07/08/25 at 8:56 AM, Resident #39 was observed on the floor in the hallway, next to her Broda chair. Blood was noted on floor beneath her head. Resident #39 was being attended by Staff L, Licensed Practical Nurse (LPN), the Director of Nursing (DON) and the Nurse Practitioner. Shortly before the fall, Staff L was observed yelling at the resident, sit down . sit down. When the LPN noted she was being observed, she added please and quieted her tone. The LPN left the resident in the hallway to continue with her morning medication pass, when Resident #39 fell out of the chair. Resident #39 was taken to the emergency room (ER) for an evaluation. On 07/08/25 at 12:24 PM, Resident #39 had returned from the ER, was in her room in the Broda chair, with one-to-one supervision by a CNA. Sutures were noted to her right forehead with swelling noted in the area of the sutures.A progress note written by Staff L, LPN, dated 07/08/25 at 1035 AM documented Resident #39 had been fidgeting sitting next to nurse when she sat up in chair, tilted body to the right, and fell out of wheelchair.During an observation and interview on 07/09/25 at 9:59 AM, Resident #39 was noted in her room in the Broda chair with Staff A, CNA. The CNA confirmed the resident was now on one-to-one care and further stated it was very difficult due to the resident's spastic movement. When asked if the resident had been on one-to-one care before, the CNA stated maybe in the past but just for a short time.During an interview on 07/09/25 at 10:17 AM, the Unit Manager was asked about the neurology consults from October 2024 and May 2025. The Unit Manager stated she would look into it. During a subsequent interview that afternoon, the Unit Manager stated she believed the lack of neurology appointments in the past was related to insurance issues, but she now has one for August 2025. The Unit Manager was asked to provide documentation of what happened with the two previous appointments that were not completed.On 07/10/25 at 1:04 PM, the DON reported she found where an appointment was scheduled in November 2024, but was not completed, and she was unsure as to why. When asked about the May 2025 ordered consult, the DON was unsure.

Based on policy review, observation, interview, and record review, the facility failed to ensure the provision of foods to address nutritional concerns for 2 of 10 sampled residents, as evidenced by the failure to include fortified foods as ordered for Resident #37 and Resident #50 , and failure to provide ordered meals for Resident #63. All three sampled residents had weight loss concerns or were underweight.The findings included:Review of the policy Fortified Foods (not dated) documented, in part, Policy: . The purpose of utilizing fortified foods is to add additional calories/protein to the oral diet in efforts to address weight loss, skin status, nutritional concerns, etc. 1) The fortified foods are to be added to the resident's diet includes but not limited to fortified cereal and fortified potatoes. 1) Review of the record revealed Resident #37 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 2, on a 0 to 15 scale, indicating the resident was severely cognitively impaired. The same assessment documented the resident was totally dependent upon staff for all activities of daily living (ADLs). Although the weight for Resident #37 had been stable for the past six months, the current quarterly nutritional assessment documented the resident was underweight for her age and was at risk for malnutrition. An order dated 09/19/22 documented the resident was to receive fortified foods with all meals. An observation on 07/07/25 at 12:09 PM revealed Resident #37 had received her lunch meal. The meal ticket documented fortified foods with all meals. The meal provided to the resident lacked any fortified potatoes or any other fortified food. Observation of the meal at 12:38 PM still lacked any fortified foods. Staff A, Certified Nursing Assistant (CNA) was placing the tray back into the cart and stated, She drank everything, but only ate like 15% of the food. During an observation on 07/08/25 at 12:18 PM, the lunch meal was provided to Resident #27. The meal consisted of a slice of turkey, a sweet potato, green beans, and diced pears. The tray lacked any fortified foods, and the meal ticket still documented the resident was to have fortified foods with all meals. During an interview on 07/09/25 at 12:55 PM, the Registered Dietician (RD) and Administrator (NHA) were made aware of the observation from Monday's lunch on 07/07/25 and shown the photo of Tuesday's lunch, both of which lacked fortified foods. The RD agreed with the findings. Both managers were surprised, and the NHA stated the kitchen was pretty good with the fortified foods. 2) A review of clinical records revealed Resident #63 was admitted to the facility on [DATE], with a diagnosis of malnutrition. The admission Minimum Data Set assessment (MDS), dated [DATE], indicated a brief interview for mental status, scoring 12, which suggested that the resident was moderately cognitively impaired. The diet order, issued on 06/04/2025, specified a no-added-salt diet with a regular texture and thin liquid consistency. A nutrition assessment conducted the same day revealed that the resident’s body mass index (BMI) indicated he was underweight for his age. Additional records indicated that the resident had experienced weight loss. Specifically, on 06/14/2025, his weight was recorded at 148.3 pounds, but by 07/04/2025, it had dropped to 138.2 pounds. The care plan was revised on 06/26/2025 and noted that the resident was at risk for malnutrition, muscle wasting, and altered nutrition. It highlighted his low BMI and the need for fortified foods. The intervention outlined was to provide the diet as prescribed. On 07/07/2025 at 10:22 AM, the interview process began with Resident #63. He expressed he had weight loss and stated that he found the food to be awful and terrible, adding that it was often presented as if the staff had piled the food on his plate disorderly. He also complained that the meals were served cold. Later, at 12:55 PM, a follow-up occurred while the resident was having lunch. He mentioned, “Today he was supposed to have spaghetti with meat sauce, but he didn’t receive any spaghetti.” He then showed the surveyor his meal ticket, which indicated spaghetti with meat sauce, while his plate lacked spaghetti. On 07/09/2025 at 8:35 AM, a follow-up observation during breakfast the resident voiced his dissatisfaction again, noted that he had received meat sauce without spaghetti on Monday. The registered dietitian (RD) was interviewed on 07/10/2025 at 12:03 PM. The surveyor informed her about the resident's food concerns and showed her a picture of the meal ticket and what the resident had received. The RD remarked, “If he got the meat sauce, he should have also received the spaghetti,” she acknowledged the issue. 3)Record review and observations revealed that Resident #50 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented that a Brief Interview Mental Status was not conducted, because the resident was rarely or never understood. Review of Resident #13 medical diagnosis revealed a history of Alzheimer's (memory loss), anorexia nervosa (eating disorder causing one to be obsessed about weight), and dysphagia (difficulty swallowing). During an observation of Resident #50’s lunch tray on 07/07/25 at 12:28 PM, the meal ticket revealed that the resident was to receive fortified foods with all meals. The tray included: pureed meat sauce, vegetables and noodles. (photographic evidence obtained) Review of the weights for Resident #50 revealed, on 01/03/25, the resident weighed 86.8 pounds and on 07/03/25, the resident weighed 78.2 pounds which is a -9.91 % weight loss in 6 months. Review of the current diet order for Resident #13 dated 06/02/25, revealed that the resident was prescribed a regular diet, pureed texture, nectar thickened fluids consistency with a planned weight gain regimen to include fortified foods at each meal. Review of the revised care plan dated 06/12/25, revealed that Resident #13, was at risk for malnutrition and the need for fortified foods, there was a goal for the resident to maintain her weight or have gradual weight gain with no significant weight changes through the next review date and one of the interventions was to provide fortified cereal at breakfast and fortified mashed potatoes at lunch & dinner. During an observation of Resident #50 lunch tray on 07/08/25 at 12:20 PM, the meal ticket revealed that the resident was to receive fortified foods with all meals. The tray was noted to have sweet potato, turkey and green beans, pears. (photographic evidence obtained)

Based on facility policy, observations, record review and interviews, the facility failed to ensure that it was free of medication errors for 3 of 7 sampled residents, as evidenced by a medication error rate of 15.6% with 32 opportunities due to failure to ensure that Resident #7 received medications ordered and was available for him, failure to ensure Resident #5 received medications that are prescribed to him, failure to notify the physician prior to holding blood pressure medications for Resident #27.The finding Included:The facility policy titled Medication Administration documented in part Policy Explanation and Compliance Guidelines 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medications for those vital signs outside the physician's prescribed parameters. 12. Compare medication source (bubble pack, rectal, etc.) with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time. (photographic evidence obtained)1.) Record review revealed Resident #7 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented a Brief Interview Mental Status score of 09 on a 0-15 scale, indicating moderate cognitive impairment. During observation of medication administration on 07/08/25 at 9:05 AM, Staff J was observed preparing and administering medications for Resident #7. As she prepared the medications, she stated what each one of the medications were. After she prepared each medication, the name of the resident was verified with the medication label for each medication she prepared. Staff J, LPN poured Enulose (medication for increased ammonia) in a clear medicine cup and the resident's name was verified with the bottle. The bottle of Enulose was noted to have a different resident's name on the mediation label. The bottle of Enulose was given back toe Staff J, LPN and she placed it back in the medication cart. She placed a cup of five pills and a cup of Enulose on a white styrofoam tray and carried them to the resident's room. After Resident #7 put the pills in his mouth Staff J offered him a drink of water from a white styrofoam cup with a straw that was already sitting on his bedside table. During a brief conversation on 07/08/25 at 9:16AM, Staff J was asked to show the bottle of Enulose that she poured the dose from to administer to Resident #7. She went into the medication cart and handed the bottle of Enulose with another resident's name on the medication label, Staff J stated, I know it's not his, but! (photographic evidence obtained)Review of the physician orders for Resident #7 revealed an order that instructed staff to administer Glycolax powder/MiraLAX (for constipation) 17gm by mouth daily) mix with 8 ounces water, juice, coffee, tea) at 9:00 AM. A second order instructed staff to administer Enulose solution 30 milliliters by mouth three times a day for hyperammonia (increased ammonia). Review of the Medication Administration Record for Resident #7 revealed that Staff J signed acknowledging that she administered the Glycolax/Miralax on 07/08/25 at 9:04 AM. (Photographic evidence obtained)During an interview on 07/08/25 at 12:30 PM, when asked do you have a bottle of MiraLAX on your medication cart, Staff J, LPN opened the medication cart and pointed to the bottle of MiraLAX. When asked did any one of the residents that were observed doing med pass, have an order to get MiraLAX at 9:00 AM, Staff J, LPN looked at the medication administration record for the residents and stated Yes, Resident #7. When she was asked if she gave it to him, while she was being observed giving medications, Staff J stated, I gave it to him in his water. When was asked when, she stated, After you left. 2) Record review revealed Resident #5 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status score of 12 on a 0-15 scale, indicating moderate cognitive impairment. During an observation on 07/08/25 at 9:18 AM, Staff J, LPN was observed preparing and administering medications for Resident #5. She prepared three pills in a clear medication cup, with each medication label being verified with the resident's name. Staff J, LPN was then observed administering the three pills in the medicine cup to Resident #5. Review of the physician orders for Resident #5 revealed an order that instructed staff to apply Triamcinolone Acetonide External cream 0.1% to affected areas daily for dermatitis (inflammation of skin). Review of the Medication Administration Record for Resident #5 revealed that Staff J, LPN signed on 07/08/25 at 9:22 AM acknowledging that she administered the Triamcinolone Acetonide External cream for the resident. (photographic evidence obtained) During an interview on 07/08/25 at 12:30 PM, Staff J, LPN was asked to show the Triamcinolone cream that she applied for Resident #5. She went to the treatment cart and looked throughout the cart and in the trash can and was unable to find the ointment. Staff J, LPN stated I can't find it 3) Record review revealed Resident #27 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status score of 15, indicating no cognitive impairment.During observation of medication administration on 07/09/25 at 9:05AM, Staff F, Registered Nurse (RN) was observed preparing and administering medication for Resident #27. Staff F went into Resident #27's room to check her blood pressure and heart rate prior to preparing medications. After she returned to her medication cart, she stated, Resident #27 blood pressure was 114/57 and heart rate was 61, which is low so I'm just going to hold her blood pressure medication, the Metoprolol, and just document that I'm holding it. After she prepared each medication, the name of the resident was verified with the medication label for each medication she prepared. Staff F, RN prepared 5 pills in a clear medicine cup. Prior to administering the medication, the nurse told Resident #27 what medications she was giving her, the resident asked the nurse I'm not getting the Metoprolol? Staff F, RN stated No, remember, because your blood pressure was low 114/57. Review of a physician order dated 03/24/25 for Resident #27, instructed the staff to administer Metoprolol Succinate ER (blood pressure medication) 100mg, give 1 tablet by mouth daily at 9:00 AM. A second physician order dated 03/24/25, instructed staff to administer Losartan Potassium 25mg, give 1 tablet by mouth daily at 9:00 AM to Resident #27.Review of the Medication Administration Record revealed that Staff F, RN documented on 07/09/25, that she did not give the Metoprolol Succinate ER or Losartan Potassium 25mg as ordered at 9:00 AM.Review of a progress noted dated 7/09/25 at 10:19 AM revealed documentation that indicated Staff F, RN did not give the Metoprolol Succinate ER due to low blood pressure. Another progress note dated 07/09/25 at 10:19 AM, revealed documentation that indicted Staff F, RN did not give the Losartan Potassium due to low blood pressure.During an interview on 07/09/25 at 11:01AM Staff F, RN was asked how many blood pressure medications Resident #27 was ordered to get during 9:00 AM medication administration, she stated It was two, the losartan and metoprolol. When asked did you hold both medications, Staff F, RN stated Yes, because her diastolic (low number of blood pressure) was really low and its common nursing judgement not to give blood pressure medications if it's below the parameter. When asked what the parameter is, Staff F, RN stated, The diastolic was below 60, if I would have given the medication the blood pressure will drop even lower. When asked is this what you usually do Staff F, RN stated Yes, I use my nursing judgement.

Based on record review and interview, the facility failed to obtain a laboratory test for 1 of 5 sampled residents reviewed for laboratory testing. (Resident #8). The findings included: A review of the clinical record for Resident #8 revealed the resident was admitted to the facility on [DATE], with diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. A physician's order on the same day specified that Divalproex Sodium Oral Tablet Delayed Release 125 mg should be administered orally twice daily for mood disorder. Additionally, the physician ordered a valproic acid level to be measured on 06/01/2025. However, the records lacked documented evidence of the valproic acid test result.On 07/10/2025 at 12:29 PM, an interview was conducted with the Director of Nursing (DON), during which a side-by-side review of Resident #8's records occurred. The DON acknowledged the absence of the valproic acid result and promptly contacted the Unit Manager, requesting a follow-up with the laboratory service regarding the missing test. A subsequent interview with the DON at 1:40 PM confirmed that the result was still unavailable. She indicated that the unit manager had contacted the laboratory and was informed they did not have the result.Valproic acid is a test conducted when using the medication Divalproex. Levels are measured in the blood to ensure the medication is within the therapeutic range, which helps to ensure effectiveness while minimizing side effects.Elevated levels can suggest an increased risk of toxicity, potentially causing symptoms like nausea and drowsiness, or more serious issues like liver damage.Low levels may indicate that the medication is not sufficiently effective, which could increase the risk of seizures or mood swings.

Based on policy review, observation, record review, and interview, the facility failed to ensure infection control practices for 3 of 30 sampled residents, as evidenced by the failure to abide by Transmission Based Precaution (TBP) guidelines, Enhanced Barrier Precaution (EBP guidelines, and failure to use Personal Protective Equipment (PPE) during direct care, for Resident #75, #288 and #71.The findings include:Review of the polices titled, Transmission-Based (Isolation) Precautions (TBP) and Enhanced Barrier Precautions (EBP) showed that the TBP policy documented, in part, 1. Facility staff will apply TBP….to residents who are known or suspected to be infected….3. (b). The provision of a private room as available/appropriate. 4. Residents… should remain in their rooms except for medically necessary care. The EBP policy documented, in part, targeted gown and gloves use during high contact resident care activities. 2.b. An order for EBP will be obtained for residents with any of the following (b)…. wounds, indwelling catheter, hemodialysis catheter…4. EBP should be used for high-contact resident care activities including providing hygiene. changing linen, and 1) Review of the record revealed Resident #75 was admitted to the facility on [DATE] with a diagnosis of fracture of left thigh bone. A review of the physician order dated 07/06/25 at 3:00 PM included placing the resident on contact isolation precaution to rule out Clostridium difficile colitis (C Diff) which is an infection in the large intestines. Review of the Physician Assessment/Plan dated 07/07/25 stated the following: “Diarrhea following recent antibiotics (doxycycline)- obtain stool sample to rule out C Diff, patient to remain on isolation until results (patient verbalize understanding)”. Review of the task list for bowel activity showed that Resident #75 had multiple loose stools from 07/02/25 to 07/06/25. Review of the facility lab book showed that the stool specimen was logged in as collected on 07/07/25. The following observations were made: On 07/07/25 at 9:30 AM, Resident #75 was observed in the hallway sitting in his wheelchair. On 07/08/25 at 12:30 PM Resident #75 was observed moving around the hallway while sitting in his wheelchair. On 07/08/25 at 4:30 PM Resident #75 was observed in a unit hallway by the nurse’s station. During the initial interview conducted with the Resident # 75, on 07/07/25 at 9:36 AM, when asked about the care and services of the facility, the resident responded, “I need to get my stool specimen results from Saturday.” The resident was in a private room and stated that he was moved to this room yesterday. An interview was conducted on 07/09/25 at 10:35 AM with the Unit Manager (UM). When asked to review the results for the C diff culture for Resident #75 the UM reviewed the electronic medical record and the results were not available. When asked how to confirm that the specimen was collected and sent for testing the UM stated that the specimen is logged in the lab book and the transporter signs the log sheet when the specimen is taken out for testing. On 07/09/25 at 5:43 PM an interview with the Infection Preventionist was conducted. This surveyor asked what the expectation was when a resident is on Contact Precautions pending lab results. The IP states that a resident should remain on contact precautions until the results are obtained. 2). Review of the record revealed Resident #288 was admitted to the facility on [DATE] with a diagnosis of [NAME] Kidney Disease requiring dialysis. A review of the physician order dated 07/01/25 at 3:00 PM included placing the resident on enhanced barrier precautions for dialysis and central line. Review of the care plan indicated that the Resident was on EBP, and the interventions and tasks included: wear gown and gloves during assistance with dressing, bathing, transferring, hygiene, changing linens, changing briefs & toileting, and during dressing change at port. On 07/07/25 at 10:10 AM Resident #288 was observed asleep in bed, with the door slightly ajar. PPE supplies and EBP signage were posted on the door. 07/08/25 at 1:15 PM, there was no EBP sign posted on the door as it was posted on the previous room occupied by Resident #288. 07/08/25 at 3:40 PM another observation was made of Resident #288’s assigned room door which was closed at this time. There was no EBP signage on the door. 3) Review of the record revealed Resident #71 was admitted to the facility on [DATE]. Review of physician orders revealed the resident was placed on contact precautions on 06/28/25 while being treated with intravenous (IV) antibiotics for a Multi-Drug Resistant Organism (MDRO) of the urine. The antibiotic was completed on 07/05/25 and the resident was removed from the contact precautions on 07/08/25 and was placed on Enhanced Barrier Precautions (EBP) related to the presence of a wound. Review of the current care plans documented as of 07/01/25 Resident #71 would be on contact isolation through 07/05/25. A second care plan initiated on 06/17/25 indicated the resident was on EBP related to an open wound, and that gowns and gloves were to be worn during high-contact care activities including linen changes and wound care. During an observation on 07/07/25 at 9:51 AM, a contact precautions sign and PPE was noted on the door of Resident #71. Staff C, Certified Nursing Assistant (CNA), was in the room of Resident #71, pulling down the resident's covers and adjusting the pillow located between her legs. As the CNA was gathering supplies to complete personal care for the resident, she explained she usually worked 11 PM to 7 AM, and that this was her first time on day shift. Staff C, CNA, proceeded to provide personal care for Resident #71, while wearing gloves, but did not don a gown at any time during the care. On 07/08/25 at 9:16 AM, it was noted Resident #71 had moved to another room and was now on EBP, instead of contact precautions, as per the sign on the door. Staff C, CNA, was in the room, providing personal care to Resident #71 and changing her adult brief. The CNA lacked any gown during this observation. During an interview on 07/08/25 at 10:50 AM, when asked if she knew what EBP and contact precautions meant, Staff C stated, It means I have to wear gloves, gown, and mask when I go into the room for care. When asked why she did not wear a gown during personal care for Resident #71 yesterday, when on contact precautions, or today, when on EBP, the CNA stated, Because I just moved to days, I wasn't sure which resident (referring to A bed or B bed) was on the precautions. When asked what the orange dot next to the name meant, the CNA did not know. During an interview on 07/09/25 at 5:49 PM, when told of the observations of Staff C, CNA, providing care to Resident #71, and the interview with the CNA, the Infection Preventionist (IP) stated the CNA should have been wearing a gown during the care tasks. When asked about the orange dots next to the resident names throughout the facility, the IP explained those dots indicate which of the residents in the room are on the EBP.

Based on observations and interview, the facility failed to have an effective pest control program. The findings included: During the initial kitchen tour, on 07/07/25 at 9:11 AM with the Food Service Director/Certified Dietary Manager (CDM), the following were noted: 1. In the hot holding area of the kitchen, two live and mature roaches were observed on a table by the conveyor toaster.2. In the food service area (where staff collect the plates from the cooks and place in the carts to take to the units and the Main Dining Room) live roaches, in all stages of life and too numerous to count were observed behind a cart containing a stack of trays and single service items (sugar packets, condiments, tea bags etc.) At the time of the observation, the CDM instructed staff to remove the cart, dispose of the single service items, clean and sanitized the cart and the trays that were stacked in the cart. On 07/10/25 at 12:35 PM, the Surveyor attempted to contact the pest control company that provided services to the facility and a voice message was left. There was no response from the pest control company.

Based on record review and interview, the nursing staff failed to follow prescribed parameters including blood sugar and blood pressure results for 2 of 4 sampled residents (Resident #1 and Resident #5). The findings included: 1) Clinical record review revealed Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes. The Minimum Data Set assessment with reference date of 12/27/24 revealed the resident was assessed as moderately impaired for skills of daily decision making and is receiving insulin and hypoglycemic medications. A review of a Care plan dated 12/21/24, documented Resident #5 has Diabetes Mellitus with Hyperglycemia. The interventions included: Diabetes medication as ordered by doctor and monitor and document for side effects and effectiveness. Review of Physician's order dated 01/23/25, documented Insulin Lispro subcutaneous solution pen injector, 100 units per milliliter, Inject 2 units subcutaneously before meals for Hyperglycemia. Hold for glucose less than 150. Review of the Medication Administration Record dated 01/2025 documents Resident #5 received the Lispro insulin on the following dates, despite documented blood sugar below 150. On 01/23/25 the evening dose was given with blood sugar reading of 110. On 01/24/25 the evening dose was given with blood sugar reading of 110. On 01/25/25 the evening dose was given with blood sugar reading of 123. On 01/26/25 the evening dose was given with blood sugar reading of 119. 2) Clinical record review conducted on 01/27/25 revealed Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including Congestive Heart Failure and Hypertension. The Minimum Data Set assessment with reference date of 12/27/24 revealed the resident was assessed as independent for skills of daily decision making and is receiving diuretic medications. Review of a Care plan dated 08/01/24 documented interventions as administer medications as ordered. Review of Physician's order dated 12/20/24 documented Entresto Oral Tablet 24-26 MG, give 1 tablet by mouth two times a day for Hypertension, hold for systolic blood pressure less than 110. Review of the Medication Administration Record dated 01/2025 documents the medication was given on 01/17/25 with a documented blood pressure of 106/60 and on 01/26/25 given with a blood pressure of 92/58. Interview with the Director of Nursing on 01/28/25 at 3:14 PM confirmed the medications were given despite the prescribed parameters.

Based on record review and interview, the facility failed to coordinate medication administration times with dialysis services for 2 of 3 sampled residents reviewed (Residents #1 and #6). In addition, the facility failed to ensure the completion of dialysis communication records to validate continuity of care for Resident #1. The findings included: 1a) Clinical record review revealed Resident #1 was admitted to the facility on [DATE] for rehabilitation services. Resident #1's pertinent diagnoses included End Stage Renal Disease, Metabolic Encephalopathy and Diabetes. Medication Administration Records (MAR) dated 05/2024 and 06/2024 indicated Resident #1 did not receive the following medications as prescribed. The explanation documented by the nursing staff noted, Resident in Dialysis: On 06/08/24 Calcium Acetate 667 mg, Ipratropium Nebulizer and Zinc 220 mg. On 06/04/24 Megestrol Acetate Suspension 40 MG/ML, give 5 ml by mouth one time a day for poor appetite for 3 Days. On 05/25/24 Calcium Acetate (Phos Binder) Oral Capsule 667 MG. The facility failed to coordinate medication administration with dialysis care to prevent medication omissions. Interview with the Risk Manager who assisted in navigating the electronic record on 07/08/24 at approximately 5:20 PM confirmed the findings. 1b) Review of the facility documents titled, Dialysis Transfer Form which documented the resident's assessment pre and post dialysis treatment revealed the nursing staff failed to document the assessment post dialysis treatment on 05/25/24. The post assessment form captures condition of the access site, vital signs, signs and symptoms of infection and any additional comments. Interview with the Risk Manager conducted on 07/08/24 starting at 4:42 PM, who assisted in locating the missing information, revealed the facility checks vital signs every shift, there is no other documentation regarding the access site (Catheter) or signs of infection after the dialysis treatment. The nursing staff failed to document medications given to the resident pre dialysis treatment on 05/21/24, 05/30/24 and 06/01/24. Interview with the Risk Manager conducted on 07/08/24 starting at 4:42 PM confirmed the medication section was left blank. Record review revealed the nursing staff failed to document a pre dialysis assessment including code status, mental status, allergies, medications given, condition of access site, vitals signs and signs of infection on 06/04/24 and 06/06/24. The nursing staff failed to document the assessment post dialysis treatment on 06/06/24. Interview with the Risk Manager conducted on 07/08/24 starting at 4:42 PM , who assisted in locating the missing information revealed the facility checks vital signs every shift, there was no other documentation regarding the other elements noted on the assessment form. Further record review revealed the nursing staff failed to document a pre dialysis assessment including code status, mental status, allergies, medications given, condition of access site, vital signs and signs of infection on 06/08/24. The nursing staff failed to document the assessment post dialysis treatment on 06/08/24. The assessment captures the condition of the access site, vital signs, signs and symptoms of infection and any additional comments. Interview with the Risk Manager conducted on 07/08/24 starting at 4:42 PM, who assisted in locating the missing information revealed the facility checks vital signs every shift, there was no other documentation regarding the other elements noted on the assessment form. 2) Clinical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnosis of End Stage Renal Disease and was receiving dialysis services at the onsite dialysis facility. Physician's orders and Medication Administration Records (MAR) dated 06/06/24 revealed the nursing staff failed to administered the following prescribed medications: Hydralazine 100 mg, hold for systolic blood pressure less than 120 (9AM and 1 PM doses); Clonidine 0.1 mg (9 AM and 1 PM dose); Carvedilol 3.125 mg (9 AM dose); Nifedipine 60 mg (9 AM dose). The reason noted Resident has dialysis today. The blood pressure documented 7-3 shift as 176/87 and pulse 66. The record failed to provide evidence of provider orders to hold the blood pressure medication on dialysis days. In addition, Medication Administration Record and Notes dated 05/29/24 indicates the nurse repeated the pattern, of holding blood pressure medications, and noted reason Resident has dialysis within 20 hours. Interview with the Risk Manager on 07/08/24 at approximately 5:30 PM revealed most likely the nurse held the medication because the resident was having dialysis and blood pressure may drop during treatment. The Risk Manager confirmed there were no others to hold the medications. Based on record reviews and interviews, the facility failed to coordinate medication administration times with onsite dialysis treatments to ensure all medications were administered as ordered. In addition, the facility failed to ensure accuracy and completion of the dialysis communication forms.

Based on policy review, record review and interview, the facility failed to ensure licensed nurses were able to demonstrate competency related to following physician's orders for medication administration and documentation for 1 of 3 sampled residents (Resident #1). The findings included: Facility policy titled, Administering Medications, last revised April 2019 documents as follows: Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. 7. Medications are administered within one (l) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 20. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be flagged. After completing the medication pass, the nurse will return to the missed resident to administer the medication. 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Clinical record review of Resident #1 revealed physician's orders dated 05/17/24 for Midodrine HCl Tablet 5 MG, Give 1 tablet by mouth two times a day for orthostatic hypotension. Hold if Systolic Blood Pressure (SBP) greater than 130. The Medication Administration Records revealed the following: On 05/19/24, 5 PM dose, the Midodrine was given with blood pressure 136/58. On 05/21/24, 5 PM dose, the Midodrine was given with blood pressure 143/70. On 05/24/24, 9 AM dose, the Midodrine was given with blood pressure 138/58. On 05/29/24, 5 PM dose, the Midodrine was held with blood pressure 126/68. On 06/01/24 9 AM dose, the Midodrine was held with blood pressure 128/61. Physician's order dated 05/21/24 documents Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML, Inject 2 unit subcutaneously before meals for Steroid induced hyperglycemia GIVE INSULIN FOR GLUCOSE ABOVE 200. The Medication Administration Records revealed the following: On 06/04/24, 11 AM dose, the insulin was administered with blood sugar 125. On 06/05/24, 11 AM dose, the insulin was administered with blood sugar 115. On 06/07/24, 11 AM dose, the insulin was administered with blood sugar 88. On 05/31/24, 11 AM dose, the insulin was administered with blood sugar 106. On 05/29/24, 11 AM dose, the insulin was administered with blood sugar 120. On 05/27/24, 6 AM dose, the insulin was administered with blood sugar 141. On 05/26/24, 11 AM dose, the insulin was administered with blood sugar 130. On 05/26/24, 4 PM dose, the insulin was administered with blood sugar 175. On 05/25/24, 11 AM dose, the insulin was administered with blood sugar 149. On 05/25/24, 4 PM dose, the insulin was administered with blood sugar 188. On 05/24/24, 6 AM dose, the insulin was administered with blood sugar 129. On 05/24/24, 11 AM dose, the insulin was administered with blood sugar 134. On 05/23/24, 6 AM dose, the insulin was administered with blood sugar 127. On 05/23/24, 11 AM dose, the insulin was administered with blood sugar 145. On 05/23/24, 4 PM dose, the insulin was administered with blood sugar 180. Interview with the Risk Manager who assisted in navigating the electronic record on 07/08/24 at approximately 5:20 PM confirmed the findings and explained the insulin order needed clarification for proper documentation.

Based on observation interviews, the facility failed to ensure 7 out of 29 sampled residents were treated with respect and dignity regarding care and dining assistance (Resident #25, Resident #212, Resident #50, Resident #159, Resident #161, Resident #73, and Resident #60 and two Anonymous residents). The findings included: The facility's policy for 'Dignity' revised February 2021, documented: Each Resident shall be cared for in a manner that promotes and enhances his or their sense of well-being, level of satisfaction with lie, and feelings of self-worth and self-esteem. 1. Residents are treated with dignity and respect at all times. 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience. 1) On 03/25/24 at 10:20 AM, Resident #25, who is documented to have a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment) stated, The [ ] aides have no compassion; they are rude and don't treat us right. This resident's spouse (Resident #212), who was also his roommate and has a BIMS score of 15 (intact cognition), came into the room at the end of the interview and stated that she agreed with Resident #25's statement concerning the rudeness of some of the certified nursing assistants (CNAs), as she also had experienced the CNAs' rudeness and disrespect at times. On 03/27/24 at 12:30 PM, an additional interview was conducted with Resident #25 and Resident #212. Resident #25 stated that he did not appreciate the way the aides had treated his wife during her shower that morning. When interviewed on 03/27/24 at 12:35 PM, Resident #212 stated, When giving me a shower this morning, the aide didn't wait for the water to get warm. She just poured water over my head and sprayed me in the face without any warning; she wasn't very considerate. The wife also added, When something is said to them [the aides] they get nasty. They also roll their eyes at us whenever they are asked to do anything for us. 2) On 03/25/24 at 10:40 AM, a Resident who wanted to remain anonymous stated, The nurses have been great, and half of the aides are very good, but the other half do not want to provide assistance. I am at the end of the hall, and some of the aides act like those of us down here at the end are not part of the facility; they mostly ignore us. It would be nice to be treated like everyone else instead of like an inconvenience. I have fallen a couple of times because I try to do things on my own. 3) On 03/25/24 at 10:28 AM, Resident #50, who has a BIMS score of 8 (moderate cognitive impairment), stated during her initial interview, Some of the staff are very good, but some of them are very bossy. They like to order me around. This morning, I told them that I didn't want to eat because I wasn't hungry, and the aide kept telling me I had to eat. Sometimes, I just don't feel hungry, and I don't want to eat, but she told me I had to eat. I try to do what they say because I don't want to make them mad. 25404 4) A medication pass observation with a random resident, who asked to remain confidential, was made on 03/27/24. Upon entering the room, the surveyor introduced herself and explained she was observing the nurse. The resident stated, The nurses are great, but you need to check up on the CNAs (Certified Nursing Assistants). On 03/27/24 in the afternoon, when asked what was meant by check up on the CNAs, the random resident stated, Some are great, but some have such attitudes. They don't care. I treat them with respect and expect the same from them, but don't always get it. The resident stated, Some act as if they don't want to be here. I know it's a tough job, but it is their job. And they don't let us know they are the CNA for the shift. The resident explained that the nurses come around at the beginning of each shift and let them know they will be the nurse for the shift. Review of the record revealed the resident was cognitively intact, as per a recent Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale. 5) During an interview on 03/25/24 at 12:19 PM, Resident #159 voiced the staff speak to each other in another language, in front of her, which makes her feel as if she is not there. The resident voiced the CNAs have talked about her outside of the room and have not been kind. During a supplemental interview on 03/27/24 at 3:28 PM, Resident #159 was visiting with her family. The resident volunteered that two CNAs had closed her curtain and door, and that she had muted her TV, and heard them say, That (resident's last name) and son . a pain in the [ ]! Resident #159 also stated that she had had today's nurse several times, and today was the first time that she introduced herself, referring to earlier in the day when the surveyor had done a medication pass with Staff L, Registered Nurse (RN). The resident and family stated the staff don't care, don't make eye contact, and are rude. During an interview on 03/28/24 at 12:07 PM, accompanied by the Risk Manager, Resident #159 and her family vented for about 15 to 20 minutes about the attitudes of the staff. The family voiced that staff were complaining about being short-staffed and overworked. They stated staff won't help with her colostomy bag. They described how last evening they had asked an RN three times for assistance, as the colostomy bag had become loose and was leaking. The family described how the RN told them three times he would get to it, yet he was seen at the nurse's station laughing with staff and playing on his cell phone, not helping them. The son stated he finally just got a new colostomy bag, and they assisted his mother and to change the bag. Both the resident and the son again stated that staff said they are a pain . and they are not going to help her again, referring to assisting her up in the bed. Review of the record revealed Resident #159 was admitted to the facility on [DATE]. Review of the Admission/Readmission Evaluation dated 03/22/24 documented Resident #159 was alert and oriented to person, place, and time, with no memory or behavioral issues. 6) During an interview on 03/27/24 at 1:01 PM, Resident #161 was still unshaven, as observed that morning. When asked what was going on with his request to shave, Resident #161 stated the staff told him he had to wait. Resident #161 then volunteered, The girls (referring to the CNAs) are just rude. I put on the call bell, and they don't answer. I have to call out for them, and they just walk by my door and ignore me. I had to get the maintenance guy to hand me my phone. The resident explained that his phone had been on the bedside nightstand, behind him and out of reach. Review of the record revealed Resident #161 was admitted to the facility on [DATE]. Multiple skilled services nursing notes documented Resident #161 was alert with no memory issues. Resident #161 was observed to be obese with bilateral lower extremity edema (swelling) and needed assistance with activities of daily living. 38893 7) Resident #73 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual Minimum Data Set (MDS), dated [DATE], documented Resident #73 had a BIMS score of 06, indicating that the resident was severely cognitively impaired. The MDS documented that Resident #73 was dependent upon staff for eating. During an observation of lunch served to the residents in their rooms on the 300 unit, on 03/25/24 at 12:58 PM, Staff C, CNA, was observed removing a tray from Resident #73. At that time, another staff member asked Staff C why the tray was being removed from the resident's room. Staff C replied, he is a feeder. When the surveyor asked about the meal being removed from the resident, Staff C again replied, he is a feeder. During an observation of breakfast served to the residents in their rooms on the 300 unit, on 03/26/24 at 8:35 AM, Staff D (CNA), was observed standing at Resident #73's right side of bed to feed resident. When asked about using a chair to sit and feed the resident, Staff D stated I am short, and I have trouble reaching the food on the table. During the observation Resident #73's bed was in a raised position. 8) Resident #60 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #60 had a Brief Interview for Mental Status (BIMS) score of 06, indicating severe cognitive impairment. The MDS documented that Resident #60 required 'Supervision or touching assistance' for eating. Resident #60's diagnoses at the time of the MDS included: Anemia, Quadriplegia, Traumatic Brain Injury, Malnutrition, Cognitive Communication Deficit, COPD (Chronic Obstructive Pulmonary Disease), Dysphagia, and History of Healed Traumatic Fracture. During an observation of lunch served to the residents in their rooms on the 300 unit, on 03/25/24 at 1:04 PM, Staff C, CNA was observed standing to the resident's left side of the bed with lunch on the residents over bed table that was positioned between Staff C and the resident. Staff C was observed reaching over the table to feed the resident, dropping portions of the meal on the resident's upper left chest. During the observation, there was a room chair positioned to the resident's right side of the head of his bed. During observations of Resident #60 eating in his room, for breakfast on 03/26/24 and 03/27/24 and lunch on 03/27/24, Resident #60 consumed more than 75% of the meals independently with the use of adaptive equipment from his overbed table, and without dropping any of the food on himself or his bed and surrounding area and equipment.

Based on record review and interviews, the facility failed to consider the views of the resident council group and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility for 9 of 9 sampled residents interviewed during the Resident Council meeting (Resident #47, #45, #8, #10, #58, #63, #33, #70, and #7). This failure has the potential to affect all residents in the facility, as the resident council represents all residents. The findings included: On 03/27/24 at 11:01 AM, interviews were conducted with 9 active, alert and oriented members of the Resident Council (Resident # 47, #45, #8, #10, #58, #63, #33, #70, and #7). The 9 resident council members were asked about the facility's response to grievances voiced by members of the Resident Council during their monthly meetings. All of the resident council members agreed that several grievances were voiced during the monthly Resident Council meetings, but none of these grievances had been resolved by the facility's administration. Three of the council members who wished to remain anonymous stated that when they have tried to bring up concerns to Administration, they were told, If you don't like it, you can find another place to live. Residents #58, #45 and #63 stated they were tired of voicing their concerns because none of the concerns ever got resolved. None of the 9 members of the council could recall a time when staff had responded to their concerns, explaining how their concerns were being addressed and/or resolved. Per interview with the 9 Resident Council members listed above, some of the grievances voiced during monthly resident council meetings that had not yet been addressed/resolved were: 1) Chairs needed for showers - The council members stated there used to be a chair for over-the-toilet and a chair placed in the shower for those needing to sit during showers. Resident #58 stated, Now there is only one chair that has to be moved back and forth from toilet to shower, and it usually requires for us, the resident to move it. This isn't safe. The administrator was informed of this issue about 2 months ago, and nothing has been done. 2) Cold food - All of the 9 council members interviewed complained that the food carts brought to the units will sit in the hallways for 1/2 an hour before staff will pass the trays, and by the time the residents get the food, the food is cold. 3) More food variety - Each of the council members interviewed wanted more food variety on the menu, including fresh fruits and vegetables. Resident #45 stated, We have asked for fresh fruits and vegetables, but we are still getting canned fruits and vegetables. 4) Laundry bags - Resident #58 stated that they used to have laundry bags provided which had their name and room number on them; however, these bags have been taken away. Now they have plastic bags with nothing written on them. I have brought up this concern several times, but nothing has been done. How do they know which laundry bag belongs to who? This is how clothes go missing. A review of the Resident Council Minutes from October - March 2024 did not reveal all of the concerns voiced by the 9 members of Resident Council on 03/27/24. When these members were asked why their concerns were not recorded in the resident council minutes, the resident council members stated they did not have an answer as to why. Resident #58 stated, I don't know why they aren't in the minutes, but I know I have went directly to the Administrator and voiced the concerns about the chairs and laundry bags. A review of the Grievance Log from October 2023 - March 2024 noted only 1 grievance documented for Resident Council in November of 2023. This grievance was related to food concerns, and it was documented that the concern was resolved on 11/17/23. Another grievance regarding menu and food quality was filed on 12/13/23 by Resident #58, one of the Resident Council members. The Grievance Log documented that the food grievance was resolved on 12/14/23. Resident #58 stated that the food issues mentioned in the grievances have not been resolved, and the other 9 council members agreed. Resident #58 did add, The food has gotten better, but there are still issues that need to be addressed. On 03/27/24 at 11:50 AM, the Activities Director confirmed that she did attend the Resident Council meetings and took the minutes for the Council President. On 03/28/24 at 6:15 PM, the Administrator was informed of the concerns voiced by the Resident Council regarding the failure to resolve the council's grievances.

Based on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 3 of 4 units (100 Unit, 300 Unit and 400 Unit). The findings included: In room [ROOM NUMBER], the room smelled of urine. It was difficult to tell from which bed the urine smell was coming from. The urine smell was strong around each of the 3 beds in the room. The floor appeared to be dirty and there was debris observed underneath bed B. In room [ROOM NUMBER], the vinyl on the arms of the resident's wheelchair in bed B was cracked and partially missing. In room [ROOM NUMBER], the surface of the foot board of bed A was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surfaces of the headboard, foot board and nightstand to the resident's right side of the bed was worn in a manner that the material under the surface was exposed. In room [ROOM NUMBER], the surface of the over bed table for bed A was worn in such a manner that the particle board underneath the surface was exposed and there was a residue under bed A . In room [ROOM NUMBER] the overbed table for bed B was worn in such a manner that the particle board underneath the surface was exposed. In room [ROOM NUMBER], the footboard of the vacant bed C was worn in a manner that the material underneath the surface was exposed. The surface of the overbed table was worn in such a manner that the particle board underneath the surface was exposed. In room [ROOM NUMBER], there was an accumulation of dead roaches behind the closet and the nightstand of bed A. In room [ROOM NUMBER], the pole that was being used to hang tube feeding supplements and intravenous medications was encrusted with residues of bed B. In room [ROOM NUMBER], upon opening the valve for the hot water at the hand sink in the resident's room, there was a loud noise coming from the plumbing. In room [ROOM NUMBER], the clock on the wall that was opposite of the residents' beds did not display the correct time. It was noted that the hands on the clock had not moved for the duration of the survey. During an environmental tour of the facility, on 03/28/24 at 2:02 PM, accompanied by the Maintenance and Housekeeping Director, the Maintenance and Housekeeping Director acknowledged understanding of the concerns. During the tour, Resident #31, in room [ROOM NUMBER] B, stated that he was unable to use the remote control for the television due to his poor vision and did not have dexterity in his hands to operate the remote control. Resident #31 also stated that the mattress on his bed felt like it had a hole in it.

Based on observation, clinical and administrative record review and staff interview, the facility failed to provide evidence they evaluated the resident's change of clinical conditions and increasing risk factors; failed to identify these risk and implement interventions to address the resident's decline and increasing needs to prevent the development of advanced stage pressure ulcers for 1 of 2 sampled residents with pressure ulcers (Resident # 1). The resident developed multiple in-house avoidable Stage III and unstageable pressure ulcers. The facility failed to consistently document the resident's current skin issues on the weekly skin assessments when compared with the corresponding physician wound assessments; and the facility failed to consistently perform the prescribed wound care for 1 of 2 sampled residents with pressure ulcers (Resident # 5). The findings included: 1) An Avoidable Pressure Ulcer means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Review of the clinical record for Resident # 1 revealed the resident was admitted to the facility on [DATE] from an Assisted Living Facility with a [DIAGNOSES REDACTED]. On admission, the resident's skin was intact. There were no identified skin issues. The Braden Scale (an assessment to determine a resident's risk for the development of Pressure ulcers) documented a score of 15.0, indicating the resident was low risk for the development of pressure ulcers. Subsequent Braden weekly assessments were performed until 09/04/19, when the resident's Braden score remained 15.0, thereby the resident's risk for the development of pressure ulcer remained low risk. There was one other Braden assessment also dated 09/04/19 documenting a score of 14.0, increasing the resident's risk to moderate. Despite the resident's slight increase in risk for the development of pressure ulcer, the facility did not provide evidence of changes in the resident's interventions to address this change nor did the facility provide evidence of additional assessments (Braden) being performed for this resident to identify the resident's apparent changing condition or increasing risk. The resident's skin remained intact for seven months and on 03/17/20, the resident developed an open area on her left buttock, which the nurses did not fully describe. However, 2 days later on 03/19/20, the physician described the open area as a Stage 3 wound. The resident's wound continued to advance to an Unstageable necrosis that developed an infection per the 04/02/20 Wound Management Assessment. The resident developed a second unstageable necrosis wound on her right buttock when identified on 04/16/20 according to the Wound Management Assessment. The resident also developed subsequent wounds/skin issues on her feet (Stage 2, left plantar lateral foot on 07/30/20; left 5th toe trauma on 10/15/20; right 5th toe trauma on 10/22/20) and left hip (Stage 3 on 08/27/20). The resident has also developed bilateral hip and knee contractures which are interfering with nursing care per the Physical Therapy evaluation on 04/17/20. The initial 08/14/19 Minimum Data Set Assessment (MDS) documented the resident was extensive assistance of two persons for bed mobility and transfer; extensive assistance of one person for eating, dressing and personal hygiene; total dependence of two persons for toilet use; always incontinent urinary and bowel continence. The resident had a formal assessment for the determination of Pressure Ulcer/Injury Risk. The resident is at risk for pressure ulcers/injuries and did not have any unhealed pressure ulcers/injuries. Skin and Ulcer/Injury Treatments identified as pressure reducing device for chair; pressure reducing device for bed and application of ointments/medications other than to feet. Functional Limitation in Range of Motion, no impairment for Upper and Lower Extremity. The 11/08/19 MDS, continued to document the above care needs and noted that the resident did not have an assessment to determine the resident's pressure ulcer/injury risk but identified that the resident was at risk for the development of pressure ulcer. The 02/06/20 MDS, continued to document the above care needs and noted that the resident had a clinical assessment to determine the resident's pressure ulcer/injury risk. However, upon further investigation, it was revealed this was coded in error. On 08/08/19 the facility identified a focus as the resident has a potential for pressure ulcer development related to immobility with interventions which included: Follow facility policies/protocols for the prevention/treatment of [REDACTED]. The resident needs assistance to turn and reposition at least every 2 hours, more often as needed or requested. The resident requires reducing device on bed/chair. Subsequent Plan of Care and interventions were initiated after the resident developed the advanced stage wounds as follows: Notation on the Potential for Pressure ulcer development care plan initiated 08/08/19 noted 07/23/20 the resident has blisters to both feet. 7/24/20 Blister to left plantar lateral foot, resolved 08/10/20. 08/04/20 blister left lateral big toe opened. Interventions included: 07/23/20 Administer treatments as ordered and monitor for effectiveness. 08/04/20 Treatment in place see current TAR (Treatment Administration Record) Bilateral boot to be worn to prevent blankets or sheets coming in contact with toes (It should be noted that the resident did not have nor did the resident wear these boots throughout the survey, when observed on 10/28/20 at 9:28 AM, 10:07 AM, 1:50 PM; 10/29/20 at approximately 10:30 AM). 08/04/20 BL (Bilateral) boots to be worn at all times to prevent friction and shearing. On 03/20/20 a focus was identified, and a plan of care initiated, for the resident has actual unstageable to right buttocks. Resident has a Stage 4 to her left buttocks. Interventions included: Encourage good nutrition and hydration in order to promote healthier skin. Identify potential causative factors and eliminate/resolve when possible. Keep skin clean and dry. Use lotion on dry scaly skin. The resident needs her nails kept short to reduce risk of scratching or injury from picking at skin. An interview was conducted on 10/28/20 at 11:58 AM with the Director of Nursing (DON), who initially stated that the nurses are to perform the Braden Assessments weekly for one month, then quarterly. She stated the nurses, or the Unit Manager was to complete and confirmed the screens did not appear to be done but would check with the Unit Manager. The surveyor requested the facility's policy for the assessment for identifying the resident's risk for the development of pressure ulcers and the frequency of these assessments. The surveyor also requested the facility's policy/protocols for the prevention/treatment of [REDACTED]. The facility policy provided by the DON, documented Pressure Ulcers/Skin Breakdown - Clinical Protocol documented under Assessment and Recognition, The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer (s). In addition, the nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; Pain assessment; Resident's mobility status; Current treatments, including support surfaces; and All active diagnoses The staff will examine the skin of a new admission for ulcerations or alterations in skin. Further review reveals the facility's policy does not provide for a timeline for the performance of assessment and does not appear to address prevention of the development of pressure ulcers. There is no evidence of further assessments to identify the resident's risk for development of pressure ulcers or modifications to the resident's Plan of Care to prevent the development of pressure ulcers. Another interview was conducted with the DON on 10/28/20 at 3:30 PM. The surveyor did further questioning of the DON regarding the information provided in the facility's policy and her previous statement regarding when assessments are to be conducted. The DON stated she miss stated and she was providing information from when she worked for a different company and that they assess the resident weekly with the weekly skin assessment. The surveyor further questioned the DON and asked for clarification about, weekly skin assessments being visual assessment to determine changes in the resident's skin condition; when does the staff determine the resident's risk for development of pressure ulcers and address the resident's changing needs due to possible increased risk and where is this assessment documented. The surveyor was not provided a concrete answer. Further review of the clinical record revealed on 03/17/20, during morning care, there was an open area noted to be the size of a dime on the resident's left buttock. There was no prior documentation of noted changes in the resident's skin condition prior to the notation of the open area being identified on 03/17/20. Additionally, the nurse did not provide additional information to give a full assessment of the opened area on the resident's buttock. This open area was later identified by the physician on 3/19/20 as a Stage 3 wound as described in the initial wound evaluation and management summary documented in this citation. The left buttock wound was noted as resolved on 09/17/20 by the wound care physician. The initial wound evaluation and management summary on 03/19/20 (2 days later) documented a Stage 3 wound measuring 1 x 1 x 0.3 with light sero-sanguineous exudate. The physician prescribed for Leptospermum honey apply once daily for 30 days; secondary dressing of foam silicone border apply once daily for 30 days. Plan of care recommendation, reposition per facility protocol; offload wound; low-air loss mattress. On the subsequent wound MD visit on 04/02/20, the wound had progressed to an unstageable necrosis wound to left buttock measuring 4 x 3 x not measurable depth; moderate purulent; 100 % thick adherent devitalized necrotic tissue, wound progress deteriorated. Wound care changed to wet to moist dressing with Dakins solution apply daily for 30 days with dry protective dressing. Plan recommendations reposition per protocol; off-load wound; low air loss mattress; X-ray left hip/pelvis multiple views rule out ostemyletitis, comprehensive metabolic panel, stat complete blood count, blood cultures x 3; [MEDICATION NAME] 1 gr (then dosing per pharmacy x 2 weeks); zozyn 3.375 intravenous every 6 hours x 2 weeks. The MD noted performing surgical excisional debridement procedure to remove infected tissue; remove necrotic tissue and establish the margins of viable tissue. On 04/05/20, the facility noted identifying a second open area on the right buttock while performing morning care. Again, the nurse did not provide information to give a full assessment of the newly acquired wound. The open area was identified as Wound 2 on the 04/16/20 wound care physician visit progress note as an unstageable necrosis wound as documented in this citation. This right buttock wound was documented as resolved on 07/16/20 by the wound care physician. However, on 04/16/20, the MD wound visit progress note documented that Resident # 1 has two (2) wounds. Wound 1, is now a Stage IV, pressure wound on the left buttock, measuring 4 x 3 x 1 cm with undermining 1 cm at 6 o'clock, moderate sero-sanguineous exudate; 30% thick adherent devitalized necrotic tissue; 70% granulation tissue, wound progress improved. Wound care of Dakins solution wet to moist dressing daily cover with a dry dressing; recommendations reposition per protocol; off-load wound. Wound 2 is an unstageable necrosis wound measuring 2 x 2 x not measurable depth, no exudate with 100% thick adherent devitalized necrotic tissue. Prescribed wound care Leptospermum honey apply once daily with foam silicone border dressing once daily x 30 days. The physician also performed surgical excisional debridement procedure on this wound on the right buttock to remove necrotic tissue and establish the margins of viable tissue. An interview was conducted with the Risk Manager the morning of 10/28/20. The surveyor reviewed the resident's risk and development of advanced staged wounds and when identified. The facility did not have documentation regarding determination whether the wound development was avoidable or unavoidable. The RM did complete a facility's administrative record which indicated that a wound had developed on the resident and treatment was initiated of cleanse left buttock wound with Normal Saline, pat dry, apply [MEDICATION NAME] alginate and cover with foam dressing every 11-7 shift. Other follow-up check for incontinency every 2 hours and keep clean and dry. Notify Doctor and family. Other actions to prevent reoccurrence check for incontinence every 2 hours to keep clean and dry. Incontinent care. Turn and reposition. Wound Care Consult, air mattress, offload, turning and positioning every 2 hours. The RM noted the resident had a decreased pre-[MEDICATION NAME] level. admitted with Impaired mobility, Adult Failure to Thrive and was High Risk for skin impairment. Dietary evaluation to increase oral intake and protein for wound healing. Wound Care Consultant ordered air mattress. Another interview was conducted with the Risk Manager (RM) on 10/28/20 at 12:30 PM. The surveyor inquired of the RM regarding the identification on her report that the resident was high risk for skin impairment; and inquired when did the resident risk increase and why interventions for the resident's increased risk were not changed prior to the resident developing the wound impairment. She was unable to provide a definitive answer. She stated that the resident's nutritional status declined, and she was remaining in bed more but unable to state when this change occurred. The RM was unable to locate nutritional assessments prior to the resident's skin breakdown. Additional supplements were implemented after the resident developed the pressure ulcer. The Air Mattress was instituted after the resident developed the advanced stage pressure ulcer. Additionally, the turning and repositioning and incontinent care every 2 hours had been in place since the resident's admission to the facility. There is no evidence of individualization of the resident's Plan of Care, regarding the resident's specific needs or possible need for more frequent attention to her care needs secondary to her change in condition and increasing risk. An observation of Resident # 1 was conducted on 10/28/20 at 10:07 AM. The resident was lying in bed on her left side, lying in fetal like position, with her legs contracted up close to her buttocks area. The resident's arms were also folded up toward her chest area and her hands were closed into a fist. The resident had a pillow wedged between her knees and the resident's feet were resting directly on the mattress. The resident was not wearing any bunny boots. The resident was noted to have a dressing on her left hip, identified as a Stage 3 wound, measuring 0.4 x 0.4 x 0.2 as of 10/22/20 according to the wound care physician's progress note. Furthermore, review of the nursing weekly skin assessment revealed there was noted discrepancy between what the nurse documented as present on the skin assessment versus what the physician wound management documented as follows: The Wound Care Physician Wound Management Progress Notes included the following identifications of wounds for Resident # 1: On 03/19/20, as noted above, the Wound Care Physician noted a Stage 3 pressure ulcer on her left buttock, and on 04/16/20, noted an unstageable necrosis greater than 1-day old on the right buttock. On 07/27/20, the Wound Care physician documented the identification of a Stage 2 wound on the left Plantar Lateral Foot. The wound was greater than 1-day old wound measuring 4 x 3 x not measurable depth. On 08/27/20, the Wound Care physician identified a Stage 3 wound, greater than 1-day old on the left hip measuring 0.5 x 0.5 x 0.2. Weekly Skin Assessments The weekly Skin Observation notes address: A. Skin Observation. 1. Skin intact/skin at baseline 2. No NEW open area noted 3. New skin alteration noted B. Description 1. Description of new skin alteration: A. On the 03/24/20 weekly skin assessment, the nurse noted that the Skin intact/Skin at baseline. Despite the resident having an open Stage 3 pressure ulcer on her left buttock. B. On the 03/31/20 weekly skin assessment, noted no new open area. However, under description of new skin alteration documented, the nurse documented 2 open areas on left and right buttocks, dressing dry and intact, drainage and odor noted. C. On the 07/27/20 weekly skin assessment, the nurse documented, the resident did not have any new open areas noted. However, under description the nurse documented a dry open area noted to right great toe and lateral side of great toe. D. On 08/15/20, 08/22/20, 08/29/20, 09/05/20, 09/12/20, the nurses documented on the weekly skin assessment, skin intact/skin at baseline despite the resident having the left buttock wound and the development of the Left hip Stage 3 wound identified on the 08/27/20 wound care physician wound assessment. Subsequent interviews with the Risk Manager and the Unit Manager were conducted on 10/29/20 beginning at approximately 2:30 PM. The surveyor asked for clarification concerning the resident's care plan, risk assessments and weekly skin assessments. The surveyor was unable to obtain definitive answers of when the resident's needs and risk changed. Despite the changes for the resident, the facility did not identify these changes and update the risk assessment or the plan of care for the resident. Nor did the facility implement additional preventative measures to prevent the resident from developing the advanced stage wounds and contractures. Additionally, the Unit Manager stated she was unable to provide information regarding the discrepancy between the Physician Wound Assessment and the weekly skin assessments done by the nurses. 2) An observation of the Wound Care for Resident # 5, with Registered Nurse, Staff B, and the Unit Manager was conducted on 10/27/20 (Tuesday) beginning at 12:50 PM. Upon initial observation, the wound dressing on the resident was dated 10/22/20 (5 days ago). Both staff present confirmed the date on the wound dressing. Staff B stated the wound dressing is to be completed on Tuesday, Thursday and Saturday and as needed. When the nurse removed the dressing on the resident's left heel, there was noted brownish colored drainage on the dressing. The resident was admitted to the facility with an unstageable deep tissue injury wound on her left heel on 09/17/20. Record review revealed on 10/10/20, the physician prescribed for the resident's wound care, Clean left heel with Normal Saline Solution (NSS), pat dry, apply Santyl and alginate calcium, cover with ABD pad and wrap with kerlix and secure with tape and every day shift on Tuesday, Thursday and Saturday for skin impairment. Review of the Treatment Administration Record (TAR) revealed the nurse placed her initials on the treatment record to indicate the dressing was done on 10/24/20. However, the 10/22/20 dated dressing indicates the dressing was not completed on 10/24/20 as documented on the TAR.

Based on observation, record review and resident and staff interview, the facility failed to provide the necessary care and services to meet the needs of 4 of 29 sampled residents (#44, #16, #173 and #131). The facility failed to provide evidence of ongoing and consistent pain assessments for 3 of 4 sampled residents reviewed for pain management; failed to provide prescribed pain medication for greater than 24 hours after the initiation of pain medication and failed to provide evidence of monitoring effectiveness of administered as needed pain medications for Resident # 44, #16, #173; and failed to provide evidence of assessing 1 of 3 residents who receive [MEDICAL TREATMENT] treatment when the resident returned from [MEDICAL TREATMENT], Resident # 131. The findings include: 1) Review of the clinical record for Resident # 44 discloses the resident was readmitted to the facility on [DATE]. The physician prescriptions revealed the physician prescribed for the resident to receive Tylenol ES (Extra Strength) 500 mg 2 tablet every 8 hours on 2/28/2013 at 8:00 AM. The medication is scheduled for 6:00 AM, 2 :00 PM and 10:00 PM. However review of the Medication Administration Record discloses the resident did not receive the medication until 3/1/2013 at 2:00 PM. Further review of the Daily Skilled Nurse's Note failed to provide evidence of the nurse's assessment of the resident's pain level on 2/28/2013 and 3/1/2013. An interview was conducted with the Licensed Practical Nurse on 3/14/2013 in the morning who stated she was the nurse that identified on 3/1/2013 that the Tylenol order had not been transcribed to the MAR. The resident is prescribed the Tylenol because the family has requested he is not given stronger medications secondary to the side effects he experiences. The resident has a sensivity from previous narcotics usage in that his blood pressure drops and he became sedated, lethargic and very confused. An interview and observation was conducted on 3/12/2013 at 9:15 AM. The resident stated he was experiencing pain in his right shoulder and denies receiving pain medication. He denied receiving help from the facility staff. He stated his pain level at this time was a level 6 on a scale of 0-10. He further stated the pain is constant and sharp in his right shoulder. The resident was again restless and grasping at the bed covers. He stated he feels the pain in his shoulder most of the time and expressed the location of his pain in his right shoulder and down his arm. Another observation and interview was conducted on 3/14/2013 at 9:47 AM, the resident stated he was experiencing sharp pain in his right shoulder. He stated the pain was an 8 on a scale of 0-10. He states he has been experiencing the pain for months. He stated he told the nurse first thing this morning and informed her that he was having severe pain in the shoulder and it radiates down his forearm toward his hand. The resident showed the surveyor where he was experiencing his pain. The resident stated he didn't know the time he informed the nurse about his pain but said the nurse said she was coming back and didn't. The resident kept using his left hand to adjust the bed covers and again appeared restless. He denied getting relief from the pain at this time. An interview was conducted with the nurse on 3/14/2013 at approximately 10:30 AM who stated she has not given the resident any pain medication but would assess the resident's pain level. An observation of communication between the nurse and the resident was conducted on 3/14/2013 at 11:00 AM. The nurse asked the resident if he was okay and he responded yes. The nurse then asked if he was in pain and the resident responded in the affirmative . She then stated, "What's the number" and the resident responded 8. The nurse failed to qualify the parameters regarding the pain scale to accurately assess the resident's pain level. Further review of the clinical record discloses the facility staff failed to provide evidence of consistently assessing the resident pain level every shift. The Daily Skilled Nurse's Note discloses the nurses did not document pain assessments for the resident as follows on numerous consecutive days from 2/28/2013 through 3/7/2013, then 3/9/2013, 3/11/2013 and 3/13/2013. Another interview was conducted with the relative of the resident on 3/14/2013 in the morning. She stated the resident will express when he is in pain, if asked and he will also tell the family. She stated the resident has previously had multiple test in the hospital to try to [DIAGNOSES REDACTED]. She stated he has complained of pain in that right shoulder for a while. He states the pain radiates down his arm. He was previously on narcotics in the hospital and he was not the person he is now. He was so confused, lethargic and his blood pressure dropped really low. He is sensitive to medications and his kidney doesn't appear to excrete the medications. We prefer the facility find alternative methods and evaluate his pain levels. The physician also prescribed for the resident to receive Tylenol 20 ml (650 mg) via Peg tube every 4 hours as needed for pain. Review of the Medication Administration Record discloses the nurse administered one as needed dose since the resident's 2/27/2013 admission. The dose was documented on 3/14/2013 at 1:25 AM for right shoulder pain. However the nurse did not accurately assess the resident's pain level in that she did not qualify the amount of pain the resident was experiencing neither did she document a follow up assessment to indicate the effectiveness of the administered as needed medication. An interview was conducted on 3/14/2013 in the morning with the Licensed Practical Nurse who stated when the pain medication is administered, the dose is to be documented, and the reason the medication is given with the assessment of the resident's pain level and a follow up assessment of the resident's pain level to determine effectiveness of the medication. 2) During an interview on 03/11/2013 at 3:10 PM, Resident #173 was asked, "Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief?" The resident answered, "Yes." Resident #173 further stated that he had to wait four hours for pain medication and that isn't sufficient to relieve his pain. Review of the record revealed Resident #173 was admitted to the facility on [DATE] after having had a right total hip replacement. The resident also has the [DIAGNOSES REDACTED]. The resident is alert and oriented and the initial assessment documents that the resident's memory is 'OK'. The resident's current orders for pain medication include [MEDICATION NAME] 10/325 mg every four hours as needed for pain and Tylenol 650 mg every four hours as needed for pain. With this medication order, the resident could receive a [MEDICATION NAME] for pain six times daily. A review of the Controlled Drug Inventory Sheet documents the resident never received six doses daily, and often only received two, three or four doses in a day. A physician progress notes [REDACTED]." The initial nursing assessment and nurses note dated 03/04/13 documents the resident has pain daily, but lacks any number or other rating system and also lacks any description. Review of the current interim/initial care plans for Resident #173 document, "Pain management ... Goal to be free of pain. Interventions to include medicate as ordered, observe for location and level of pain, evaluate effectiveness of pain medication, and notify MD (physician) if pain medication ineffective." Review of the "Controlled Drug Declining Inventory Sheet" from 03/05 through 03/14/2013 documented a [MEDICATION NAME] was removed from the medication cart 33 times. Review of the "Unstable Pain Flow Sheet" for the same time period only documented the administration of the medications 21 times. This flow sheet has a place to document the date, time, location of pain, current intensity, non-verbal symptoms, non-med (medication) interventions, RX(medication / prescription) / Dose, nurse initial, level of arousal and intensity of pain after 30 minutes, 1 hour, side effects and initials. Further review of this flow sheet lacked complete documentation on 03/06 at 1:45 AM, 03/08 at 5 PM and 03/13/2013 at 2:50 AM. Review of the actual MAR (Medication Administration Record) documented multiple scribbled initials and times during this same time period with only five corresponding entries that were duplicated documentation to the pain flow sheet entries. Final review of the "Daily Skilled Nurse's Notes" dated 03/05 through 03/13/2013 revealed an area with the vital signs to document yes or no to pain, and further instructs the nurse to describe the pain on side two of the note. 10 of the 27 shifts lacked any assessment of pain on either side of the nurse's note and the notes that documented that the resident did have pain lacked any numeric value or description. The nursing staff failed to consistently document the level of pain and effectiveness of the pain medication. During an interview on 03/14/2013 at 11:50 AM, the LPN (Licensed Practical Nurse) caring for Resident #173 stated that when she removes a [MEDICATION NAME] from the medication cart to administer to a resident, she is to sign it out on the Controlled Drug Inventory Sheet and on the MAR. She further explained that the nurse's are to document on the pain flow sheet the administration of the medication with the evaluation of the pain and follow-up effectiveness. An additional interview was conducted with Resident #173 on 03/14/2013 at 3 PM. Resident #173 stated that his pain level was currently acceptable at a 2 or 3. He stated that it has been at a 10 or above. (Note, a review of the assessments that were completed lacked any documented pain level greater than an "8".) The resident confirmed that he has to ask for the pain medication and does get it if it's been four hours. The resident recalls an instance that he asked for pain medication, it had been longer than the four hours, "But they told me I had to wait." The resident could not recall the specifics, but stated it was 5 or 6 days ago. The resident stated that the nurses do ask him to rate his pain when he asks for pain medication, but he does not recall any nurse returning after the administration of the pain medication to re-evaluate his pain level or the effectiveness of the medication. During an interview on 03/14/2013 at 4:10 PM, the evening supervisor confirmed that the nurses are to document pain medications on the narcotic sheet (Controlled Drug Inventory Sheet), the MAR and the pain flow sheet. She also confirmed that pain should be assessed each shift and documented on the daily skilled nurse's notes. A side by side review of the record with the evening supervisor confirmed the lack of assessments and pain medication documentation for Resident #173. She confirmed that without consistent assessments, the staff can not ensure effective pain management. Review of the facility policy "Pain - Clinical Protocol" documents, "Assessment and Recognition ... 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. a. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. ... Treatment/Management ... 3. The staff will evaluate and report how much and how often the individual asks for PRN (as needed) pain medication. ... Monitoring 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain ..." 3) Resident #16 was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. On the admission Resident (MDS) data set [DATE], the resident was assessed at moderate risk for pressure ulcers. Minimum Data Set (MDS) assessment dated [DATE] documented in section C for cognition, the resident scored 12 on the BIMS and had no [MEDICAL CONDITION] or mood problems. On the Section J referring to pain, the resident is documented as having occasional pain and has PRN medication. In section G for functional status, the resident is documented as needed the assistance of one person and uses a walker, but is not steady. In an interview conducted at 1:56 PM on 3/11/2013, when asked whether she has pain, Resident #16 replied, " The hip and the left leg are hurting me now. " A review of the Medication Administration Record (MAR) for March reveals Tylenol 325 mg was ordered on [DATE] by the physician for pain as needed. The MAR has indicates that no Tylenol was administered in the month of March, and the Unstable Pain Flow Sheet is blank. However, a review of the nurse ' s notes documents on 3/01/2013 at 7 AM post fall, Resident complains of pain in Left (L) hip with movement. Tylenol given. On 3/02/2013, the nurse documents Tylenol given for pain. Effective result. A review of the subsequent nurse ' s notes from 3/02 until 3/13, reveal no further administration of Tylenol or pain documented. On 3/13/13, post hospitalization , a physician order for [REDACTED]. In an interview on 3/13/2013 at 10AM, the risk manager stated, " the fall happened on 2/28/2013 at 5:10 AM. After being called by the aide, to the room, the nurse found her sitting on the floor next to the shower. On the post fall assessment, she had no pain, and was able to get up with the nurse. She did not complain about pain until the next day. We got an xray immediately, which was negative. Prior to the fall, Restorative documented on 2/05/2013 she was walking 150 feet with a rolling walker three times a week. The primary physician saw her on 3/07/13 and she denied pain in the hip. On 3/12/12 at 2:14 PM the surveyor informed the abuse coordinator that Resident #16 had made allegations of abuse. Specifically "I tell them I am hurting and they are hurting me when they move me. They are intentionally trying to hurt me." The abuse coordinator stated the psychologist and the psychiatrist are seeing the resident and that she does have some paranoia and hallucinations. The abuse coordinator stated there were no previous reports of abuse for the facility in the past year and she would start the investigation for Resident #16. In an interview on 3/12/12 at 2:45 PM, the 7-3 direct care certified nurse assistant stated concerning Resident #16 " She has pain in the legs. She tries to turn. She cannot get out of bed by herself. She is incontinent. She is confused sometimes. She can be violent. She said a lady who came to see her killed her husband and took her money. Sometimes she will tell us not to approach her. Sometimes when she has to turn she has pain. She will tell us if she needs more time to turn. She does not like to shower. She has a bath in the bed. " In an interview on 3/12/12 at 4:07 PM, the 3-11 direct care certified nurse assistant stated concerning Resident #16, "When she gets in her rants, we give her space. She raises her voice and throws things and threatens to call the police. When moving her left leg or thigh it hurt to turn her, so I turn her slowly and ask if it is ok. In an interview on 3/12/2013 at 4:30 PM, the 7-3 direct care nurse stated " At the end of the shift, she said her hip hurt when it was touched. They are sending her out to check out the hip. I even went back to talk to her and she refused the Tylenol. She said she did not want the pain medication. " A review of the Resident Transfer Form dated 3/12/13 reveals on reason for transfer- Post fall complaint of left hip pain. The resident was transferred to the local hospital on [DATE] at 4:50 PM. On 3/13/13 at 9:15 AM, the Director of Nursing stated "I examined her myself. She had not complained of pain. When we ask if she has pain, she said "all over". She was walking with restorative. I looked at the hip and there was swelling and it was tender to touch. I had her sent out. " The resident returned to the facility on [DATE] at 6:30 PM. On 3/14/2013 at 10AM, a review of the hospital clinical records document on page five of the interim report "Fractures of the left superior and inferior pubic rami. The osseous structures are severely osteopenic." 4) Review of the clinical record for Resident # 131 discloses the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician prescribed for the resident to receive [MEDICAL TREATMENT] treatment three times a week on Tuesday, Thursday and Saturday at a community outpatient [MEDICAL TREATMENT] center. Further review of the clinical record provided evidence of [MEDICAL TREATMENT] communication sheets with the [MEDICAL TREATMENT] center dated 3/5/2013, 3/7/2013, 3/9/2013 and 3/12/2013. The communication sheets provided information regarding the resident status/assessment and care and services before [MEDICAL TREATMENT] and at the [MEDICAL TREATMENT] center. However the communication sheet does not provide evidence of the facility's assessment of the resident upon return to the facility after [MEDICAL TREATMENT] documenting the resident's stability, acknowledging evaluation of the resident's vital signs, access site or assessment of bleeding and other concerns subsequent to the [MEDICAL TREATMENT] treatment. Review of the nurses' progress note for the above dates also did not provide evidence documenting the staff assessed the resident upon return to the facility. An interview was conducted on 3/12/2013 at 2:29 PM with the nurse who stated the resident attends [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday. The resident leaves the facility about 10:00 AM and returns about 1:00 to 2:00 PM. She further stated she completes the documentation on the communication sheet to note the resident's status prior to receiving [MEDICAL TREATMENT] and the [MEDICAL TREATMENT] center will complete information regarding the resident while at [MEDICAL TREATMENT]. Another interview was conducted on 3/13/2013 at approximately 4:00 PM with the nurse regarding the facility evaluation of the resident upon return to the facility. She stated that they visually assess that the resident has returned from [MEDICAL TREATMENT] but this is not documented specifically. An interview was conducted on 3/13/2013 at approximately 5:00 PM with the Director of Nursing who stated the current [MEDICAL TREATMENT] communication sheet does not provide provisions to evaluate the resident upon return to the facility but added the nurses' should document in the nursing progress note. Upon review of the nurses' notes she confirmed this information was not provided in the nurses' notes.