Every finding on record at Kinnic Health and Rehabilitation Center

Based on interviews, the facility did not ensure full time Director of Nursing (DON) coverage. This has the potential to affect all 48 residents. Former DON C resigned effective 06/17/25. The facility did not have a full time DON from 6/17 - 6/30/25. This is evidenced by: On 06/30/25 at 8:15 AM, Surveyors entered the facility and requested to meet with the Nursing Home Administrator (NHA) A or DON B. Social Worker Assistant (SWA) D stated DON B works part-time Tuesday, Wednesday, Thursday and the Assistant Director of Nursing (ADON) E is on vacation. On 06/30/25 at 4:05 PM, Surveyor interviewed NHA A asking about a full-time 40 hour a week DON. NHA A stated DON C left on 06/17/25 with no advance notice and DON B was initially hired to start in August in full-time status. DON B agreed to start on 06/17/25 part-time until August, when DON B could work full time. NHA A stated ADON E is here full-time and is on vacation this week. NHA A stated ADON E is a Licensed Practical Nurse (LPN). Surveyor asked NHA A if there was a plan of an interim DON to be full-time 40 hours a week. NHA A stated DON B will be full-time in August.

Based on interview and record review, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 out of 1 resident sampled, R1. The facility did not adequately monitor and assess R1's ventriculoperitoneal (VP) shunt having the potential to result in serious complications. This is evidenced by: According to the National Institute of Health, VP shunts should be regularly monitored and assessed for complications. Signs and symptoms of shunt malfunction/infection include headache, lethargy, diplopia, nausea, vomiting, seizure, irritability, fever, and neck rigidity. Shunt system has to be assessed manually for proper function and visible for evidence of redness or swelling along the shunt tubing. Additional assessment of abdomen should be completed regularly monitoring for abdominal cerebrospinal fluid (CSF) that may result in ascites, pseudocysts, or inguinal hernia. R1 was admitted to the facility on [DATE], with pertinent diagnoses of congenital hydrocephalus and presence of cerebrospinal fluid drainage device. R1's most recent quarterly Minimum Data Set (MDS) assessment, dated 06/19/25, noted a Brief Interview for Mental Status (BIMS) score of 6/15, indicating severe cognitive impairment. R1's care plan, dated 11/26/24, with a target date of 07/11/25, states: R1 has potential for alteration in neurological status related to hydrocephalus and placement of VP shunt with interventions of RN [Registered Nurse] will pump ReFlow valve on VP shunt as per direction of Neurosurgeon. -Of note: care plan did not include assessment of VP shunt line for signs or symptoms of infection or abdominal assessment for signs or symptoms of fluid overload from drainage of Cerebrospinal Fluid (CSF) fluid from VP shunt. R1's physician orders: On 11/21/24, RN staff to pump shunt 10 times twice daily per neurology. (Order discontinued 02/18/25) On 02/18/25, Nursing staff to pump shunt 10 times twice daily. (Order discontinued 06/26/25) On 06/26/25, RN or Licensed Practical Nurse (LPN) staff to pump shunt 10-20 times two times a day for VP shunt drain. -Of note: no additional orders for assessment of VP shunt noted. On 06/30/25, Surveyor reviewed R1's nursing progress notes and noted no assessments completed of R1's abdomen to include circumference measurement, appearance, or bowel sounds related to VP shunt and CSF drainage. No assessment of VP shunt noted to include signs and symptoms of infection noted. On 06/30/25, Surveyor reviewed R1's Treatment Administration Record (TAR). Between 06/26/25 - 06/20/25, VP shunt was pumped per order. No indication of how many pumps completed were noted. On 06/30/25 at 9:57 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F regarding care of R1's VP shunt. LPN F stated no assessments of R1's abdomen of VP shunt are documented. LPN F stated the only training given on the care for R1's VP shunt was to palpate the pump under the skin and press it 10 times. On 06/30/25 at 10:19 AM, Surveyor interviewed Registered Nurse (RN) G regarding R1's VP shunt. RN G stated receiving one day of training by LPN F on how to pump R1's VP shunt. Surveyor asked RN G what assessments would be included for R1 related to the VP shunt. RN G stated monitoring neurological status and any changes in baseline would be noted in a progress note and provider would be notified. Surveyor asked if any additional assessments should be completed. RN G stated nothing else came to mind. On 06/30/25 at 1:18 PM, Surveyor interviewed Director of Nursing (DON) B regarding care of R1's VP shunt. DON B stated the previous DON had gone with R1 to a previous neurology appointment and was trained on how to complete the pumping of R1's shunt and trained nursing staff in this care. Surveyor asked DON B for documentation of what assessment and training was completed for R1's VP shunt care. DON B stated not being sure of what was taught to nursing staff and was unable to provide an example of education or training on assessments for R1's VP shunt or potential complications.

Based on interview and record review, the facility did not ensure licensed nurses had the specific competencies and skill set necessary to care for a resident's needs, as identified through resident assessment, and described in the plan of care, for 1 of 1 resident (R) reviewed for ventriculoperitoneal (VP) shunt care, R1. The facility did not provide training and education to licensed staff to ensure competency in the care of R1's VP shunt. This is evidenced by: Facility Assessment, dated 08/07/24, states in part: .Competencies: Kinnic considered the .clinical characteristics of the resident population to determine the skills and competencies required to meet our resident needs. We identified four categories of competencies: knowledge, assessment, pharmacological/treatment/care considerations, and technical/hands-on skills. Refer to the worksheet Facility Education/Staff Competencies Necessary to Care for Resident Population. The worksheet identifies which staff require certain competencies and skill sets, and the frequency of education. Our facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. We complete an educational needs assessment and develop a curriculum and training plan based on staff need and resident characteristics. The content at a minimum includes: .special needs of residents. Kinnic Health and Rehab conducts a formal evaluation of the training program. Training binders and checklists have been implemented to help those mentoring the new hire . R1 was admitted to the facility on [DATE], with pertinent diagnoses of congenital hydrocephalus and presence of cerebrospinal fluid drainage device. R1's most recent quarterly Minimum Data Set (MDS) assessment, dated 06/19/25, noted a Brief Interview for Mental Status (BIMS) score of 6/15, indicating severe cognitive impairment. R1's care plan, dated 11/26/24, with a target date of 07/11/25, states: R1 has potential for alteration in neurological status related to hydrocephalus and placement of VP shunt with interventions of RN will pump ReFlow valve on VP shunt as per direction of Neurosurgeon. -Of note: care plan did not include assessment of VP shunt line for signs or symptoms of infection or abdominal assessment for signs or symptoms of fluid overload from drainage of Cerebrospinal Fluid (CSF) fluid from VP shunt. R1's physician orders: On 11/21/24, RN staff to pump shunt 10 times twice daily per neurology. (Order discontinued 02/18/25) On 02/18/25, Nursing staff to pump shunt 10 times twice daily. (Order discontinued 06/26/25) On 06/26/25, RN or LPN staff to pump shunt 10-20 times two times a day for VP shunt drain. -Of note: no additional orders for assessment of VP shunt noted. Surveyor reviewed facility education and training topics for nursing staff. VP shunt care was not included as a topic for training or competency evaluation. On 06/30/25 at 9:57 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F regarding training and education for R1's VP shunt. LPN F stated that the only training given on the care for R1's VP shunt was to palpate the pump under the skin and press it 10 times by the previous Director of Nursing (DON). Surveyor asked LPN F if they received any formal training or instruction on amount of pressure to use for pumping the shunt, when to adjust the number of pumps, or the rate/depth of compression of shunt was completed. LPN F stated no additional training or education was provided. Surveyor asked LPN F to state potential complications related to VP malfunction. LPN F was unable to answer other than to monitor neurological status. On 06/30/25 at 10:00 AM, Surveyor interviewed Registered Nurse (RN) H regarding training and education for R1's VP shunt. RN H stated no recollection of formal education or training having been completed. RN H stated she does not normally work with R1 but may have been shown how and where to push on the VP shunt to pump it but was not sure. On 06/30/25 at 10:19 AM, Surveyor interviewed RN G regarding training and education for R1's VP shunt. RN G stated receiving one day of training by LPN F on how to pump R1's VP shunt, but no formal training or education was completed. Surveyor asked RN G if a competency of this skill was completed. RN G stated that LPN F just showed her where to push and that is it. Surveyor asked RN G what assessments would be included for R1 related to the VP shunt. RN G stated monitoring neurological status and any changes in baseline would be noted in a progress note and provider notified. Surveyor asked if any additional assessments should be completed. RN G stated nothing else came to mind. On 06/30/25 at 1:18 PM, Surveyor interviewed DON B regarding training and education for R1's VP shunt. DON B stated the previous DON went with R1 to a previous neurology appointment and was trained on how to complete the pumping of R1's shunt and trained nursing staff in this care. Surveyor asked DON B for documentation of what assessment and training was completed for R1's VP shunt care. DON B stated not being sure of what was taught to nursing staff and was unable to provide an example of education, training, or competency for R1's VP shunt. Surveyor asked DON B for current training related to R1's VP shunt. DON B stated they did not have any current training on this.

Based on observation, interview and record review, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R), R2, R5, and R1 reviewed. R2, R5 and R1 had fallen; the facility did not initiate immediate intervention to prevent future falls, investigate the root cause of the fall and review and revise care plan fall interventions. This is evidenced by: Facility policy titled, Falls Management, with no initiated or reviewed date, states in part: Policy: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries .Procedure: 3. Discuss goals and interventions with resident/family for inclusion in the interdisciplinary plan of care. 4. Implement the Plan of Care - Fall Risk Reduction based on individual resident needs. 5. Complete the individual resident care plan .8. Review and revise interdisciplinary Plan of Care at subsequent care plan meetings. Facility policy titled, Protocol: Post Fall, with no initiated or reviewed date, states in part: 1. Assess the resident and implement appropriate measures to provide immediate care. 2. Nursing to complete per policy and procedure: a) Fall Tracking Form, b) Incident report ., c) FSI-Fall Scene Investigation Report (used to identify the root cause analysis). 3. Review Fall Risk Assessment for any changes in fall risk, reassess post fall. 5. Review the Plan of Care. 6. Discuss findings and interventions with the resident and family for inclusion in the interdisciplinary plan of care. 7. Adjust/add intervention on the Plan of Care. 8. Present the resident at the morning interdisciplinary team meeting. a) Review current assessments and reports, b) Compare data from previous assessments, c) Discuss identified trends or potential new risk factors. 9. Review and revise Interdisciplinary plan of care. 10. Update and communicate interventions on the plan of care. R2 was admitted to the facility on [DATE], with diagnoses including dementia with other behavioral disturbance, adult failure to thrive, Alzheimer's disease, major depressive disorder, anxiety disorder, cognitive communication deficit, and chronic pain. Minimum Data Set (MDS), dated [DATE], which is a quarterly assessment documents R2 having a Brief Interview for Mental Status (BIMS) score of 7/15, meaning severe cognitive impairment. R2 is independent with activities of daily living and ambulation. R2 had 2 or more falls without injury, and 1 fall with injury that was not a major injury. R2's care plan states, [R2] is at risk for falls r/t (related to) decreased mobility, Dementia with behavioral disturbance .Interventions to anticipate and meet [R2's] needs. Be sure [R2's] call light is within reach and encourage [R2] to use it for assistance as needed. [R2] needs prompt response to all requests for assistance .Educate [R2]/family/ caregivers about safety reminders and what to do if a fall occurs .Gripper socks to be applied at bedtime .Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate [R2]/family/caregivers/IDT [Interdisciplinary Team] as to causes . On 06/13/25 at 9:15 PM, the fall incident report documented @ 2115 a noise came from [R2s] room, [R2] was found to be lying on her back on the floor by bed, room light was on, tv on, [R2] had on regular socks, and no shoes on, [R2] c/o (complained of) pain to the back of her head, a small lump was noted with small amount bloody drainage, VSS (vital signs stable) afebrile. [R2's] description: [R2] was trying to fix sheets on her bed and fell. Surveyor noted the fall incident report did not include immediate interventions to prevent falls. Surveyor requested the interdisciplinary team (IDT) investigation notes for R2's fall, root cause and interventions to prevent future falls. Surveyor's review of R2's care plans did not identify an update for fall interventions. Example 2 R5 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting left dominant side, muscle weakness, difficulty in walking, pain in left hip, and dizziness and giddiness. R5's MDS, dated [DATE], an admission 5-day assessment, documents a BIMS score of 15/15, meaning cognitively intact. R5 has impairment to one side of upper and lower extremity. R5 requires moderate assistance from staff for toileting hygiene, upper body dressing, bed mobility, sit to stand, and transfers. R5 had a fall prior to admission and no fall during this assessment period. R5's care plan documented, Risk for falls related to decreased mobility, CVA with left hemiparesis .Date initiated: 06/17/25 .Interventions dated 06/17/25, Anticipate and meet [R5's] needs. Be sure [R5's] call light is within reach and encourage [R5] to use it for assistance as needed. [R5] needs prompt response to all request for assistance, educated [R5]/family/caregivers about safety reminders and what to do if a fall occurs. Encourage [R5] to wear shoes/gripper socks at all times .Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate [R5]/family/caregivers/IDT as to causes. On 06/04/25, a fall risk assessment was completed with a score of 3 indicating at low risk for falls. On 06/22/25 at 4:00 AM, a fall incident report documented Had just been in the BR (bathroom) and was sitting at the side of the bed, CNA (Certified Nursing Assistant) said [R5] was taking off shoes and slid off the bed. The CNA did not see the fall as she was moving the w/c (wheelchair). When writer got to the room, [R5] stated [R5] was reaching to put his shoes in the chair. Surveyor noted the fall incident report did not include immediate interventions to prevent falls. Surveyor requested from NHA A the IDT investigation notes for R5's fall, including the root cause and interventions to prevent future falls. Surveyor's review of the care plans did not identify an update for fall interventions. On 06/30/25 at 4:04 PM, NHA A stated we don't have IDT investigation fall notes for these falls. Example 3 R1 was admitted to the facility on [DATE], with diagnoses including congenital hydrocephalus and presence of cerebrospinal fluid drainage device. R1's most recent quarterly MDS assessment, dated 06/19/25, noted a BIMS score of 6/15, indicating severe cognitive impairment. R1 had no impairment with range of motion in upper or lower extremities and has not had any falls since admission or prior assessment. R1's care plan, dated 10/25/24, with a target date of 07/11/25, stated: R1 is at risk for falls with interventions of review information on past falls and attempt to determine cause of falls, record possible root causes, OT [Occupational Therapy] to evaluate and treat for wheelchair positioning (initiated 01/23/25), bariatric bed to minimize risk of rolling off the bed (initiated 03/26/25). On 01/23/25 at 11:15 AM, the fall incident report documented: Housekeeper called out that resident had fallen out of his wheelchair. Nurse on duty arrived to find resident laying on right side against roommate's recliner. Checked for pain and injuries. Noted to have a hematoma and superficial abrasions to right side forehead. Denies pain on initial check. Alert to self per baseline, disoriented and confused per baseline. Neuros checked an WNL [Within Normal Limits]. Able to move all extremities per baseline. Vitals obtained and WNL. Resident description: [R1] states he doesn't know what happened. [R1] was reportedly wheeling himself around in his room prior to the fall. Immediate Action Taken: Assisted into bed via [H][NAME] lift, applied ice to right side forehead, notified daughter/POA [Power of Attorney], notified provider who instructed that [R1] should be seen in ED [Emergency Department] for evaluation. Resident sent to ED at 12:23 PM. Intervention: OT to evaluate and treat for wheelchair positioning. -Of note: No further update or documentation of OT evaluation and recommendation for intervention. No root cause of fall noted. Surveyor requested from NHA A the IDT investigation notes for R1's fall, root cause and interventions to prevent future falls. Surveyor's review of at care plans did not identify an update for fall interventions. On 06/30/25 at 4:04 PM, NHA A stated we don't have IDT investigation fall notes for R1's fall.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system from 7/1/24 - 3/31/25 which triggered excessively low weekend staffing. This has the potential to affect all 49 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal Year Quarter 4 2024 (July 1-September 30), Quarter 1 2025 (October 1-December 31), and Quarter 2 2025 (January 1- March 31) all indicate the following: Excessively low weekend staffing. On 6/10/25, Surveyor reviewed a sample of the nursing working weekend schedule in each quarter. Surveyor was not able to identify any systematic concerns with staffing during this review. On 6/10/25 at 11:54 AM, Surveyor interviewed Scheduler K, who stated the facility assesses census and acuity of the residents to determine if they should schedule extra staff by obtaining staff input. Scheduler K stated, If the census is below 47, we would typically have the same number of nursing staff on the weekends, as we do on the weekdays, except for the Director of Nursing (DON) or ADON F. Scheduler K stated if the census is greater than 47 or there are higher acuity resident(s) there will typically be more Certified Nursing Assistants (CNA) scheduled. The CNAs are scheduled for 8-hour days, so if they are short, they can ask them to work longer hours and on other shifts. On 6/11/25 at 9:00 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked why the facility triggers for low weekend staffing. NHA A stated she is not sure why they trigger for the low weekend staffing, as they schedule the same amount of nursing staff on the weekends as they do during the week. NHA A stated they will request staff to work longer shifts to cover if staff calls in sick. NHA A confirmed the number of direct care staff scheduled does not change on the weekends versus during the week. NHA A reported the nursing hours worked are submitted to the owner through their payroll system and are entered into the PBJ system by the owner. NHA A reported attempts were made to contact the owner to verify how hours are being submitted into the PBJ system, but no further information was provided to Surveyor. Surveyor did not identify evidence of excessively low weekend staffing. NHA A reported she believes staff hours worked went unreported into the PBJ system entered by the owner, as some staff may enter information incorrectly on their timecard which may have triggered low weekend staffing. NHA A reported she will review with the owner when she is able to contact.

Based on observation, interview and policy review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not allowing thermometer to dry prior to checking temperatures of food items and not inverting mixer and bowls in storage. This had the potential to affect all 49 residents in the facility. Findings: Example 1 On 06/08/25 at 10:45 AM, Surveyor conducted the initial tour of kitchen with [NAME] T who has been on staff 12 years. Surveyor observed the Kitchen Aide mixer on the counter with bowl under it that was not inverted. Surveyor also observed large industrial size mixer in kitchen with bowl stored under it which was not inverted. Neither of the mixers were covered. Surveyor interviewed [NAME] T and asked what the normal way is to store when not in use. [NAME] T stated both mixers are used 2-3 times a week and stored uncovered and not inverted when not in use. Surveyor observed a rack of large bowls and pans that were not inverted. [NAME] T stated that is normal to store the rack of dishes in this manner. Surveyor discussed potential for contamination with storing items uncovered and not inverted. [NAME] T indicated understanding there is a risk of bacteria with the manner the mixing bowls, bowls and pans are stored. [NAME] T acknowledged the mixing bowls, bowls and pans should be inverted or covered when not in use. Example 2 On 06/09/25 at 7:30 AM, Surveyor observed [NAME] R perform food temps and food service. [NAME] R used an alcohol pad for thermometer probe used to temp oatmeal. [NAME] R wiped probe and inserted the undried probe into the cream of wheat. [NAME] R then wiped and inserted the undried probe into the scrambled eggs with no wait time for probe to air dry. [NAME] R proceeded to wipe the probe with alcohol pad and insert in pureed eggs with no wait time for probe to air dry. [NAME] R continued to wipe the probe with the alcohol pad and insert into sausage. [NAME] R exited kitchenette to obtain additional alcohol pads. [NAME] R returned, wiped the probe and inserted into pureed toast. Surveyor interviewed [NAME] R asking what education he has had for sanitizing the thermometer probe prior to inserting into food items. [NAME] R stated he was not exactly told nor really ever trained on waiting to allow probe to air dry. Surveyor asked if the undried thermometer has the potential to contaminate food items with the sanitizer. [NAME] R verbalized understanding as to why he should wait for the sanitizer to dry prior to inserting into food items. On 06/11/25 at 9:41 AM, Surveyor interviewed Dietary Manager (DM) U. DM stated the bowls should be covered. DM U acknowledged after dishwashing moisture remains in the dishes and is an opportunity for bacteria to grow. The dishes are stored in areas where anything could fall in the dishes and contaminate them. The dishes should be inverted or covered.

Based on record review and staff interviews, the facility did not ensure Certified Nursing Assistant (CNA) received a performance review every 12 months for three of three CNAs reviewed (CNA C, CNA D, CNA P). The facility failed to have a system in place to ensure that performance reviews were being done for any of the facility CNAs. This had the potential to affect all 49 residents residing in the facility. This is evidenced by: On 06/10/25, a sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information: CNA C has been employed at the facility since 12/15/20. An annual performance review could not be located. CNA D has been employed at the facility since 09/2019. An annual performance review could not be located. CNA P has been employed at the facility since 12/06/21. An annual performance review could not be located. On 06/10/25 at 8:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about yearly performance evaluations on staff. NHA A was not able to find yearly reviews, only yearly wage adjustment form. The lack of regular performance reviews significantly impacts the quality of care provided by the staff.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R2), observed during catheter cares. Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care. Findings: Facility had no policy for staff to follow and direct the care for a suprapubic catheter site care. Facility policy titled Hand Hygiene with no date implemented or date revised stated in part: .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .after handling contaminated objects .before performing invasive procedures .before and after handling clean or soiled dressings .after handling items potentially contaminated with blood, body fluids, secretions, or excretions . R2 was admitted to the facility on [DATE], with diagnoses of multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), neuromuscular dysfunction of the bladder, and appendicovesicostomy (surgeons use your appendix to create a channel that connects your bladder to an opening (stoma) in your abdominal wall). R2's Minimum Data Set (MDS) assessment, dated 03/26/25, documented a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated R2 was cognitively intact. On 06/09/25 at 12:56 PM, Surveyor observed suprapubic catheter site care by RN G. RN G gathered dressing supplies, performed proper hand hygiene when entering the room as well as put on the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP). RN G removed the old dressing. No hand hygiene or glove change. RN G washed the site of the catheter insertion without hand hygiene or glove change. RN G then put a new T-sponge gauze over the insertion site. RN G then threw away the garbage, removed PPE and performed hand hygiene. On 06/10/25 at 8:35 AM, Surveyor asked Assistant Director of Nursing (ADON) F, When would you perform hand hygiene and glove changes when doing a suprapubic catheter site care? I would perform hand hygiene before I start the procedure, and I would have my items set up. I would remove the old dressing. Take off my gloves perform hand hygiene then put on new gloves and put on the new dressing. On 06/10/25 at 9:35 AM, Surveyor explained the process observed yesterday with the site care with RN G. Surveyor then asked RN G, Where in this procedure should you have performed hand hygiene and glove change? RN G replied, Oh I see what you're asking, yes I should have removed my gloves and performed hand hygiene before I put the new dressing on the site.

Based on observations, interviews and record reviews, the facility failed to allow resident the right to choose physicians/treatment options for 1 of 18 residents (R) reviewed. (R4). -Facility denied R4 the right to follow up with the wound provider of choice. R4 wanted to follow up with the VA wound provider and not the facility in-house provider. -R4 was seen by provider of choice and when returned to the facility with new orders, staff told R4 the facility will not do those treatments and had the attending physician discontinue the orders. Findings include: According to the Board on Aging and Long-term Care, residents have a right to self-determination which includes, in part: - Offered choices and allowed to participate in decisions important to you. - Expect a reasonable accommodation of your needs and preferences. - Participate in the planning of your care and services, and to receive care and services in a way that respects your personal and cultural wishes. - Request, discontinue or decline care and treatment. - Choose your health care provider. R4 was admitted to the facility on [DATE] with diagnoses including left femur fracture, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and edema to both lower legs with venous ulcers. R4 was dependent on staff to meet the dressing changes and care for daily living. R4 was expected to have a short term stay and return to the community. On 06/09/25 at 7:55 AM, R4 informed Surveyor R4 did not have the right to choose own provider. On 06/09/25 at 10:48 AM, Surveyor interviewed Registered Nurse (RN) G and Licensed Practical Nurse (LPN) J and asked about appointments for R4. RN G and LPN J denied any frequently cancelled appointments. LPN J stated R4's daughter would take her to the VA clinic and nursing had no idea an appointment was even made. Then they would return with all the orders from the VA. There was a lot of collaboration with the VA and DON L. The floor nurses were instructed by DON L to run everything past the medical director. On 06/09/25 at 1:33 PM, Surveyor interviewed R4. R4 said she was told on admission R4 needed to cancel all VA appointments and only use in-house providers except for the orthopedic doctor. R4 said R4 and R4's daughter got in an argument with the previous DON L and felt DON L was not listening, so daughter set up R4's own appointments and transportation. On 06/09/25 at 1:41 PM, Surveyor interviewed Director of Rehab (DOR) M and asked if DOR M was aware of treatment concerns for R4. DOR M stated DON L refused to allow staff to change the order and said what they are doing is fine. DOR M said DON L pulled off all the dressings the VA had on R4, stuffed them in a bag and put them in the closet. DOR M pulled a bag out of the bottom of R4's closet with all the supplies needed for the new orders from the VA provider. DOR M stated DON L just contacted the primary provider who discontinued the orders. Now DON L is no longer employed at the facility, everything is back on track, and R4 can see the provider of her choice. DOR M said due to the nature of the issues, the concern was reported to Nursing Home Administrator (NHA) A. R4's records indicate: R4 was seen on 04/28/25 by the VA wound provider. Specific orders were received for treatments to leg wounds which including silvadene, [NAME] boots, kerlix, tubigrip, and abdominal pads. DON L sent a copy of orders with a note to the primary doctor indicating R4 expressed concerns with the VA orders and asked them to be discontinued and resume the previous orders. The attending physician did discontinue the orders on the same day and the treatments were not transcribed. On 06/09/25 at 1:54 PM, Surveyor interviewed Social Services Director (SSD) H and asked if residents are allowed to choose their own physicians. SSD H stated it is in the admission packet. Surveyor informed SSD H there is a resident who felt they did not have that right until a family member made an appointment themselves for the resident. SSD H stated she was aware of that incident, and DON L investigated the grievance. Surveyor asked SSD H if it would be ethical for staff to change orders with another provider without a resident's consent. SSD H felt this was a violation of R4's rights. On 06/09/25 at 2:56 PM, Surveyor interviewed NHA A. Surveyor asked what the expectation would be regarding residents choosing their own provider. NHA A said residents have the right to pick their own providers. They are aware of the behaviors of DON L and addressed this in QAPI but missed the resident's right to choose aspect.

Based on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) of non-coverage for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 2 of 3 residents (R) reviewed. (R43, R33) R43 and R33 were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility did not provide an ABN informing the residents of their liability once Medicare coverage ended. Findings include: On 06/09/25 at approximately 9:00 a.m., Surveyor reviewed documents provided by the facility for residents who had been discharged from Medicare Part A with benefit days remaining. R43 start of services: 4/14/25, Last Covered Date (LCD): 6/02/25, notice of non-coverage 5/29, with no notice of patient liability provided to R43. R43 remained in the building. R33 start of services: 4/01/25, LCD: 5/30/25, notice of non-coverage 5/27/25 and no notice of liability was provided to R33. R33 remained in the building. On 06/09/25 at 2:13 PM, Surveyor interviewed Business Office Manager (BOM) I who is responsible for providing notice of non-coverage and potential liability when services end. BOM I indicated she has been doing notices for a few years. BOM I stated when the forms changed a few years ago she misinterpreted the forms and was not providing notice of potential liability for residents who remained in the building and Medicare non-coverage was provided.

Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 18 residents (R) reviewed for abuse (R98). The facility did not ensure all staff were trained on the abuse policy, did not complete audits of staff to protect residents from abuse, or ensure staff knowledge of the abuse and reporting policy, and did not have a quality improvement plan to prevent further verbal abuse. This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, II. Employee Training, B. Existing staff will receive annual education through planned in-services and as needed .III. Prevention of Abuse, Neglect and Exploitation, H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors .VIII. Coordination with QAPI, A. The facility has written policies and procedure that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program .iv. Measures to verify the implementation of corrective actions and timeframes, and v. Tracking patterns of similar occurrences. R98 was admitted to the facility on [DATE] with hospice services. R98's diagnoses included nondisplaced fracture of base of neck of right femur, pain right hip, palliative care, dementia without behavioral, major depressive disorder, protein-calorie malnutrition, anxiety disorder, and cervical disc degeneration. On 02/10/25, an admission Minimum Data Set (MDS) assessment documented R98's Brief Interview of Mental Status (BIMS) score of 3/15 meaning R98 has severe cognitive impairment. MDS documented R98 had acute onset of mental status change, inattention and disorganized thinking that is continuously present. R98's care plan documented on 02/20/25, The resident has impaired cognitive function r/t Dementia. Care plan on 03/11/25 documented, The resident has a behavior problem r/t dementia. Resident often tries to get up to walk not remembering she is unable to do so safely independently. Resident becomes agitated at times and often requires 1:1 to keep her safe and content. Resident can become verbally and physically aggressive. Review of the Facility Reported Incident (FRI) investigation documented on 03/10/25 Certified Nursing Assistant (CNA) C reported to Assistant Director of Nursing (ADON) F on the night shift on 03/09/25 into 03/10/25 Registered Nurse (RN) E had raised his voice and swore at R98 while attempting to assist R98, CNA D not attempting to do interventions with R98, and CNA D appeared to be intimidating R98. The facility immediately suspended RN E and CNA D and completed an investigation and educated all staff on dementia behavior. Surveyor reviewed the staff education sign in sheets for behaviors in dementia dated 03/10/25 which included 27 staff names. Review of the current employee list documented a total of 78 staff were employed on 03/10/25. Surveyor reviewed the list of staff education sign in sheets for abuse dated 03/10/25 after this incident. The list included 17 staff names. Surveyor reviewed the staff sign in sheets for abuse and reporting training from 11/11/24, which documented 23 staff signatures and did not include RN E. On 06/11/25 at 9:26 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about the 03/09/25 incident. Surveyor asked if NHA A completed audits of staff interactions and knowledge of abuse policy to ensure no further verbal abuse occurred. NHA A stated no formal audits were completed. Surveyor reviewed the education that was provided to staff on 03/10/25 of abuse education informing NHA A the staff sign in sheet did not include all staff. Surveyor asked how NHA A ensures all staff are trained. NHA A stated she sends out an email that there is education to be reviewed and signed. NHA A stated the system can be improved to ensure all staff are educated. Surveyor asked if the facility's Quality Assessment & Assurance (QAA) had identified abuse as an issue to be reviewed and to initiate a plan. NHA A stated this was talked about and we could do better. NHA A stated they don't have a written PIP (Performance Improvement Plan).

Based on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of verbal abuse in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but no later than 2 hours to the administrator and local law enforcement in accordance with state law through established procedures for 1 of 2 residents (R) reviewed (R98). This is evidenced by: Facility's policy titled Abuse, Neglect and Exploitation with no date implemented, read in part, VII. Reporting/Response, 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury R98 was admitted to the facility on [DATE] with hospice services. R98's diagnoses included nondisplaced fracture of base of neck of right femur, pain right hip, palliative care, dementia without behavioral, major depressive disorder, protein-calorie malnutrition, anxiety disorder, and cervical disc degeneration. On 02/10/25, an admission Minimum Data Set (MDS) assessment documented R98's Brief Interview of Mental Status (BIMS) score of 3/15, meaning R98 has severe cognitive impairment. MDS documented R98 had acute onset of mental status change, inattention and disorganized thinking that is continuously present. MDS documented R98 had impairment to one side of lower extremity. R98 requires moderate assist of staff for toileting hygiene, bed mobility, sit to stand, toilet transfer, shower transfer, and to walk 10 feet. R98 has a history of falls prior to admission. Review of the Facility Reported Incident (FRI) investigation documented on 03/10/25 Certified Nursing Assistant (CNA) C reported to Assistant Director of Nursing (ADON) F on the night shift on 03/09/25 into 03/10/25 Registered Nurse (RN) E had raised his voice and swore at R98 while attempting to assist R98, CNA D not attempting to do interventions with R98, and CNA D appeared to be intimidating R98. The facility immediately suspended Registered Nurse (RN) E and CNA D and completed an investigation and educated all staff on dementia behavior. On 06/09/25 at 2:25 PM, Surveyor interviewed CNA C about when the incident on 03/09/25 was reported. CNA C reported to ADON F in the morning. This happened Sunday night and no other nurses were on at that time. CNA C could have called the Director of Nursing (DON) but waited until morning until they came in. On 06/10/25 at 12:44 PM, Surveyor interviewed ADON F about the incident on 03/09/25. ADON F stated she came into the facility around 6:00-6:30 AM, and CNA C came to ADON F and reported CNA D and RN E's treatment to R98 was rough. ADON F reported to former Director of Nursing (DON) L about the report. RN E was immediately interviewed, and DON L reported to Nursing Home Administrator (NHA) A. On 06/11/25 at 9:26 AM, Surveyor interviewed NHA A asking when DON L reported the 03/09/25 incident. NHA A stated ADON F reported to former DON L, and DON L texted NHA A between 7-7:30 AM. DON L told NHA A that R98 was having behaviors and CNA C reported not liking how the guys (RN E and CNA D) handled R98. They were verbally aggressive. Surveyor asked NHA A when CNA C should have reported the verbal abuse. NHA A stated CNA C should have called in the middle of the night within 2 hours. Surveyor asked if the allegation was reported to police. NHA A stated it was not reported to police because when talking with RN E and CNA C it was determined RN E was not swearing directly at R98. RN E was frustrated and swore, and it was not calling R98 names but a reply when R98 called RN E an asshole and RN said, Ya I am an . Of note the facility's investigation was not completed and reported to the state agency until 03/17/25.

Based on observation, record review and interview, the facility did not ensure residents (R) received proper treatment and assistive devices to maintain hearing abilities. This affected 1 of 3 residents reviewed who needed hearing aids (R28). R28's hearing aid was broken and not replaced for several months. R28 continues with no left ear hearing aid, which impacts R28's ability to adequately hear. Findings Include: R28 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, primary open-angle glaucoma right eye-moderate state, low vision right eye, blindness left eye, disorientation-unspecified, and cognitive communication deficit. R28's Minimum Data Set (MDS) assessment, dated 3/31/25, indicated R28's Brief Interview for Mental Status (BIMS) score is 9/15, which means mild cognitive impairment. R28 requires supervision or touching assistance with eating, substantial/maximal assistance with toileting hygiene, shower, partial/moderate assistance with dressing, personal hygiene, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, walking, and set up with rolling left to right, sit to lying, R28's care plan: Focus -The resident is HOH and wears bilateral HA's. I need assistance putting them in my ears and taking them out at bedtime. Is missing left hearing aide, Health Drive is replacing hearing aid. Date initiated 1/17/2023. Revision 3/11/2025. -The resident will be able to make basic needs known daily through the review date. Date initiated 1/17/2023. Revision 4/14/2025. Target Date 7/25/2025. -Anticipate and meet needs. Date Initiated: 01/17/2023. -Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 01/17/2023. -COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 01/17/2023. -Ensure bilateral hearing aids are in place. Assist as needed. Date Initiated: 01/17/2023 -Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Date Initiated: 01/17/2023 -Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL, deterioration in respiratory status, oral motor function, hearing impairment (ear discharge and cerumen (wax) accumulation, poor fitting/missing dental appliances etc. Date Initiated: 01/17/2023. -Monitor/document resident's ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend. -Refer to Audiology for hearing consult as ordered. Date Initiated: 01/17/2023. -Report to Nurse changes in: Ability to communicate, Possible factors which cause/make worse/make better any communication problems. Date Initiated: 01/17/2023. On 06/08/25 at 12:09 PM, Surveyor observed staff who were taking R28's order for lunch and speaking in louder than normal voice to R28's right ear. On 06/08/25 at 1:01 PM, Surveyor observed staff, who were standing near R28 and talking about cake, were talking close to R28's right ear loudly, but not yelling and R28 was responding. On 06/09/25 at 6:35 AM, Surveyor spoke with R28 in attempt to obtain permission to observe cares. R28 was unable to hear Surveyor talking when Surveyor was standing on R28's left side. When Surveyor was on R28's right side and spoke with a loud tone of voice and asked if care could be observed, R28 said it was ok to observe but repeated incorrect name of Surveyor. R28 had 2 hearing aids, and one broke several months ago and was not replaced. R28 needs people to talk in the right ear with the hearing aid and then she does fine, otherwise she can't hear. Left hearing aid was never replaced. On 06/10/25 at 6:43 AM, R28 was sitting in lounge area with peers, had glasses on and hearing aid in right ear. Surveyor attempted to speak to R28 on R28's left side and R28 did not respond. On 06/09/25 at 11:00 AM, Surveyor interviewed Social Service Director (SSD) H. Surveyor asked about R28's hearing aid. SSD H stated the issue should have been followed up on sooner. SSD H stated R28's husband had the hearing aid and was going to have it replaced. Unfortunately, R28's husband passed away. R28's nephew became R28's Power of Attorney (POA) and nephew was unsure of the status of the hearing aid. SSD H stated SSD H was supposed to schedule an appointment with the Health Drive audiologist. SSD H stated there is not a good system in place, and SSD H dropped the ball. SSD H did contact Health Drive and process is in place at this time. SSD H stated she should have responded sooner because R28 has sensory issues with vision and hearing, so she should have her hearing aid.

Based on observation, interview and record review, the facility did not ensure that residents with a suprapubic catheter received the appropriate care and services for 1 of 2 residents (R2), observed during catheter cares. -The facility had no policy to direct staff for daily suprapubic catheter site care. -R2 had a urinary tract infection (UTI) with sepsis in September 2024. -Registered Nurse (RN) G did not perform hand hygiene or glove change during suprapubic catheter care. Findings: Facility had no policy for staff to follow and direct the care for a suprapubic catheter site care. According to MediLexicon International. (n.d.). What to know about e.coli uti treatment. Medical News Today.https://www.medicalnewstoday.com/articles/e-coli-uti-treatment, If bacteria get into the bladder and travels to the bladder, they can cause an infection. CAUTIs can become serious, especially in those with weakened immune systems and other health conditions. Risk of infection can be significantly reduced by washing hands before and after changing, emptying, or handling the catheter, or changing a dressing and applying a new one. R2 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), neuromuscular dysfunction of the bladder, and appendicovesicostomy (surgeons use the appendix to create a channel that connects your bladder to an opening (stoma) in your abdominal wall). R2's Minimum Data Set (MDS) assessment documents a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated R2 was cognitively intact. A discharge summary note dated 10/02/2024 stated R2 had met sepsis criteria for a UTI. On 06/09/25 at 12:56 PM, Surveyor observed suprapubic catheter site care by RN G to R2. RN G gathered dressing supplies, performed proper hand hygiene when entering the room as well as put on proper personal protective equipment (PPE) for enhanced barrier precautions (EBP). RN G removed the old dressing. No hand hygiene or glove change after removing the dressing. RN G washed the site of the catheter insertion. RN G then put a new T-sponge gauze over the insertion site. RN G then threw away the garbage, removed PPE, and performed hand hygiene. *Note: Placing a clean sponge gauze at catheter insertion site with dirty gloves after handling a soiled dressing significantly increases the risk of bacteria entering the catheter and traveling to the bladder and causing an infection. On 06/09/25 at 1:01 PM, Surveyor asked Assistant Director of Nursing (ADON) F for a policy on suprapubic catheter site care. ADON F said she would find it. On 06/09/25 at 1:23 PM, ADON F informed Surveyor, I cannot find a policy on suprapubic catheter site care. I am making one now. We have a suprapubic catheterization policy but nothing which talks about site care. Surveyor reviewed the suprapubic catheterization policy and section f of section 7 which states to quickly change to sterile gloves but does not indicate to wash hands between glove changes. On 06/09/25 at 1:30 PM, Surveyor received policy titled Suprapubic Catheter Care created today, 06/09/25. This policy also has no indication for hand hygiene between old dressing and new split gauze dressing which increases the risk for bacteria to enter the catheter and travel to the bladder and cause an infection. On 06/10/25 at 8:35 AM, Surveyor asked ADON F when would you perform hand hygiene and glove changes when doing a suprapubic catheter site care to prevent an infection. ADON F stated, I would perform hand hygiene before I start the procedure, and I would have my items set up. I would remove the old dressing. Take off my gloves perform hand hygiene, then put on new gloves, and put on the new dressing. On 06/10/25 at 9:35 AM, Surveyor explained the process observed yesterday with the site care with RN G. Surveyor asked RN G where in this procedure should you have performed hand hygiene and glove change so as to prevent an infection. RN G replied, Oh I see what you're asking. Yes, I should have removed my gloves and performed hand hygiene before I put the new dressing on the site.

Based on observation, interview and record review, the facility did not assess trauma and care plan person centered approaches to prevent re-traumatization for 1 out of 1 resident reviewed for trauma informed care (R30). R30's diagnosis includes post-traumatic stress disorder (PTSD) and past trauma of her sister dying. The facility did not assess R30's trauma and care plan individual person-centered approaches to prevent potential re-traumatization. Findings Include: The facility policy titled Trauma Informed Care not dated, states the following: Policy: It is the policy of this facility to provide care and services, which in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/re re-traumatization. Policy Explanation and Compliance Guidelines: 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. R30 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, Alzheimer's disease, unspecified psychosis not due to substance or known psychological condition, panic disorder and post-traumatic stress disorder (PTSD). R30's most Recent Minimum data Set (MDS) completed on 5/19/25 notes R30 understands, is understood, is cognitively intact and has no mood or behavioral concerns. Takes antipsychotics (AP), antidepressants (AD), diuretic (D), anticonvulsants, and is hypoglycemic. Surveyor reviewed R30's record and found no assessment of R30's trauma. R30's care plan: The resident has a mental illness: depression. PTSD diagnosed d/t sister's death when she was 9. Reports her parents didn't allow her to grieve the loss or talk about her following her death. Date Initiated: 11/12/2024 Revision on: 11/25/2024 The resident will remain free of signs/symptoms (s/sx) of distress, symptoms of depression, anxiety or PTSD by/through review date. Date Initiated: 11/12/2024 Revision on: 05/29/2025 Target Date: 08/31/2025 o My PASRR screening will be completed. Date Initiated: 01/20/2025 Revision on: 05/29/2025 Target Date: 08/31/2025 Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 11/12/2024 o Assist the resident in developing a program of activities that is meaningful and of interest. Encourage and provide opportunities for exercise and socialization Date Initiated: 11/12/2024 Revision on: 11/12/2024 o Discuss with the resident any concerns, fears, issues regarding health or other subjects. Date Initiated: 11/12/2024 Revision on: 11/12/2024 o Encourage the resident to express feelings and allow time to talk Date Initiated: 11/12/2024 Revision on: 11/12/2024 o Follow state program requirements Date Initiated: 11/14/2024 o Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, and tearfulness. Date Initiated: 11/12/2024 o Praise accomplishments Date Initiated: 11/14/2024 o Referral for level II screening Date Initiated: 11/14/2024 The resident has had a decline in psychosocial well-being r/t admission and decline in health status. Would prefer to be home, but her husband is unable to provide the care needed. Date Initiated: 01/20/2025 Revision on: 01/20/2025. The resident will show evidence of adjustment to nursing home by eating all meals in dining room, attending out of room (ORR) activities daily through the review date. Date Initiated: 01/20/2025 Revision on: 05/29/2025 Target Date: 09/05/2025. On 06/08/25 at 3:55 PM, Surveyor attempted to interview R30. R30 did not wish to discuss past trauma. On 6/10/25 at 10:20 AM, Surveyor requested a trauma informed assessment from Social Service Director (SSD) H. SSD H informed Surveyor the facility does not currently complete trauma informed assessments for residents with identified trauma. SSD H learned of R30's trauma during social services initial assessment when R30 was admitted . Facility developed a care plan in attempts to meet R30's emotional needs. SSD H stated she can see why it would be important to assess resident's specific trauma and develop person-centered approaches to address potential triggers and prevent re-traumatization. On 06/10/25 at 1:33 PM, Surveyor interviewed Certified Nursing Assistant (CNA) X who has been on staff almost 3 years and is familiar with R30. CNA X explained she did not know anything about R30's past trauma or PTSD diagnosis. CNA X further explained R30 has been upset and indicated she is having nightmares related to hearing of a father who had killed his three daughters which was recently on the news. CNA X expressed she has been talking with R30 about it but is unaware of specific approaches staff should follow related to R30's past trauma. On 06/10/25 at 1:38 PM, Surveyor interviewed CNA P who has been employed at the facility for 3 years working 4-5 days a week on R30's wing full time on day shift. CNA P is familiar with R30. CNA P is unaware of past trauma. CNA P has noticed R30 has some sensitivity to lights and is startled if you go into her room too fast or loud. CNA P reported R30 apologizes a lot. CNA P is unaware of care planned approaches specific to R30's past trauma.

Based on observation, interview and record review, the facility did not ensure expired medications were removed from currently used supply in the medication storage room refrigerator. This occurred for 1 of 1 medication storage rooms observed. An opened bottle of a resident's (R) multiuse medication kept in the medication storage room refrigerator was labeled with a beyond use date of 6/7/25. This medication was expired and had been given to resident (R34) since it expired, resulting in the potential to affect 1 out of 49 residents that reside in the facility (R34). Findings include: The facility's policy titled, Storage of Medication Requiring Refrigeration not dated with an implemented or reviewed date, but provided by facility upon request of policy, states in part, .5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily tasks and should demonstrate safety in regard to the medication's integrity, such duties should include but not be limited to: . c. Remove any expired medications from active stock and discard medications according to facility policy. On 6/09/25 at 9:20 AM, during review of medication storage room with Licensed Practical Nurse (LPN) J, Surveyor observed refrigerated liquid medication for R34, omeprazole 20 ml po twice daily (BID) was labeled with a beyond use date of 6/7/25. No other expiration dates were noted on this bottle. On 6/9/25 at 12:39 PM, Surveyor reviewed medication record, and the expired medication was destroyed. On 6/10/25 at 8:44 AM, Surveyor interviewed Assistant Director of Nursing (ADON) F who reported the expectation is that all medications have the expiration date checked by nursing staff prior to being given to a resident and if a medication is expired, it will be disposed of in accordance with facility policy. ADON F reported ADON F does inspect all refrigerated medications every Wednesday when doing new medication orders.

Based on record review, interview, and policy review, the facility failed to ensure written notice of transfer was provided for three residents (R) (R2, R7, and R8) of three residents reviewed for hospitalization s. These failures had the potential to contribute to confusion at discharge or a lack of understanding of appeal rights. Findings include: Review of the policy titled, Transfer and Discharge (including AMA [against medical advice]), dated August 2020, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge b. The effective date of transfer or discharge c. The specific location . to which the resident is to be transferred or discharged d. An explanation of the right to appeal the transfer or discharge to the State e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests f. Information on how to obtain an appeal form g. Information on obtaining assistance in completing and submitting the appeal hearing request h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman . 1. Review of R2's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted on [DATE]. Review of R2's discharge Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/02/24, revealed he was discharged on [DATE] to short term general hospital with a return anticipated. Review of R2's EMR revealed there was no evidence of written notice of transfer with the required information included given to R2 or to his responsible party. During an interview on 02/26/25 at 11:26 AM, Registered Nurse (RN) 2 stated she was the nurse on duty when R2 was transferred to the hospital on 11/02/24. RN2 stated she did not provide any written notice of the reason and location for transfer, with the necessary ombudsman and appeals information to R2, or to his responsible party who was at the facility at the time of the emergent transfer., RN2 stated she provided verbal notification of the reason and location of transfer to R2's responsible party. In an email sent by the Administrator on 02/28/25 at 11:56 AM, the Administrator explained she had located the notice of transfer for R2. She provided an attachment with blank pages and a signature page of a transfer form with no resident name on it. The attachment was again emailed by the Administrator on 03/03/25 at 10:09 AM and contained a Notice of Resident Transfer or Discharge, dated 11/02/24, which included the reason for transfer, the name of the receiving hospital, and the contact information for the State long-term care Ombudsman. The contact information for the state survey agency in order to file an appeal was not included. The form documented, Verbal phone call 11-4-24 - [wife] understood. There was no signature from R2's wife or evidence she was provided with the form containing the necessary documentation. 2. Review of R7's Profile tab of the EMR revealed he was admitted on [DATE]. Review of R7's discharge MDS, with an ARD of 10/14/24, revealed he was discharged to a short-term general hospital on 10/14/24 with a return anticipated. In an email sent by the Administrator on 02/28/25 at 11:56 AM, the Administrator explained she had located the notice of transfer for R7. She provided an attachment with blank pages and a signature page of a transfer form with no resident name on it. The attachment was again emailed by the Administrator on 03/03/25 at 10:09 AM and contained a Notice of Resident Transfer or Discharge, dated 10/14/24, which included the reason for transfer, the name of the receiving hospital, and the contact information for the State long-term care Ombudsman, and the contact information for the state survey agency in order to file an appeal. The form documented, Spoke [with] dtr [daughter] - resident unable [at] time of transfer, understood. There was no signature from R7's daughter or evidence she was provided with the form containing the necessary documentation. 3. Review of R8's Profile tab of the EMR revealed she was admitted on [DATE] with a diagnosis of left femur fracture. She was discharged from the facility on 11/16/24. Review of R8's discharge MDS, with an ARD of 11/16/24, revealed she was discharged on [DATE] to a critical access hospital with a return anticipated. Review of R8's EMR revealed there was no evidence of written notice of transfer with the required information included given to R8 or to her responsible party. In an email sent by the Administrator on 02/28/25 at 11:56 AM, the Administrator explained she had located the notice of transfer for R8. She provided an attachment with blank pages and a signature page of a transfer form with no resident name on it. The attachment was again emailed by the Administrator on 03/03/25 at 10:09 AM and contained a Notice of Resident Transfer or Discharge, dated 11/18/24, which included the reason for transfer, the name of the receiving hospital, and the contact information for the State long-term care Ombudsman. The contact information for the state survey agency in order to file an appeal was not included. The form documented, Verbal phone call [with daughter] - will pick up copy. There was no signature from R8's daughter or evidence she was provided with the form containing the necessary documentation. During a concurrent interview on 02/26/25 at 12:38 PM, the Administrator stated a written notice of bed hold was provided to the residents (R2, R7, and R8) or their responsible party upon transfer, but the notice did not contain the location and reason of transfer or appeal rights and contact information. The DON also stated the written bed hold notice was given to the residents or their responsible party at transfer, but there was no written notice of the reason for transfer, transfer location, or appeal rights and contact information that was typically provided. In a follow-up interview on 02/26/25 at 1:18 PM, the Administrator stated there was a transfer form the facility used with the required information; however, she could not find evidence of written notice of transfer for R2, R7, or R8.

Based on interview and record review, the facility did not develop and initiate a comprehensive care plan with targeted interventions for a resident to identify and manage behavioral tendencies. This occurred for 1 of 5 residents (R) reviewed for care planning (R4). Facility did not develop and implement a behavioral care plan with intervention identified for handling potential inappropriate sexual behaviors for R4. Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, paraplegia unspecified, type 2 diabetes mellitus, and muscle weakness. R4 was admitted with knowledge of being registered on sex offender list for minor issues. R4's Minimum Data Set (MDS) assessment, dated 09/08/24 identified R4 had a Brief Interview for Mental Status (BIMS) score of 15. This indicated R4 has intact cognition. The MDS assessment also identified R4 required substantial to maximal assistance of two people for transfers, chair to bed, and toileting. R4 required moderate assistance of one person for bed mobility and rolling left to right. R4 is independent once in wheelchair and able to self-propel when in wheelchair. Surveyor reviewed admission documentation and noted that R4 has a history of illicit sexual behavior. Surveyor reviewed R4's care plan. R4 did not have a behavioral care plan for R4's potential sexual inappropriate behaviors related to R4 being registered on the sex offender list. On 10/14/24 at 1:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked does the staff know that R4 is a registered sex offender and how do staff address potential inappropriate sexual behaviors. NHA A indicated the facility was trying to keep it low key as to not create turmoil for R4. Surveyor asked NHA A if R4 had a care plan in place to address measures and interventions for staff to minimize or implement alternative measures if potential inappropriate sexual behaviors arise. NHA A indicated there should be interventions put into place to address the potential inappropriate sexual behaviors that could arise and there is not a care plan in place at this time. On 10/14/24 at 1:47 PM, Surveyor interviewed Director of Nursing (DON) B and asked how staff address potential inappropriate sexual behaviors that may occur with R4. DON B indicated that staff have never complained of R4 being inappropriate, and R4 has been very pleasant in the facility. Surveyor asked DON B if R4 had a care plan in place to address measures and interventions for staff to minimize or implement alternative measures if potential inappropriate sexual behaviors arise. DON B indicated there should be interventions put into place to address the potential inappropriate sexual behaviors that could arise but there is not. DON B indicated that R4 does not have a care plan in place for potential inappropriate sexual behaviors and how to address. DON B indicated that DON B would develop a behavioral care plan right away for R4.

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff were observed not wearing covering over facial hair while preparing and serving food in the kitchen. This had the potential to affect all 46 residents in the facility. Findings include: According to the FDA Food Code 2022 documents at 2-402.11 Hair restraints: Effectiveness. (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single use articles. Facility policy and procedure entitled Maintaining a Sanitary Tray Line: States, in part, .During tray assembly, staff shall: .Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food . On 05/01/24 at 7:25 AM, Surveyor observed Dietary Manager (DM) I in food prep areas of the kitchen with a hair net on, but no net covering facial hair. On 05/01/24 at 11:19 AM, Surveyor observed Dietary Cook (DC) J take stainless steel containers of food and prepared the food for mechanically altered and pureed diets. DC J had a hair net on head covering all hair but did not have a net over facial hair while preparing the mechanically altered foods. Surveyor interviewed DC J asking why they were not wearing a net or covering over facial hair. DC J stated because the beard was freshly trimmed and tidy, it did not need to be covered. Surveyor asked if that was the facility policy in food prep areas. DC J was not sure but would cover the beard now. On 05/01/24 from 11:09 AM to 11:55 AM, Surveyor observed DM I walk back and forth multiple times in the kitchen while lunch was being prepared with no beard net covering facial hair. On 05/01/24 at 12:50 PM, Surveyor observed DM I at the steam table dishing up food to serve to residents in the dining room. Surveyor did not observe a beard net on DM I's face. On 05/01/24 at 1:08 PM, Surveyor interviewed DM I and asked what the facility policy and procedure for kitchen staff was if they had facial hair. DM I was not sure they had a specific policy about facial hair, but stated they instruct kitchen staff they need to shave or wear a beard net over facial hair when working in the kitchen. DM I stated he was aware DC J was not wearing a beard net over facial hair when working with food at lunch time today. DM I instructed DC J to either shave or wear a beard covering. Surveyor asked DM I if DM I wore a beard net while in the kitchen. DM I stated he did not think he needed to wear a beard covering because he was not working directly with food.

Based on observation, record review and interviews, the facility did not ensure that 2 of 4 sampled residents (R) who are unable to carry out activities of daily living received the necessary services of toileting and incontinence care to maintain good personal hygiene. (R16 and R29) Findings include: R16 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, muscle weakness, atrial fibrillation, and transient ischemic attack. R16's minimum data set (MDS) assessment, completed on 04/08/24, confirmed R16 scored 09 during a brief interview for mental status (BIMS), indicating severely impaired cognition. R16 is incontinent of urine and frequently incontinent of bowel movements. R16 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R16's care plan was initiated on 08/03/20, and included the following interventions: PERSONAL HYGIENE care plan: -The resident requires the assistance of one. TOILET USE care plan: -The resident is dependent on the assistance of 2 with EZ-Stand for toilet use. -Toilet before and after meals and bedtimes as resident allows. TRANSFER care plan: -The resident requires the assistance of two with EZ-Stand. -Assistance of one for locomotion on the unit in Broda. RESISTIVE TO CARES care plan: -If resident resists ADLs, reassure resident, leave and return 5-10 minutes later and try again. -If the resident is resistant with staff, leave, and have another staff member reapproach. -The resident needs assistance with all decision-making. FREQUENT BLADDER INCONTINENCE: -The resident uses disposable briefs. Change as needed. -Clean peri-area with each incontinence episode. -Monitor/document for signs and symptoms of urinary tract infection: burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behaviors, and change in eating patterns. Surveyor reviewed progress notes that stated in part: 07/05/23 Frequency of urination and increased agitation, test urine. 07/10/23 positive urine culture, start Keflex antibiotics. 09/20/23 Start Cipro 250mg 1 tab twice a day for 7 days with positive urine culture. Surveyor's observations are continuous from 05/01/24 at 7:34 AM until 05/01/24 at 3:16 PM: On 05/01/24 at 7:34 AM, Surveyor observed R16 sitting in R16's room in a wheelchair watching television. R16 called out for staff to assist R16. R16 stated out loud several times that R16 was ready to go to the dining room for breakfast. Surveyor did not observe any staff stop to take R16 to dining room. On 05/01/24 at 8:01 AM, Surveyor observed Certified Nurse Assistant (CNA) E wheel R16 to the dining room. Surveyor did not observe CNA E offer or ask if R16 needed to use the bathroom. On 05/01/24 at 8:52 AM, Surveyor observed Director of Nursing (DON) B wheel R16 down the hall out of the dining room to R16's room. DON B placed the call light in reach. Surveyor did not observe DON B offer or ask R16 if R16 needed to use the bathroom. On 05/01/24 at 9:07 AM, Surveyor observed CNA C enter R16's room and ask R16 if CNA C could take R16 to grab a weight on the scale. R16 refused and stated that R16 had just arrived in the room. CNA C indicated that CNA C would check back with R16 to grab weight later. Surveyor did not observe CNA C offer or ask R16 if R16 needed to use the bathroom. On 05/01/24 at 9:52 AM, Surveyor observed R16 yell out at CNA D and state, Please come here. CNA D was donning PPE for entering another room. CNA D indicated to R16 that CNA D would come back in and check on R16 when CNA D was done in another room. CNA D entered the other room to help assist another resident. On 05/01/24 at 10:01 AM, Surveyor observed CNA D walk out of the other resident room, drop trash bags in the soiled utility room, and then walk down the hallway away from R16's room. Surveyor did not observe CNA D go back in to follow up with R16's needs. On 05/01/24 at 10:09 AM, Surveyor observed CNA E enter R16's room and ask if R16 needed toileting. R16 indicated no R16 does not. CNA E asked R16 if she would let CNA E know when R16 was ready to toilet. R16 started talking about something else unrelated to using the bathroom and never answered CNA E about toileting. CNA E did not say anything more and exited R16's room. On 05/01/24 at 12:08 PM, Surveyor observed CNA D enter R16's room and took R16 in a wheelchair down the hallway to the dining room. Surveyor did not observe CNA D offer or ask R16 if R16 needed to use the bathroom. On 05/01/24 at 12:12 PM, Surveyor interviewed CNA D and asked if CNA D toileted R16 before taking to the dining room. CNA D indicated CNA D did not toilet R16. CNA D indicated CNA D asked to take R16 to the bathroom but R16 stated R16 did not have to go. CNA D indicated that sometimes R16 is resistant to care, so CNA D took R16 to the dining room instead of the bathroom. On 05/01/24 at 1:03 PM, Surveyor observed CNA D and CNA E enter R16's room with EZ-stand. CNA D asked R16 if CNA D and CNA E could toilet R16. R16 indicated no they could not. CNA D attempted to explain to R16 about being concerned that R16 was wet and sitting in urine for too long. R16 refused further, and CNA D and CNA E left room with EZ-Stand. On 05/01/24 at 1:05 PM, Surveyor interviewed CNA D and CNA E and asked if R16 had been toileted today. CNA D and CNA E indicated that R16 had not been to the bathroom since morning. Surveyor asked CNA D and CNA E what the process is for toileting and changing R16's brief as it has been since 7:30 AM when Surveyor observed R16 in a wheelchair and not toileted all day. CNA E indicated that CNA E always lets the charge nurse know of the refusal and then grabs another staff member to reattempt. CNA E indicated that CNA E would get another staff member to try asking R16 again in about an hour. Surveyor asked CNA E about R16's care plan which stated, Reattempt in 5-10 minutes and asked if CNA E followed the care plan specific to R16. CNA E indicated that usually CNA E follows R16's care plan but that CNA E would reattempt in an hour. CNA E told Registered Nurse (RN) F about R16's refusal. On 05/01/24 at 1:37 PM, Surveyor interviewed RN F and asked what the expectation is for checking and changing R16's incontinence brief. RN F indicated that staff need to reattempt and approach R16 as best as staff can to prevent skin breakdown. On 05/01/24 at 2:17 PM, Surveyor observed RN F and CNA E enter R16's room and attempt to toilet R16. R16 indicated she was not getting out of the wheelchair. RN F indicated that CNA E and RN F will reattempt when the daughter arrives as R16 does better when the daughter is present. On 05/01/24 at 3:16 PM, Surveyor observed RN F and CNA E enter R16's room and attempt to toilet R16. R16's daughter was present and assisted staff in helping toilet R16. R16's daughter used distracting techniques such as talking about family and activities and R16 was cooperative with care. CNA E took the brief off and Surveyor observed the brief to be soaked in urine. Surveyor observed some redness on R16's bottom. On 05/01/24 at 3:25 PM, Surveyor interviewed DON B and asked what expectation is for staff when toileting and repositioning. DON B indicated that all staff are to follow the individualized care plan for toileting and repositioning but for the most part, all residents are toileted and repositioned who need the assistance before and after meals and at bedtime. Surveyor asked DON B what the expectation is for staff attempting to toilet R16 when R16 refuses. DON B indicated that staff need to reattempt often and with other staff members. Surveyor indicated that R16 had not been changed or toilet from 7:30 AM-3:16 PM and that staff didn't attempt 5-10 minutes later with different staff members as the care plan states for R16. DON B indicated the expectation is that staff go back in shortly after within 10 minutes and attempt to toilet and reposition R16. DON B indicated that attempts need to continue until R16 is toileted and changed due to a history of urinary tract infections. Surveyor reviewed R16's behavior monitoring from 04/19/24-05/02/24. Surveyor did not find documentation on 05/01/24 for the day shift on any behavior changes or resistance to care from R16. Example 2 R29 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, muscle weakness, dysphagia, and heart failure. R29's MDS assessment, completed on 02/03/24, confirmed R29 scored 12 during a BIMS, indicating moderate impaired cognition. R29 is incontinent of urine. R29 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R29's care plan was initiated on 08/09/23, and included the following interventions: PERSONAL HYGIENE care plan: -The resident requires the assistance of one. TOILET USE care plan: -The resident is dependent on the assistance of 2 with EZ-Stand for toilet use. -Toilet before and after meals and bedtimes as resident allows. TRANSFER care plan: -The resident requires the assistance of two with EZ-Stand. -Assistance of one for locomotion on the unit Surveyor's observations are continuous from 05/01/24 at 7:20 AM until 05/01/24 at 11:16 AM: On 05/01/24 at 7:20 AM, Surveyor observed R29 sitting up in a wheelchair at the entry of the bedroom door halfway out in the hallway. R29 was observed sleeping in a wheelchair. On 05/01/24 at 7:27 AM, Surveyor observed CNA D take R29 to the dining room for breakfast. Surveyor did not observe CNA D offer or ask if R29 needed to use the bathroom. On 05/01/24 at 8:38 AM, Surveyor observed R29 try to self-propel in a wheelchair out of the dining room. Surveyor observed Social Services Director G ask R29 where R29 was going and R29 indicated R29 would like to sit in the television (TV) room. Surveyor did not observe Social Services Director G offer or ask if R29 needed to use the bathroom before heading to the television room. On 05/01/24 at 8:59 AM, Surveyor observed CNA C wheel R29 out of the TV room to weigh R29 on the scale and returned R29 back to TV room. Surveyor did not observe CNA C offer or ask if R29 needed to use the bathroom before or after weighing R29. On 05/01/24 at 9:05 AM, Surveyor interviewed CNA C and asked if CNA C toileted R29 when CNA C took R29 out of TV room. CNA C indicated that CNA C only took R29 out of the TV room to obtain a weight. On 05/01/24 at 9:16 AM, Surveyor observed Activities Director H offer an audiobook to R29 in TV room. On 05/01/24 at 11:16 AM, Surveyor observed CNA C enter R29's room. CNA C indicated CNA C would be toileting R29. CNA C grabbed the EZ-stand lift and brought it into R29's room. Surveyor observed a strong urine smell in R29's room. CNA C took R29 into the bathroom and pulled R29's pants down. Surveyor observed R29's brief to be soaked with urine. CNA C took the soiled brief out, threw it in the garbage, and changed it to a new brief. CNA C offered for R29 to sit on the toilet for a minute. CNA D entered R29's room and asked if CNA C needed assistance with the transfer. CNA C indicated yes. CNA D elevated R29 from the toilet and CNA C completed peri care. CNA C pulled the new brief and pants up and then placed R29 in a wheelchair. On 05/01/24 at 11:26 AM, Surveyor interviewed CNA D and CNA C and asked if R29 was on a toileting schedule or had been toileted since 7:20 AM. CNA D indicated that R29 is not on a set toileting schedule but will let staff know when she has to go. CNA D stated R29 had not been toileted since R29 got up for the morning. CNA D indicated that sometimes R29 is confused so staff automatically toilet R29 every two hours. CNA C indicated that all residents who need help to the bathroom who are not on a toileting schedule automatically get checked or toileted and then changed as needed every two hours. CNA D and CNA C confirmed that R29 has not been toileted or checked since getting up in the morning before 7:20 AM. Surveyor reviewed behavior monitoring from 04/19/24-05/02/2024. Surveyor did not find documentation on 05/01/24 for the day shift on any behavior changes or resistance to care from R29.

Based on record review and interview, the facility did not have an effective system in place to ensure residents received the correct medications, at the correct dose, at the appropriate times as ordered by a physician. This resulted in a risk for serious harm to 15 of 45 residents (R7, R9, R17, R18, R19, R20, R22, R23, R24, R25, R26, R27, R28, R30, and 1 unnamed resident). Review of the facility's medication error reports found evidence of numerous medication errors, some occurring multiple times before being identified without appropriate follow-up to ensure staff transcribed the physician's orders [REDACTED]. The immediate jeopardy began on 12/02/16 when staff administered 5 times the prescribed dose of Methadone to a resident and was identified on 04/04/17. The Nursing Home Administrator, Director of Nursing, and Director of Clinical Services were notified at 4:00 p.m. on 04/04/17. The immediate jeopardy was removed on 04/05/17 but noncompliance remained at the lower scope and severity level of F (potential for more than minimal harm/widespread) as the facility continues to implement its plan of correction. This is evidenced by: Facility policy titled, Medication Administration, dated 03/16/15, states the following: - Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. - The nurse is responsible to read and follow precautionary or instructions on prescription labels. - If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. - Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved. - Follow safe preparation practices. - Never administer medications supplied for one resident to another resident. - Record the name, dose, route and time of medication on the medication administration record. Facility policy titled, Medication: Controlled Drugs, dated 06/01/16, states the following: - Records must be accurate and include: name of the resident, prescription number and name of issuing pharmacy, drug name and strength, medication form, route of administration, strength and dose of administered, date and time of administration and signature of the person administering the drug. - Report any discrepancy in the count to the Director of Nursing - The DON initiates an investigation as to where the dose was administered or refused. - Complete a Medication Variance Report identifying the nursing shift involved in efforts to reconcile the discrepancy. - Notify the appropriate agency as required by State and/or Federal regulations. Facility policy titled, Medication-Orders and Review, undated, states the following: - When recording orders for medication specify: the type, route, dosage, frequency and strength of the medication ordered. - All medications administered to the resident must be ordered in writing by the resident's attending physician. - All verbal orders must be counter-signed by the ordering upon the physicians' next scheduled visit. - Dosages must not exceed current standards of practice with justification - The Interdisciplinary team will review medications with the physician as needed and as appropriate. On 04/03/17 at 1:00 p.m., Surveyor reviewed the facility's medication error reports dated 05/03/16 - 02/25/17 and noted the following medication errors: - 05/03/16: R29 had a physician's orders [REDACTED]. R29 only received one tablet of 10 mg. Error could have been prevented if nursing staff double checked the order prior to giving and the potential outcome to the resident would be decreased pain control. - 06/08/16, 06/10/16, 06/12/16: R28 had a physician's orders [REDACTED]. Pharmacy sent the incorrect medication, Xarelto 10 mg, and nursing staff administered the incorrect medication to R28. Error could have been prevented if nursing staff would have checked the MAR and checked rights of administration of medication prior to administering to resident. Potential outcome to resident would have been bleeding and bruising. - 06/26/16 and 06/27/16: R27 did not receive scheduled dose of Lovenox 40 mg subcutaneous on 06/26/16 and 06/27/16. R27 has a [DIAGNOSES REDACTED]. Error report states medication error could have been prevented if nurse had followed orders more closely and checked the MAR for all due medications. The potential outcome to the resident would be issues related to DVT (deep vein thrombosis). - 06/28/16: R26 had an order for [REDACTED]. Error report states nurse pulled oxycodone/APAP 5/325 mg instead from the contingency box and administered it to the resident. Error could have been prevented if nurse had double checked the medication following proper rights of medication administration. - 07/11/16: R25 had an order for [REDACTED]. R25 did not receive medication on 07/11/16. Error report states communication from admitting nurse to rest of staff would have prevented medication error and potential outcome to resident could be A-fibrillation. R25 has a [DIAGNOSES REDACTED]. - 07/12/16: R25 had an order for [REDACTED]. R25 did not receive medication on 07/12/16. Error report states communication from admitting nurse to rest of staff would have prevented medication error and potential outcome to resident could be A-fibrillation. R25 has a [DIAGNOSES REDACTED]. - 08/12/16: R25 had a physician's orders [REDACTED]. Error report states R25 received vitamin K 2.5 mg and should not have received vitamin K while resident was taking coumadin. Error report states checking the order with the physician could have prevented the error and the potential outcome to the resident would be a error to the INR lab results. - 09/21/16: R23 was not given scheduled pain medication, Percocet 5/325 mg tablet at 8:00 a.m. on 09/21/16. Error report did not state how error could have been prevented or what the potential outcome to the resident would be. - 09/22/16: R24 had a physician's orders [REDACTED]. Error report states R24 received 0.125 ml due to nurse reading an old physician's orders [REDACTED]. - 09/29/16: Medication error report did not state a resident's name. Error report states PICC Line dressing change not changed since admission on 09/12/16, order to change dressing on 09/17/16 with caps 09/14/16 and 09/17/16 not transcribed on MAR. Error could have been prevented if nurse double checked orders and potential outcome to resident would be an increased risk for infection. - 10/13/16: R23 did not receive scheduled medication oxycodone-acetaminophen 5/325 mg tablet on 10/13/16. Error report states nursing staff are to double check the MAR for holes and the potential outcome to the resident would be an increase in pain. - 10/25/16: R22 received 50 mg's more of the medication Lopressor than the original order received. Medication error report does not state correct dosage of medication that was to be given. Error report states nurses are to double check the order with a second nurse and the potential outcome for the resident was hypotension. - 10/28/16: R20 had a current physician's orders [REDACTED]. Error report states R20 was noted to have 3 Fentanyl patches on her person, one on each shoulder blade and one on the right collar bone. Error report states facility nursing staff should read the MAR (medication administration record) prior to giving medications and the potential outcome to the resident is opioid overdose. - 11/09/16: R20 was noted to have an old transdermal Fentanyl patch on her person which was not removed when a new patch was placed on. Error report stated R20 had a physician's orders [REDACTED]. Error report states a new Fentanyl patch was placed on R20 on 11/09/17 and the prior Fentanyl patch was not removed. Education to nurse was to pay attention to the medication order, and the outcome to the resident could be opioid overdose and/or death. - 12/02/16: R17 received the incorrect dose of the medication Methadone. The original physician's orders [REDACTED]. The facility nursing staff gave R17 2.0 ml of Methadone (5 times the ordered dose). Nurse educated on ensuring appropriate checks on all medication were completed to ensure correct dosing. - 12/03/16: R17 received the incorrect dose of the medication Methadone. The original physician's orders [REDACTED]. The facility nursing staff gave R17 2.0 ml of Methadone. Nurse educated on ensuring appropriate checks on all medication were completed to ensure correct dosing. - 12/07/16 - 12/08/16: R17 received the incorrect dose of the medication Dilaudid. The original physician's orders [REDACTED]. The error report states facility nurse, RN X, took a telephone order over the phone and entered an incorrect dose of 60 mg an hour as needed for pain and R17 received 4 doses of 60 mg instead of 16 mg during the time frame of the evening of 12/07/16 through the a.m. hours of 12/08/16. Education was provided to all nursing staff on importance of medication clarification and proper way to clarify a medication. All nurses educated on the process of medication change for a narcotic medication via the telephone. Hospice services educated all nursing staff on hospice comfort medications and appropriate dosing. - 12/13/17: R19 received the wrong medication x 5 doses. R19 received the medication Gabepentin 300 mg (1 tablet) 5 times during the time frame of 12/12/16 - 12/16/16. R19 did not have a physician's orders [REDACTED]. Error was discovered on 12/18/16 and medication was immediately discontinued. Education sheet (no nursing signatures provided), attached to medication error report, states education was provided to ensure all medications being pulled from contingency box must be verified with the medication administration record (MAR) and doubled checked that it has been sent from pharmacy. Nursing staff cannot pull a medication from the contingency stock without verifying there is an order. Anytime a resident is sent to the emergency room (ER), nursing staff are to fill out a communication form. If a medication error occurs, always notify family and the physician and the resident must then be placed on alert charting for 3 days of monitoring for adverse effects. - 01/17/17: R30 had a physician's orders [REDACTED]. give 0.12 ml twice daily. R30 received 1.2 ml of Methadone. Error could have been prevented by double checking medication with physician orders [REDACTED]. - 02/25/17: R18 received the incorrect medication. The original physician's orders [REDACTED]. The error report states facility nursing staff removed Oxycodone 5 mg tablet from the facility's contingency box and gave to R18. Education was provided to nurse on the need to verify medications being removed from the contingency box and to do the appropriate checks to ensure the correct medication and dose is given. On 04/03/17 at 9:03 a.m., Surveyor interviewed the Director of Nursing (DON) and the Nursing Home Administrator (NHA) in regard to the above noted medication error reports. The DON stated the facility had identified some issues with medication administration and transcriptions 3-4 months ago especially in areas of significant medication errors. The DON stated they first identified an issue with R17 on 12/08/16 when the second incident had occurred. The DON stated the nurse who had taken the medication order over the phone from the hospice nurse for the Dilaudid had misunderstood it and written it incorrectly. The DON stated the nurse was a brand new nurse and wasn't able to connect that the dose was way too high for a normal order. The DON stated there was no adverse effect from the high dosage of Dilaudid given. The DON stated the Medical Director, during a Quality Assurance (QA) meeting on 02/28/17, had expressed concern in regard to the high number of medication errors within the facility. The DON stated the QA team immediately implemented all staff education in regard to medication errors, transcription of medications and completing all required rights when administering medications. The DON stated the nursing staff are no longer allowed to take verbal narcotic orders over the phone and education was provided on the proper way to take an order and how to write an order. The DON stated the facility management team has been checking orders daily to ensure no further transcription errors have occurred, stating, all orders get three checks every morning. Surveyor asked the DON if audits were being completed to ensure no further significant medication errors were occurring and the DON stated she had no documented audits available but nurses have been audited during medication pass. On 04/04/17 at 2:40 p.m., the NHA provided the following timeline of education to all nursing staff in regard to the significant medication errors that had occurred with R17 and R30 as noted above: - 11/22/16: Medication pass audit completed. - 12/02/16: Medication error occurred (R17) - 12/03/16: Medication error occurred (R17) - 12/07/16: Medication error occurred (R17) - 12/08/16: Medication error occurred (R17) - 12/08/16: All nurses educated on no verbal telephone orders for narcotic pain medications were to take place. - 12/09/16: Nurse who made the error was educated. - 12/28/16: Medication pass audit completed. - 01/07/17: Medication error occurred (R30) - 01/20/17: Nurse who made the error was educated on the next scheduled working shift. - 01/23/17: Medication pass audit complete. - 01/27/17: Medication error occurred (Surveyor was not provided a copy of this medication error) - 02/25/17: Medication error occurred (R18). - Undated: Medication pass audit x 6 residents completed in the month of February 2017 - 03/14/17: Medication pass audit completed. - 03/20/17: Medication pass audit completed. - 03/27/17: Medication pass audit completed. On 04/03/17 at 2:30 p.m., Surveyor interviewed RN Y and RN Z in regard to medication errors. RN Y and RN Z both stated they have not been aware of any audits that had been done in the past 3-4 months on ensuring no further significant medications errors had occurred or if nursing was appropriately completing all rights for medication administration or entering/transcribing narcotic orders correctly. RN Z stated she remembered narcotic education in the past (unable to remember a date) due to a hospice event and a resident receiving too much Dilaudid. RN Z stated she remembered audits being done about 6 months ago but not since then. On 04/03/17 at 8:30 a.m., Surveyor reviewed the nursing notes for the above noted residents listed in the medication error reports. Surveyor identified no comprehensive nursing assessments for the above residents and was unable to identify where the facility continued to monitor the residents for any adverse affects. At 9:03 a.m., Surveyor interviewed the DON. The DON stated she was unable to locate comprehensive assessments for the above noted residents and she was not aware that the nursing staff had not completed one. The DON stated the nursing staff should have completed a more in depth assessment on the residents due to the significant medication errors being done and should have been monitoring the residents for adverse effects after the error(s) had occurred. The DON stated she felt the nursing staff needed more in depth training and more audits and follow up should have taken place. The facility's failure to have a system in place to ensure accurate medication administration created a finding of immediate jeopardy. The facility removed the jeopardy on 04/05/17 by which time it had implemented the following: 1. Audits of all resident MARs assure accurate transcription of medication orders; 2. Re-education of all nurses on medication calculation, medication administration, adverse drug reactions, controlled substances, medication orders and review prior to the start of their next shift; 3. Began auditing medication administration by nurses; and, 4. Developed an audit of or new admissions to ensure accurate transcription of orders.

Based on interview and record review, the facility did not ensure a resident who entered the facility without a pressure injury did not develop a pressure injury; and a resident with a pressure injury receives the necessary treatment to promote healing and prevent infection, for one of three sampled residents with pressure injuries (R6); the facility did not put preventative measures in place when the resident was assessed as being at a high risk for developing pressure injuries. This includes evaluating and replacing a wheelchair cushion, educating the resident on the importance of repositioning and offloading pressure, and following current standards of practice for preventing and treating pressure injuries. Resident 6 (R6) developed a stage IV pressure injury to the right buttock, which is currently infected. The failure to have a system in place for preventative care for a resident who is at high risk for developing pressure injuries created an Immediate Jeopardy situation. The jeopardy began 03/20/17, when R6 presented with symptoms suggestive of an infected wound. The facility was notified on the Immediate Jeopardy on 04/06/17. The facility removed the Immediate Jeopardy on 04/07/17. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: On 04/05/17, Surveyor received and reviewed a facility policy entitled, Wound Care Management. The policy, revised 03/13/15, states the following, in part: .Policy .Each resident is evaluated by the interdisciplinary team to determine his or her risk for skin compromise or the presence of wounds and/or pressure ulcers. A plan of care is developed and implemented based on this evaluation with ongoing review. If skin compromise occurs, evaluation is conducted by the interdisciplinary team to ensure appropriate measures are in place to minimize further compromise and aide in healing to extent possible . A. General Guidelines .2. Risk Factors for Pressure Ulcers: Impaired/decreased mobility and decreased functional ability .Exposure of skin to urinary or fecal incontinence .Refusal of care and treatment . C. Procedure .2. Residents identified as at risk for development of pressure ulcers will have a plan and interventions included in the care plan to address each resident specific risk factor .6. Residents with newly identified or known pressure ulcers will be assessed by the interdisciplinary team upon notification and weekly thereafter, and a care plan will be developed, implemented, evaluated, and re-evaluated to treat actual pressure ulcers and reduce further pressure ulcers . On 04/04/17, R6's medical record was reviewed. R6 has [DIAGNOSES REDACTED]. R6 is not able to completely feel the lower extremities, but is able to feel some pressure. R6 smokes cigarettes daily. R6 was admitted to the facility for long term care in 2011. The medical record indicates R6 requires the assistance of a full-body mechanical sling lift, with two staff members. R6 is non-ambulatory. R6's Brief Interview for Mental Status (BIMS) score, dated 03/03/17, was a 15 out of 15 possible points. According to the BIMS assessment, a score of 15 indicates the resident has intact cognitive function. Until 03/21/17, R6 used a Panacea foam mattress, which may be used for residents who have up to a stage III pressure injury (or ulcer). R6's Minimum Data Set (MDS), with an assessment reference date of 12/09/16, identifies the resident requires staff assistance for bed mobility, transfers, dressing, personal hygiene and bathing. The MDS indicates the resident has an indwelling urinary catheter, and is always incontinent of bowel function. The MDS indicates the resident is at risk for developing pressure injuries, and indicates R6 has no current areas of skin breakdown or impairment. The MDS's Care Area Assessment (CAA), completed by the facility, states the following, in part: .Extrinsic Risk Factors .Need(s) special mattress/seat cushion to reduce/relieve pressure .Requires staff assist to move sufficiently to relieve pressure over any one site .[MEDICATION NAME] Risk Factors .Immobility .Incontinence .Antianxiety agents .Cancer .[MEDICAL CONDITION] .[MEDICAL CONDITION] .Pain .[MEDICAL CONDITION] .Bedfast or wheelchair bound .Devices that can cause pressure such as oxygen or indwelling catheter tubing .Notes: CAA triggered d/t (due to) bed mobility, being at risk. Res. (Resident) has a dx (diagnosis) of MS, parapalegia (sic) .total assist with transfers with a hoyer (full body lift), extensive assist with bed, dressing, toileting, hygiene, bathing. Does not ambulate. Staff will assist with oral cares as needed .Incont (Incontinent) of BM (Bowel Movement). Skin is observed during cares. Skin checks during bathing and PRN (as needed) .Pressure reducing mattress to bed and w/c (wheelchair). Res is A&O (alert and oriented) and is able to make needs known .Pharmacy reviews meds routinely .Care plan in place. Will continue . The resident's CAA does not identify R6 refuses pressure injury prevention interventions, such as repositioning, or offloading and does not address what to do if she does refuse. The CAA does not identify the resident is at risk of developing pressure injuries due to sitting up in a wheelchair for several hours throughout the shift. R6's quarterly MDS, with an assessment reference date of 03/03/17, identifies the resident requires staff assistance for bed mobility, transfers, dressing, personal hygiene and bathing. The MDS indicates the resident has an indwelling urinary catheter, and is always incontinent of bowel function. The MDS indicates the resident is at risk for developing pressure injuries, and indicates R6 has no current areas of skin breakdown or impairment. R6's nurses' notes were reviewed. The notes state the following, in part: -03/01/17: Notified per CNA (Certified Nursing Assistant) .res. has bruise lower R (Right) buttock, writer .noted: Pale purple bruise lower R buttock, measures 2.5x1 cm. (centimeter) Res. stated 'last noc (night). felt a pinch from her inc. (incontinent) pad and that's what caused it' Res. take's (sic) Eliquis BID (twice a day), bruises easily .MX (Monitor): changes or pain QD (every day) Q shift x3 days then QPM (every PM shift) until resolved. FAX regarding this left for AP (sic, PA-Physician's Assistant) to check on rounds .INT (Intervention): will check pad placement NOC . -03/07/17: CNA's had assisted res. to bed with bruised area intact-when repositioned res. turned onto her side noted area sheared with scant bleeding, sheared area measures- (0).8x(0).2cm with skin intact over rest of bruisied (sic) area-cleaned area and TX'd (Treated): clean with w/w (wet wipe), apply skin prep over area and cover with Douderm (sic) drsng (dressing)-change Q7D (every 7 days) or PRN (as needed)-fax regarding this left for PA to check on rounds . Surveyor reviewed a Wound Assessment Report, dated 03/09/17. The report states the following, in part, .Wound Type: Abrasion .Infection: No .Measurements: Length-2.50 cm Width-1.00 cm Depth-0.00 cm . By 03/20/17, R6's pressure injury progressed from a bruise with shearing to one that was unstageable as evidenced by a fax the facility sent to Nurse Practitioner (NP) on 03/20/17. The fax states the following, in part: .Concern: Unstageable PU (Pressure Ulcer) buttock R ischial tuberosity (the sitting bone below the buttock). Sub Q (subcutaneous tissue or tissue beneath the skin) visible around slough (dead tissue), bed is dry. PT (Patient) agrees to offload 1hr to bed HOB (Head of Bed) 30 (degree angle) (and) sit in chair 1hr. Need (1) Air Mattress (2) WC Gel Foam Cusion (sic) (3) Multivitamin (with) Minerals qd, Juven qd Dressing order Apply skin protectant to peri-area, apply Hydrogel to wound bed if dry/dessicated (sic), apply [MEDICATION NAME] (sic) as primary drsg (and) cover (with) comfort foam border (change) q3d (and) prn . The NP was in agreement with the above recommendations. Note: Although R6 has agreed to one-hour repositioning, there is no evidence that staff updated the CNA care card to include one hour repositioning or that staff attempted one-hour repositioning. On 04/04/17 at 1:07 p.m., Registered Nurse (RN) U stated R6 moves every two hours, and nursing staff assist with repositioning the resident approximately every two hours. RN U stated R6 is generally agreeable to be repositioned. At 1:10 p.m. on 04/04/17, CNA T stated staff attempt to reposition the resident every two hours, but R6 gets mad. CNA T further indicated CNA staff don't generally inform the nurses of the resident's refusals since it's just the resident's personality. CNA T stated CNA staff do not chart in the resident's medical record of the resident's refusals to reposition or to offload. On 04/05/17 at 7:40 a.m., LPN R stated nursing staff enter R6's room every couple of hours. LPN R further indicated she informed CNA staff this morning, the resident should be off the right hip more often than every two hours. According to the National Pressure Ulcer Advisory Panel (NPUAP), the current standard of practice is to have a person sitting up in a chair for no longer than sixty minutes, when a pressure injury is present on an area such as an ischial tuberosity. R6's nurses' notes continue to read, in part: -03/20/17: res. has open area right buttocks started as sheering (sic) area. has become larger/draining bloody drg. (drainage) area measures2.5cm x 2cm dark edges at 0900am position/yellow slough at 9pm position. area worst from last wk (week). cleansed area with wound cleanser/skin prep and applied duoderm drsg. reported condition to director of nurse. will monitor. -03/22/17: res. has open area from sheering on right buttocks. dressing dry/intach. (sic) has started res. on juven (therapeutic nutritional drink) daily/multivitamindly (sic) for wound healing. res. c/o (complains of) increase weakness this forenoon. t (temperature)-98.1. given prn Tylenol 650mg x1 . On 03/23/17, the facility sent a fax to the Physician's Assistant, which states the following, in part: Res. pressure area on R butt. larger in size 4 cm x 2.5 cm (with) serous (clear, watery drainage) bloody drg. Appears worse last week. Would like order to DC (Discontinue) present tx. Hydrogel to wound bed/[MEDICATION NAME] DRSG. (Change) Dressing to cleanse (with) wound cleanser (and) apply skin prep to peri wound/Foam Dressing As Primary dressing (and) cover (with) Border Gauze (and change) qOD (Every Other Day) (and) PRN until resolved. Apply Low Air Loss Mattress to Bed . R6's nurses' notes continue to read, in part: -03/24/17: Dressing to R buttocks changed this morning. Moderate amount of serous drainage to old dressing. Temp 99.4 this morning. Has noted increased weakness in the morning. Resident requests Tylenol as needed for temperature or pain. -03/26/17 at 11:03 p.m.: Temps ranging from 100.3 to 101 this shift; refused Tylenol or [MEDICATION NAME]; increased weakness is present; stayed in bed . On 03/26/17, a fax was sent to the resident's physician stating the following, .Concern: Foul (dressing) refuses temp non-compliant (with) repositioning needs eval. There is no documentation in R6's medical record the resident was refusing to have temperatures taken, and refusing to be repositioned. The physician responded to the above fax and [MEDICATION NAME](an antibiotic) 500 mg, twice a day for seven days, for R6's wound. There was no wound culture taken to determine [MEDICATION NAME] be effective in treating the resident's infection. According to current standards of practice, antibiotics are generally not prescribed until a a wound culture is completed. The culture determines if a wound is infected, and susceptibility testing is usually done to determine which antibiotic will inhibit the growth of the bacteria and treats the infection. The resident's nurses' notes state the following, in part: -03/27/17 at 4:39 a.m.: res given prn [MEDICATION NAME] at 2300 (11:00 p.m. on 03/26/17) for temp of 101.6. temp at 0215 (2:15 a.m. on 03/27/17) 101. prn Tylenol given at that time. at 0400 temp is 100. res is weaker. skin warm and dry. turned and repositioned in bed by nursing staff. -6:17 a.m.: resident temp at 0615 is 99.7. res declines offer of any Tylenol or [MEDICATION NAME] at this time. res repositioned by staff at this time. -3:58 p.m.: Resident had a temp of 102.1 this am r/t (related to) wound, administered [MEDICATION NAME], temp dropped to 99.7. Administered 2 Tylenol, temp stayed at 101.6 PA ordered .labs to be done. Wants improvement with in 72 hours. Will continue to monitor . -10:58 p.m.: Wound to R buttocks, size remains 3.0x5.0 cm, palpable induration to 1.5 cm periwound, new orders received,[MEDICATION NAME] mg .QID (four times a day) x 7 days, labs .Pelvic Xray (of) ischial tuberosity ordered . On 03/27/17, the PA ordered the following: Santyl be applied to R6's wound, daily, until the wound is debrided; a four ounce nutritional supplement, twice a day, between meals for increased healing needs; and Physical and Occupational therapies (PT and OT) to evaluate and treat the resident for wheelchair positioning, a wheelchair cushion and to preserve the resident's skin integrity. R6's nurses' notes continue, in part: -03/28/17 at 8:34 a.m.: .Temp was 99.7 and was given Tylenol with relief .She does reposition self onto her (L) side freq (frequently). -3:20 p.m.: .changed dressing on right butt. large amt (amount) of bloody serous drg/foul smelling. 3/4 of open area necrotic (dead)/foul smelling at 1pm has open area 1cm in size and 2cm in depth clock wise. received prescribed tx to area .temps 98.7/99.9/100.4. medicated x1 with Tylenol 650mg due to low grade fever/increase weakness . -03/29/17 at 5:57 a.m.: .res turned by staff frequently during the noc. does make needs known to staff. On 03/29/17 a culture of the resident's wound was taken. Surveyor reviewed R6's PT and OT evaluation notes, dated 03/29/17. The PT eval states the following, in part, .Reason For Referral .presents to therapy with Stage 4 ischial pressure ulcer wound of the R buttock with feature of undermining as a result of Inadequate pressure relief techniques . The OT eval states the following, in part, .Reason For Referral .presents to therapy with positioning deficits, including Need for new pressure relieving cushion for Power wheelchair as a result of Pt has pressure ulcer on right buttocks .The patient has declined from No wounds to Pressure ulcer on buttocks and need for new wheelchair cushion, which impacts Pt skin integrity and safety while seated in w/c. Previous positioning intervention includes Pt has a Power wheelchair .and a custom cushion .but patients (sic) cushion is 5-6 years old and Pt remains at risk and skilled therapy is required to improve positioning for Pt's skin integrity and safety . On 04/05/17 at 9:18 a.m., Surveyor interviewed Occupational Therapist (OT) V. OT V indicated the resident used an old foam wheelchair cushion, from 2012, which needed to be replaced. OT V stated due to the condition of the wheelchair cushion, R6 leaned more towards the left side, which resulted in nursing staff boosting the resident up in the chair. OT V stated this placed more pressure on the resident's right side of the buttocks. OT V stated based on her professional opinion, a resident's wheelchair cushion should be replaced about every year. At 9:24 a.m. on 04/05/17, the Physical Therapy Director (PTD) W was interviewed. PTD W explained his evaluation documenting the resident's pressure injury was a result of Inadequate pressure relief techniques, was based on the resident having an old wheelchair and an old seating system. PTD W explained this brought the resident poor pressure relief while sitting up in the wheelchair. Surveyor reviewed a Wound Assessment Report, dated 03/30/17. The report states the following, in part, .Wound Type: Pressure Ulcer .Date wound identified: 3/7/2017 .Wound Status: Deteriorated .Stage 4 .Drainage: Serosanguineous, Moderate .Infection: Yes .Wound Bed: [MEDICATION NAME] Tissue-Granulation Tissue-Slough-Eschar .Measurements: Length-4.60 cm Width-2.70 cm Depth-3.20 cm .Symptoms of Infection: Fever, Increased Drainage, [DIAGNOSES REDACTED] (reddening of the skin), Malodorous (odor present) or purulent drainage .Wound Edges .Macerated .Undermining 9, 3 . A nurses' note, dated 03/30/17, states the following, in part, Debridement of the wound took place .needs an appt (appointment) for an Xray .to rule out osteo[DIAGNOSES REDACTED] (infection of the bone) .Temps were 100.6-100.8; Tylenol and [MEDICATION NAME] was given this shift . On 03/31/17, the facility Director of Clinical Services (DCS) A wrote an Interdisciplinary Team (IDT) note in R6's medical record. The note states the following, in part: Late entry for: 03/29/17 .IDT met to discuss resident wound. Resident admitted [DATE] Resident has a strong history of refusing interventions for care and prevention. She refuses to lie down and will stay in WC from 9am-9pm unless she is incontinent of bowel .she does not stay off the right hip, she was resistant to change in WC cushion, however, she did allow for gel cushion to be placed .Area first presented at a .bruise .on 3/20, and resident stated she bumped on the WC armrest. On 3/20 area presented as abrasion and treatment was implemented .Suspect area started at the bone and has worked itself outward AEB (As Evidenced By) increase in size, infection and potential undermining under the skin on palpation . It is noted, there is no documentation in R6's medical record the resident refused interventions for pressure injury prevention and treatment interventions. There is no documentation found in which the resident refuses to lie in bed, and stays upright in the wheelchair for approximately twelve hours at a time. There is no documentation found in the medical record R6 was offered and refused different wheelchair cushions. There is no evidence or an investigation the resident's bruise was caused by bumping the arm on the wheelchair. On 03/31/17, the resident's wound culture returned, and the NP discontinued [MEDICATION NAME] ordered [MEDICATION NAME] (an antibiotic medication) 300 mg, four times a day for seven days. The culture report identifies the resident's wound infection is susceptible to the Clindamyacin. R6's nurses' notes identify the resident had the following temperatures, which may be a symptom of a continued infection: -03/31/17 at 2:19 p.m.: 99.2; 10:44 p.m.: 100.7 and 99.6 -04/01/17 at 2:47 a.m.: 100.2; 4:36 a.m.: 99.7; 7:47 a.m.: 100.2 and 99.7; 10:59 p.m.: 101.3 -04/03/17 at 12:07 p.m.: 99.8; 9:31 p.m.: 100.8 and 99.7 -04/04/17 at 1:09 p.m.: 99.7; 1:24 p.m.: 100.0 R6's Wound Assessment Report, dated 04/05/17, was reviewed. The report states the following, in part, .Wound Type: Pressure Ulcer .Date wound identified: 3/7/2017 .Wound Status: Unchanged .Stage 4 .Drainage: Serous, Small .Infection: Yes .Wound Bed: [MEDICATION NAME] Tissue-Granulation Tissue-80.00% Slough-20.00% Eschar .Measurements: Length-4.20 cm Width-3.20 cm Depth-3.30 cm .Symptoms of Infection: [DIAGNOSES REDACTED], Malodorous or purulent drainage .Wound Edges .Macerated .Undermining 10, 3 . On 04/06/17, the resident's X-ray report indicated a negative result for osteo[DIAGNOSES REDACTED]. Surveyor reviewed R6's CNA care plan. The care plan does not identify the resident has any wounds or open areas. The care plan does not identify if the resident is to be repositioned, the frequency in which to be repositioned, or if the resident is to be educated on the importance of repositioning and/or offloading. The resident's comprehensive care plan was reviewed. The resident's care plan states the following, in part: .Problem Onset: 04/01/2011 At risk for pressure ulcers d/t HX (History) of Pressure Ulcers, Impaired Mobility, DX MS .[MEDICAL CONDITION]. 3/1/17-Bruise (R) buttock 3/7/17-Shearing (R) buttock 3/22/17-Unstageable wound (R) buttock Res noncompliant (with) Bed rest, Refuses interventions (at) times, (Ref (Refuses) Juven, Ref Offloading) Goal .Will remain free of skin breakdown 6/08/17 . Approaches .Electric w/c is designed to 'tilt in space' and resident is able to tilt to change pressure .Pressure redistributing cushion in electric wheelchair .3/21/17-Low Air Loss Mattress 3/22/17-Tx per orders-Juven, MVI (Multivitamin) .3/27/17 .Keep off R hip as much as poss (possible) . This section of the care plan was signed by Licensed Practical Nurse (LPN) C, on 03/17/17. There is no date in which the hand-written entry indicating the resident is non-compliant and refuses interventions, was added to the resident's care plan. A different section of the resident's comprehensive care plan states the following, in part: .Problem Onset: 04/01/2011 Requires assistance from staff with ADL's, bed mobility and transfers Independent in electric w/c once up .Hx of Ref to be repositioned during the day (and) noc .Hx Ref to be laid (down) during the day, Hx Ref staff education, Hx Ref cares Goal .Will be compliant through next review 6/8/17 . Approaches .Attempt to Re-approach/Re-educate any noncompliance/Refusals . This section of the care plan was signed by LPN C, on 03/17/17. There is no date in which the hand-written entries indicating the resident has a history of refusing to be repositioned, refusing to lay down, and refusing staff education and cares, was added to the resident's care plan. The comprehensive care plans do not identify R6 is to offload one hour in bed, and one hour in the wheelchair, and the head of the bed is to remain at 30 degrees, per the fax sent to the NP, on 03/20/17. The care plans do not recognize the current standards of practice for offloading pressure injuries. On 04/04/17 at 9:08 a.m., R6 was interviewed. R6 stated the pressure injury resulted from the foam cushion which was used in the resident's power wheelchair, prior to 03/21/17. R6 stated the foam cushion was about five years old, and was bad for her. When asked if the initial buttock bruising occurred from an incontinence pad, R6 stated this never happened. The resident explained she does not have much feeling in the lower extremities and is not able to feel when things pinch. During the continued interview, R6 stated nursing staff do not come into the room and do not remind or ask the resident to reposition or offload. The resident further indicated nursing staff have not been providing education on the risks of not repositioning or offloading. The resident is aware she has to lie down, and try to lie side to side. The resident was able to demonstrate to Surveyor the appropriate use of the tilt in space feature of the wheelchair, and states understanding of how this feature provides some offloading to the buttocks. At 1:10 p.m. on 04/04/17, Surveyor interviewed CNA T. CNA T stated she placed R6 in the wheelchair approximately 8:30 a.m. this morning, and did not lay the resident in bed until just prior to this interview. CNA T did not explain why R6 was sitting up in the wheelchair for over four and a half hours. At 1:32 p.m. on 04/04/17, Surveyor interviewed DCS A. DCS A stated she observed R6's wound last week, and states it is a stage IV pressure injury on R6's right ischial tuberosity. DCS A indicated R6 initially had a foam wheelchair cushion, which was then replaced with a gel cushion after the wound opened, on or around 03/20/17. DCS A then indicated a Roho cushion (which is air-filled) was placed in the resident's wheelchair on 03/28/17. DCS A stated the resident previously leaned to the side while sitting in the wheelchair, but DCS A did not remember which side R6 leaned towards. During the continued interview, Surveyor asked why a culture of the wound was not initially completed prior to [MEDICATION NAME] administered, as this is not a current standard of practice. DCS A replied the wound culture results will always come back as being dirty, and [MEDICATION NAME] started due to signs and symptoms of the infected wound. DCS A indicated when she was located at the facility nurses' station during the week before 04/05/17, she was able to smell the foul odor of R6's wound, while the resident was located in her personal room. It is noted, R6's room is located over half-way down a hallway from the nurses' station (four rooms away from the nurses' station). At this time, Surveyor and DCS A reviewed R6's CNA and comprehensive care plans. DCS A stated she would expect the resident's pressure injury to be identified on the resident's CNA care plan. Surveyor asked when the hand-written information was added to the resident's comprehensive care plans, to which DCS A stated she assumes the date of 03/17/17 (the date signed by LPN C), was the date the care plan was updated and revised. During the continued interview, DCS A stated R6's pressure injury is unavoidable due to R6's refusals to be repositioned, the resident is up in the wheelchair from 9:00 a.m. to 9:00 p.m., and the wound developed from beneath the initial bruise first identified on 03/01/17. DCS A stated nursing staff educates the resident on repositioning, and the risks involved if the resident would become septic from the wound infection, which includes death. DCS A further stated R6 has previously refused different mattresses and different wheelchair cushions, prior to the wound development. Surveyor asked for any documentation regarding any education which has been provided to the resident on repositioning and offloading, and any documentation indicating R6 has refused different cushions, mattresses, repositioning and offloading being offered. DCS A stated she would have to speak with the DON for this documentation. No additional information, regarding documentation related to R6's refusal of pressure injury prevention and treatment, or education provided to R6 was provided to Surveyors. The facility's failure to update R6's care plan, to replace an old wheelchair cushion, to reposition R6 more frequently, and to address with staff what to do if R6 refused repositioning created a finding of immediate jeopardy. The facility removed the jeopardy on 04/07/17 by which time it had implemented the following: 1. R6 received a new gel cushion; 2. The facility completed an audit of all wheelchair cushions to ensure they were in good repair; 3. All clinical staff were reeducated on pressure relieving interventions, implementation of devices, and repositioning; and, 4. A schedule of auditing was developed.

Based on interviews and record reviews, the facility did not provide appropriate assistive devices for 1 of 7 sampled residents (R2) reviewed for falls. R2 experienced a fall from a mechanical lift on 12/20/16, when staff did not place the safety strap around R2's legs which allowed her foot to slip off the stand and caused a fracture to her left arm. This is evidenced by: R2 [DIAGNOSES REDACTED]. On 04/04/17 at 12:45 p.m., Surveyor reviewed R2's clinical record. Surveyor reviewed a document entitled Resident Incident Report. Dated 12/21/16, the document read: Resident was transferred with the EZ (stand) when foot slid off causing left arm pain. Interviews were attached. An interview by Certified Nursing Assistant (CNA) J, said R2 was being transferred when R2's foot slipped out of place. CNA H's interview stated, .R2's foot coming off the bottom of the lift The incident report was undated and unsigned. On 04/05/17 at 6:30 a.m., Surveyor interviewed CNA J. CNA J stated that they were assisting the resident in the bathroom when R2's foot slipped off the stand up lift. CNA J stated that they (the staff) were not using the leg straps. On 04/05/17 at 6:45 a.m., Surveyor interviewed CNA H. CNA H stated that R2's arm was extended when her foot slipped off the stand up lift. CNA H confirmed that the leg strap was not in place. On 04/05/17 at 6:55 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) I, who was the nurse on duty at the time of the incident. LPN I stated that she did not think that the resident had pain until a few days later. LPN I stated that she did not report the incident to the Registered Nurse (RN), did not contact the physician and did not document the incident in the nurses' notes or fill out an incident report. LPN I stated that the unsigned and undated incident report was not filled out by her. Asked why LPN I did not fill out an incident report or notify the physician, LPN I stated, I don't recall. On 04/05/17 at 1:45 p.m., Surveyor interviewed the Director of Nursing (DON). Surveyor asked the DON how the facility became aware of the incident. The DON stated, We didn't even know about the incident until during the day (shift). The DON clarified that the incident occurred on 12/20/16, between 5:00 a.m. and 6:00 a.m. The facility began an investigation on 12/20/16, after the resident complained of pain with transfers, and the x-ray identified a left humerus fracture. The DON had contacted the night shift staff to determine what had happened. There was no documentation in the clinical record or incident report noted by the night staff explaining the incident. The DON stated that she provided phone counseling immediately to the CNAs who were responsible for the transfer. In person counseling was provided on 12/22/16. Counseling included using the leg strap with each sit to stand transfer. No information was provided to Surveyor regarding counseling to LPN I, or other staff, regarding proper reporting of a possible resident accident or injury. The DON stated that she did not perform all staff teaching regarding proper use of the sit to stand lift.

Based on observation, interviews and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 2 residents (#1, #4) which were reviewed for a decline in bowel function and 1 of 4 residents (Resident #6) reviewed for pain. Resident #1 was continent of the bowels, and eight months later was incontinent of bowels. The facility did not complete an accurate or new bowel assessment to determine the potential factors which caused the decline, or new interventions in order to restore and/or improve the resident's bowel function. Resident #4 was continent of bowels, and three months later was frequently incontinent of the bowels. After identifying the decline, the facility did not complete an accurate or new bowel assessment to determine the potential factors which caused the decline, or new interventions in order to restore and/or improve the resident's bowel function. Resident #6 had pain from an excoriated gastrostomy site and general pain. Complete pain assessments were not completed, and scheduled pain medicine was not provided. This is evidenced by: On 04/15/14 at 10:20 a.m., Surveyor received and reviewed a copy of the facility's bladder and bowel assessment policy. The undated policy states, in part: "Policy: It is the policy...to ensure that each Resident has a Bladder and Bowel assessment performed with the goal of achieving continence or restoring as much normal bladder and/or bowel function as possible. Based on the assessment, appropriate treatment and services will be offered. The continence program utilized is a structured Bladder and Bowel Rehabilitation Program designed to help Resident's progress from incontinence to continence and from constipation to regularity, through guided nursing management. The program is based on current Bladder and Bowel assessment and treatment concepts combined with the newest theoretical and practical knowledge about rehabilitating the incontinent elderly. Care will be provided based on the type, severity and cause of the bladder or bowel incontinence... Steps in the Procedure... 1. Implement Bladder and Bowel (B&B) assessment on all Residents at the time of admission, quarterly, and when there is a change in cognition, physical ability or...bowel function. 2. Record Resident bladder and bowel patterns for 72 hours using the Bladder and Bowel Record. 3. Following completion of the 72 hour Bladder and Bowel Record and the Bladder and Bowel Assessment...will be completed by qualified staff. Assessment will be forwarded to MDS (Minimum Data Set) Coordinator/Care Plan Coordinator. 4. If deemed appropriate...the bowel toileting or training program will be implemented. The following factors will also be evaluated: a. The results of the Resident's assessment and treatment of [REDACTED]. e. The presence of permanent physical impairment or disease which could prohibit restoration of normal bladder function such as...neurologic diseases (e.g. [MEDICAL CONDITION], stroke)... BOWEL ASSESSMENT FORM PROCEDURE: 1. Assess each Resident for bowel continence...best done during a 7-day trial or during the 7-day look back period per MDS... 4. If a Resident is experiencing bowel incontinence, identify signs and symptoms of bowel function. 5. Identify all contributing medical diagnoses/conditions that may contribute to episodes of bowel incontinence. 6. Identify all current medications that may contribute to bowl incontinence... 8. Determine the type of bowel continence program best suited for the Resident... 10. Review bowel continence at least quarterly and/or after a new decline in bowel continence is identified." 1. On 04/14-16/14 Surveyor reviewed Resident #1's medical record. The resident has multiple [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS) assessments, under section "H4 Bowel Continence," identified the following information: - 06/21/13: The assessment indicates the resident is continent of bowels - 02/28/14: The assessment indicates the resident is frequently incontinent (two or more episodes of incontinence but at least one continent bowel movement) within the last five days of the assessment. Surveyor also reviewed Resident #1's bowel elimination patterns, from 02/14/14 to 04/15/14. During this time, Resident #1 was continent of her bowels 4 times and incontinent 29 times. On 04/14/14, Surveyor received and reviewed a copy of Resident #4's comprehensive care plan. The care plan does not identify the resident is incontinent of bowels. On 04/14/14, Surveyor was provided the resident's most recent bowel assessments. The "Nursing Risk Assessments," dated 09/13/13 and 12/04/13, identifies the following: -09/13/13: "Bowel Continence Status: Resident is currently continent of bowel. Resident has the following risk factors for bowel incontinence. None." -12/04/13: "Bowel Continence Status: Resident is currently continent of bowel. Resident has the following risk factors for bowel incontinence. None." Per Resident #1's MDS assessments, the resident went from always continent of her bowels, to being frequently incontinent of her bowels in eight months, with no accurate bowel assessment being completed. A current and accurate bowel assessment would address potential causes for Resident #1's decline in bowel incontinence. The assessment would also determine possible interventions to improve and/or restore the resident's bowel continence. The medical record also did not identify any changes in the plan of care in order to assist Resident #1 in achieving the highest practicable physical well-being. On 04/15/14 at 5:20 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) T, who routinely works with Resident #1, CNA T stated that Resident #1 no longer uses the bathroom every two hours, and is incontinent frequently. CNA T stated that Resident #1 is checked and changed every two hours now as she continually refuses to get up out of bed. CNA T stated that Resident #1 has been this way for a few months now, at least. On 04/16/14 at 8:00 a.m. and again at 12:55 p.m., Surveyor interviewed Licensed Practical Nurse (LPN) H. LPN H stated there is no real assessment related to Resident #1's increase in bowel incontinence. LPN H indicated that since Resident #1's son passed away she has declined, she refuses to get up from bed and would prefer to be checked and changed only. LPN H indicated that both the family and Resident #1 have decided to have comfort cares only, and all of her medications were discontinued. LPN H and Registered Nurse (RN) G also indicated the facility discovered they had a problem with assessments not being completed related to bowel functioning, and the facility has a new program they are putting into place. 2. On 04/14/14 at 4:00 p.m., Surveyor reviewed Resident #4's medical record. The resident has [DIAGNOSES REDACTED]. Surveyor also reviewed Resident #4's MDS assessments, from 09/20/13 to 03/07/14. Under section "H4. Bowel Continence," the MDS's identify the following information: -09/20/13: The assessment indicates the resident is continent of bowels -12/13/13: The assessment indicates the resident is continent of bowels -03/07/14: The resident is frequently incontinent (two or more episodes of bowel incontinence but at least one continent bowel movement) within the last five days of the assessment. Surveyor also reviewed Resident #4's bowel elimination patterns, from 02/15/14 to 04/15/14. During the resident's MDS assessment period, from 03/01/14 to 03/07/14, Resident #4 was continent of her bowels four times, and incontinent nine times. Based on the Surveyor's calculations, the resident was continent of her bowels a total of 12 times, and incontinent of her bowels 29 times, from 02/15/14 to 04/15/14. On 04/14/14, Surveyor received and reviewed a copy of Resident #4's comprehensive care plan.The care plan does not identify the resident is incontinent of her bowels. On 04/14/14, Surveyor was provided the resident's most recent bowel assessments. The "Nursing Risk Assessments," dated 12/10/13 and 03/01/14, identifies the following: -12/10/13: "Bowel Continence Status: Resident is currently continent of bowel. Resident has the following risk factors for bowel incontinence. Constipation..." -03/01/14: "Bowel Continence Status: Resident is currently continent of bowel. Resident has the following risk factors for bowel incontinence. None. Current diagnoses/medical conditions that may affect bowel [MEDICAL CONDITION]." Resident #4's bowel assessment, dated 03/01/14, does not identify the resident is frequently incontinent of her bowels, as indicated on the MDS assessment, as well as the bowel elimination patterns from that time. Per Resident #4's MDS assessments, the resident went from always continent of her bowels, to being frequently incontinent of her bowels in three months, with no accurate bowel assessment being completed. A current and accurate bowel assessment would address potential causes for Resident #4's decline in bowel incontinence, such as the [DIAGNOSES REDACTED]. On 04/15/14, Surveyor interviewed LPN H, and MDS Coordinator, (RN) G. Surveyor discussed Resident #4's bowel incontinence, along with the frequency in which the resident has been incontinent since 02/15/14. LPN H reviewed the resident's bowel elimination documentation. LPN H then stated Resident #4 is more incontinent of bowel than what LPN H originally thought, and further stated, "I wouldn't have known that." During the interview, RN G stated Resident #4's bowel incontinence may be due to factors such as "laziness," and stated the resident "enjoys being waited on." Surveyor asked what is assessed when reviewing a resident's decline or change in bowel function. RN G stated she looks to see if the resident has had a recent illness, is taking antibiotics, is lactose intolerant and has had any previous patterns of incontinence. During the continued interview, Surveyor showed RN G the resident's comprehensive care plan, which was provided on 04/14/14. RN G reviewed Resident #4's comprehensive care plan, and stated the resident's bowel incontinence was listed on the resident's care plan. RN G reviewed Resident #4's care plan in the computer, and printed off a one-page, undated section of the resident's care plan. RN G and LPN H were not able to identify when the issue of bowel incontinence was added to Resident #4's care plan. The comprehensive care plan provided to Surveyor by RN G was reviewed. The care plan section states, in part, "Problem Onset: At risk for pressure ulcers d/t (due to) decreased mobility and frequent incontinence of bowel. Goal: Will remain free of skin breakdown...Approaches: Reposition every 2 hours and PRN (as needed)...Apply house barrier ointment/cream following bowel incontinent episodes. Thorough cleansing following bowel incontinence episodes." The care plan does not identify any interventions in order to restore and/or increase Resident #4's bowel continence, the frequency of her incontinence, and how it relates to having a progressive disease such as [MEDICAL CONDITION]. On 04/15/14 at 4:05 p.m., Surveyor interviewed CNA L. CNA L stated Resident #4 is able to let staff know when the resident needs to use the bathroom. CNA L further stated the resident sometimes has "accidents" when having a bowel movement. On 04/15/14 at 4:05 p.m., Surveyor interviewed Resident #4. The resident stated she is currently incontinent of her bowels at times, as she has difficulty holding her bowel movements. The resident stated she uses her call light when she needs to use the bathroom. On 04/16/14 at 7:50 a.m., Surveyor interviewed CNA O. CNA O stated Resident #4 is, at times, incontinent of her bowels at the start of having a bowel movement. On 04/16/14 at approximately 10:00 a.m., Surveyor interviewed the Interim Nursing Home Administrator (NHA), and the facility's Regional Director of Clinical Services (RDCS) M. Surveyor discussed Resident #4's decline in bowel function, as well as the inaccurate and lack of a new bowel assessment after a decline in bowel function was identified on 03/7/14. The RDCS M stated the facility bowel and bladder policy, which was provided on 04/15/14, is a new policy that has not yet been implemented. The NHA and RDCS M stated the facility's Quality Assurance Program identified bowel and bladder assessments and elimination patterning as an issue, prior to the survey. The NHA and RDCS M stated the new interventions, bowel assessments, and elimination patterning have also not yet been implemented. During the continued interview, Surveyor asked to review the facility's bowel assessment policy. The RDCS stated the former bowel and bladder policy was not as thorough, as this was why a new policy was written. On 04/16/14 at approximately 1:00 p.m., the NHA informed Surveyor the former bowel and bladder policy has been "archived" in the facility's system, and therefore cannot be pulled for review. The NHA believed this policy has been archived within the past quarter. The undated facility policy, titled "Pain Management," states in part: "Policy: The facility will effectively recognize residents with risk for pain. Any resident who experiences pain will be reviewed and a plan will be established to treat his or her pain. Purpose: 1. To ensure the physical and psychological well being of the resident 2. To maintain optimum functional ability Procedure: 1. Pain will be reviewed/scored using a numeric 0-10 scale. 2. Care plans will be implemented once it is established the resident is at risk for pain or has experienced pain. 3. Every resident will be regularly and systematically reviewed for pain; a. upon admission b. Significant Change c. Quarterly Assessment d. And as needed 4. Nursing staff will communicate to the physician whenever the resident's pain management regimen is not effective in meeting the goals for pain relief. 5. The resident's care plan will be updated quarterly and as needed to reflect current goals, interventions and review findings." 1. Resident #6 was admitted to the facility following a stroke, which left the resident immobile. Resident #6 was not able to swallow, and a tube feeding was placed. Other [DIAGNOSES REDACTED]. The MDS, dated [DATE], identifies Resident #6 needs extensive assist of two staff for transfers. The Brief Interview for Mental Status (BIMS), identifies the resident as having severe cognitive impairment. The MDS also identifies the resident's pain is a "5" out of a scale of 10. On 04/14/14, Surveyor reviewed Resident #6's care plan. The care plan indicates the resident uses a Hoyer lift (a mechanical lift involving a sling) for transfers. The care plan did not identify Resident #6 had pain. Surveyor also reviewed Resident #6's nurses' notes. The notes state, in part: -2/12/14 "Gtube site peri skin remains pink and slightly excoriated...." -02/19/14 "Gtube site where skin remains pink. a small amount of yellow gastric drainage noted to dressing when removed. States that area is sore..." -02/26/14 "G tube periskin remains pink and intact. a small amount yellow gastric drainage noted to dressing when remove. States that area is tender." -03/07/14 "...G tube site is inflamed and has some scant bloody drainage...G tube site cleansed with wound cleanser and patted dry..." A fax, sent to the physican on 03/07/14, states in part, "Resident is very raw from gastric leaking around [DEVICE] site. Currently using Calzine with zinc. Can we instead try some skin prep, followed [MEDICATION NAME], covered with a [MEDICATION NAME]?...Physician order: Okay." This fax does not identify Resident #6 was having pain associated with the raw [DEVICE] site. The resident's nurses' notes continue to read, as follows: -03/12/14 "Gtube site remains reddened and excoriated. Continues to drain a large amount of gastric drainage..." -03/19/14 "Gtube site remain slightly reddened and excoriated. Area continues to drain a large amount of gastric drainage around base of tube/skin." -03/26/14 "Gtube site continues to drain a large amount of gastric drainage. Skin surrounding tube remains reddened and excoriated..." -04/02/14 "Gtube site cont to drain a moderate amount of gastric drainage. Skin surrounding tube remains red and excoriated. Remains tender to touch..." -04/09/14 "Gtube site cont to drain a moderate amount of yellow gastric drainage. Skin surrounding then tube remains red and excoriated. Tender to touch." -04/15/14 4:21 p.m. "...wrote fax to Dr. regarding area and also addressed scheduling his pain medication for better management..." On 04/14/14 at 12:00 p.m., Surveyor observed Resident #6 in the assisted dining room, and CNA R was assisting the resident. The resident was pointing to his stomach and said, "I can't eat, it hurts." CNA R continued to offer food to Resident #6, until he completed the meal. On 04/15/14, Surveyor reviewed Resident #6's Medication Administration Record (MAR). The resident had been given an as needed pain medication at 8:00 a.m. on 04/14/14. There was no documentation of any pain medications being given to the resident until 10:00 p.m. that evening. On 04/15/14 at 08:30 a.m., Surveyor observed RN E change the dressing to the gastrostomy ([DEVICE]) site. When RN E took the dressing off, Resident #6 stated, "Oh, Oh, that hurts." RN E replied, "I know I will get you some Tylenol in a little while," and continued the dressing change. During the continued observation, Surveyor observed the reddened, excoriated area extending about 1 and 1/2 inches from the site of the [DEVICE] insertion. RN E then cleansed the excoriated area, to which Resident #6 stated, "What are you doing, using the tin snips?" The resident also grabbed the excoriated area. RN E stopped for a few seconds and then applied the calazine ointment. After the observation was completed, Surveyor reviewed the resident's MAR, dated 04/15/14. The MAR indicates an as needed dose of [MEDICATION NAME] (narcotic) 5 mg had been given at 6:50 a.m. that day. On 04/15/14 at 1:00 p.m., Surveyor attempted to interview Resident #6. Surveyor asked the resident if he was having pain. Resident #6 then pointed at his gastrostromy area and said, "It hurts really bad sometimes, but it is not too bad now." On 04/15/14 at 1:30 p.m., Surveyor interviewed CNA R about Resident #6's pain. CNA R stated, "It seems to be a lot worse lately; he grabs at his stomach and says it burns, and then I tell the nurse." On 04/15/14 at 2:05 p.m., Surveyor interviewed RN E about Resident #6's pain. RN E stated, "He has problems with his stomach hurting from the gastrostomy site. I have given him something for pain two times today." Surveyor asked if Resident #6 was on any scheduled pain medicine, to which RN E replied, "No, nothing scheduled." On 04/16/14, Surveyor requested Resident #6's pain assessments. RN G provided the Surveyor with the resident's pain assessment, dated 02/07/14. This date was prior to Resident #6 having an excoriated area on his abdomen, and this pain assessment identifies the resident as having no pain. The next pain assessment, dated 03/11/14, states in part, "Does the resident have pain? Yes. On a scale of 0-10, what is the intensity how does the resident rate the pain? 5. Describe any non-verbal indicators of pain the resident is exhibiting: Facial wincing." No other information is listed on this pain assessment. The last completed pain assessments for Resident #6 is dated 03/11/14. The review of the nurses' notes from 02/12/14 (the date the excoriation is first documented) to 04/16/14 do not address the resident's pain intensity, duration, location, aggravating factors, or interventions to relieve pain, prior to the gtube dressing changes or otherwise. The MAR was reviewed for March and April 2014. In March, Resident #6 used PRN pain medication 47 times; eight of these were documented as Tylenol 650 mg, and 39 were [MEDICATION NAME] 5 mg. The reason is documented as JT (Jtube) c/o (complaint of discomfort) 19 times. The reason for the use of the PRN pain medication is left blank seven of these times in March. Twenty of these PRN uses do not document the effectiveness of the pain medication; the other PRN use is documented as effective or helpful. On 03/30/14, Resident #6 took the [MEDICATION NAME] 5 mg four times, with no documented reason or effectiveness. The pain scale that was documented on the MAR, ranged from 3-4 at the start of March, with a scale of 5-6 from 3/20 - 3/30th. The April MAR documents the use of the PRN pain medication 31 times from April 1- 16th. Seven of the PRNs documented as given, were Tylenol 650 mg., and [MEDICATION NAME] 5 mg 24 times. The reason documented is Jtube pain 14 times, and then general discomfort. The effectiveness is left blank seven times; the rest of the PRN use is documented as effective, or helpful. The pain scale was documented on the MAR as "6" on 3 days, "4" on 12 days, and "0" on one day in April. On 04/15/14 at 3:00 p.m., interviewed RN G, who is the MDS nurse and does the care planning. RN G said she would check for a pain care plan. RN G provided Surveyor with a care at 7:30 a.m. on 04/16/14, with a date of 04/15/14 and print time of 6:36 p.m. Surveyor asked for clarification. RN G stated, "I did not have one, and started it yesterday. We have faxed the physician for an order for [REDACTED].