Every finding on record at Lady of the Oaks Retirement Manor

Based on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 (#3, #86, #91, #104) of 4 (#3, #86, #91, and #104) residents reviewed for ADLs. Findings: On 05/19/2026, a review of the facility's policy titled AM Care Policy and Procedure with a last reviewed date of 09/05/2025, read in part: Policy: AM care will be provided to all residents daily and as needed. Procedure.7. Shave resident if applicable.12. Assist resident with combing and brushing hair. Resident #3 Review of Resident #3's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, other intervertebral disc degeneration, obstructive and reflux uropathy, and venous insufficiency (chronic) (peripheral). Review of Resident #3's Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/26/2026, revealed in part: Section C the resident had a BIMS score of 09 indicating his cognition was moderately impaired. In Section GG the resident was dependent on staff for personal hygiene care. Review of Resident #3's care plan revealed a focus area dated 08/23/2025 that read in part, The resident requires staff assistance for ADL care. Interventions in part: Assist the resident with hygiene and grooming tasks. On 05/17/2026 at 12:46 pm., an observation was made of Resident #3. The resident was awake and lying in bed. His fingernails on both hands were dirty with a dark brown caked substance underneath the outgrown portion of his nails. The resident stated he could not remember the last time his fingernails were cleaned. On 05/18/2026 at 10:00 a.m., a second observation was made of the resident in his bed. The resident's fingernails remained dirty with a dark brown caked substance underneath the outgrown portion of his nails. Resident #3 stated staff did not clean his nails. On 05/18/2026 at 10:20 a.m., an observation of Resident #3's nails and an interview was conducted with S2DON. She confirmed Resident #3's nails were dirty and stated the resident's nails should have been cleaned. Resident #86 Review of Resident #86's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and cardiomegaly. Review of Resident #86's care plan dated 11/13/2025 read in part, resident requires staff assistance for ADL care. Interventions read in part: Assist the resident with hygiene and grooming tasks. Review of Resident #86's Quarterly MDS (Minimum Data Set) dated 02/10/2026 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicates severe problems with thinking and memory. On 05/17/2026 at 12:23 p.m., an observation was made of the resident in the dining room on the memory unit. The resident's hair was observed with a greasy appearance, disheveled, and uncombed. On 05/18/2026 at 8:32 a.m., a follow up observation of the resident was conducted while the resident was in her room. Further observation revealed the resident's hair remained uncombed and greasy. Attempted an interview with the resident, but resident was not interviewable. Resident #91 Review of Resident #91's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses that included, but not limited to, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, muscle weakness, contracture of muscle, right lower leg, and contracture of muscle left lower leg. Review of Resident #91's care plan dated 07/10/2024 read in part, resident requires staff assistance for ADL care. Assist resident with hygiene and grooming tasks. Interventions read in part: Assist the resident with hygiene and grooming tasks. Review of Resident #91's Annual MDS (Minimum Data Set) 03/24/2026 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicates severe problems with thinking and memory. On 05/17/2026 at 1:44 p.m., an observation was made of Resident #91 while he was in his room. The resident's hair was uncombed and matted in the back of his head. On 05/18/2026 at 12:35 p.m., another observation of Resident #91 was conducted while the resident was in his room. The resident's hair remained matted on the back of his head. Attempted an interview with the resident, but the resident was not interviewable. On 05/18/2026 at 12:36 p.m., an observation and interview was conducted with S16LPN who was the nurse on the unit. S16LPN observed and confirmed that Resident #86 and #91's hair was uncombed. She stated staff was supposed to comb the residents' hair after they had gotten them dressed for the day. Resident #104 A review of the facility's policy titled, AM Care Policy and Procedure with a review date of 09/05/2026, read in part Policy: AM care will be provided to all residents daily and as needed. Procedure:. 7. Shave resident if applicable . Review of Resident #104's Electronic Health Record (EHR) revealed that she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysarthria, anxiety disorder, depression, and cognitive communication deficit. Review of Resident #104's annual MDS, with an assessment reference date of 05/06/2026, Section C revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated Resident #104 was cognitively intact. Review of Section GG revealed in part:.Personal hygiene: The ability to maintain personal hygiene. shaving. dependent. Review of Resident #104's care plan revealed in part, that the resident required staff assistance for Activities of Daily Living (ADL) care. The interventions read in part: . Assist the resident with hygiene and grooming tasks. Further review of Resident #104's care plan revealed in part: . resident had a communication problem related to aphasia, dysarthria with an intervention that read: resident is able to communicate by using: communication board, gestures. On 05/17/2026 at 9:00 a.m., an interview and observation was conducted with Resident #104. An observation of Resident #104 revealed white and black facial hair on her neck, cheeks, chin, and around her mouth. The hair on her neck were long enough to cover her skin. The hair on her cheeks were long enough to curl. The hair on her chin and around her mouth appeared as stubble. Resident #104 was unable to speak and used head nods to communicate. The resident nodded her head up and down to indicate yes when asked, do you know you have long hair on your face? The resident nodded her head up and down to indicate yes when asked, would you like staff to shave your face? The resident nodded her head up and down to indicate yes when asked, does the hair on your face bother you? The resident was asked was your last shower yesterday, 05/16/2026, and resident nodded her head up and down to indicate yes. Resident #104 was asked if staff shaved her face yesterday, 05/16/2026, and she turned her head left to right and back to left to indicate no. The resident was asked if she would have wanted staff to shave her face yesterday, and she nodded her head up and down to indicate yes. On 05/18/2026 at 12:00 p.m., an interview and observation was conducted with Resident #104 and S23LPN. S23LPN observed the resident standing at the foot of the resident's bed, and confirmed Resident #104 had excessive long hair on her neck, hair on her cheeks that curled, and hair around her mouth. S23LPN confirmed the resident should have been shaved when she received a shower on Saturday, 05/16/2026, but was not. Resident #104 was asked if she would have wanted to be shaved when she had a shower on Saturday, 05/16/2026, and she nodded her head to indicate yes. On 05/18/2026 at 1:00 p.m., an interview and observation was conducted with Resident #104 and S2DON. S2DON confirmed Resident #104 had long hair on her face and she needed to be shaved now. Resident #104 was asked if she would have wanted to be shaved when she had a shower her Saturday, 05/16/2026, and she nodded her head to indicate yes.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. This was evidenced by:A dirty trash can on Resident #115's bed.Staff failing to perform appropriate hand hygiene during medication administration; andStaff failing to follow enhanced barrier precautions (EBP) for Resident #33 and Resident #78.Findings: 1. On 05/17/2026 at 10:49 a.m., an observation was made of Resident #115's room. The resident was not in her room. There was a yellow wet floor sign at the entrance to the room. Resident #115's bed was made and a black trash can with a white plastic bag liner was observed on the resident's bed. On 05/17/2026 at 10:49 a.m., an observation of Resident #115's room was conducted with S20HK and S21CNA. They both confirmed the above observation and stated the trash can should not be on the resident's bed. S20HK stated she had placed the trash can on the resident's bed and should not have done so. On 05/18/2026 at 9:50 a.m., an interview was conducted with S3ADON/IP. She was asked whether it was good practice to place a dirty trash can on the resident's bed. S3ADON/IP stated that was not o.k. She stated something (germs) could have been transferred to the resident's bed from the dirty trash can. 2. The facility's Hand Hygiene Policy and Procedure read in part,.Purpose: 1. To provide guidance and procedure to hand hygiene when providing direct care to residents. 2. To reduce the potential transmission of germs to residents. 3. To reduce the risk of healthcare provides acquiring germs form resident direct care. Policy: Hand hygiene shall be performed.3. Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. On 05/17/2026 at 09:35 a.m., S14LPN was observed administering medications to the residents on the hall. She was observed touching the door knob to Resident # 56's room and opened the door. She looked in the room and then returned back to her medication cart. She started dispensing the resident's medications without performing hand hygiene. A bottle of hand sanitizer was observed on the right side of S14LPN's medication cart. While dispensing Resident #56's medications, she was observed touching her nose and computer screen without sanitizing her hands afterwards. Then, S14LPN filled a drinking cup with water and went in Resident #56's room to administer the medications. She returned to her cart to prepare the next resident's medication without sanitizing her hands before preparing the medications. On 05/17/2026 at 09:38 a.m., S14LPN was observed going into Resident #100's room to give the resident his medications. She was observed going to the foot of the resident's bed and touching the handle at the foot of the bed to adjust the resident's head of his bed up before giving him his medications. After administering Resident #100's medication, she returned to the foot of the bed and touched the handle again to adjust the resident's head of his bed. S14LPN returned to her medication cart and started preparing medications for the next resident without sanitizing her hands. On 05/17/2026 at 09:43 a.m., S14LPN was observed going into Resident #40's room to administer the resident her medication. She returned to her medication cart and started to prepare the next resident's medication without sanitizing her hands. On 05/17/2026 at 09:50 a.m., an interview was conducted with S14LPN. She confirmed that she had not performed hand hygiene between administering medications to Resident #56, Resident #100 and Resident #40 and she should have. On 05/18/2025 at 12:33 p.m., an interview was conducted with S3ADON/IP. S3ADON/IP confirmed that the nursing staff should perform hand hygiene between residents during medication administration. 3. Resident #33 A review of the facility's policy titled Enhanced Barrier Precautions Policy & Procedure, with a last reviewed date of 09/05/2025, read in part: Purpose: To prevent the spread of potential infection by implementing Enhanced Barrier Precautions (EBP). Procedure: 4. For residents for whom EBP are indicated, EBP is employed when performing the following. a. Dressing b. bathing/showering c. Transferring. 5. PPE is to be applied prior to performing the high-contact resident activity according to below. b. Put on a gown and gloves. A review of the facility's policy titled Hand Hygiene Policy and Procedure, with a last reviewed date of 09/05/2025, read in part: Definition(s); Hand Hygiene – Hand hygiene means cleaning your hands by using either hand washing (washing hands with soap and water), antiseptic hand wash, antiseptic hand rub (i.e. alcohol based hand sanitizer including foam or gel) . Policy: Hand hygiene shall be performed:. 7. Before and after assisting a resident with meals. A review of Resident #33's EMR (Electronic Medical Record) revealed an admission date of 02/28/2022, with diagnoses that included, but were not limited to, anemia with chronic kidney disease, type 2 diabetes mellitus with chronic kidney disease, and Alzheimer's disease. A review of Resident #33's current care plan revealed in part: The resident has a clinical condition. that warrants enhanced barrier precautions. On 05/17/2026 at 9:25 a.m., an observation was conducted of Resident #33 being transferred from his bed to his wheelchair by S28CNA and another Certified Nursing Assistant (CNA) from another hall. S28CNA and the CNA that came from the other hall did not wear gowns during the resident transfer. The other CNA from the other hall left immediately after the transfer and was unable to interview. On 05/17/2026 at 9:36 a.m., an interview was conducted with S28CNA. S28CNA confirmed she did not wear a gown when transferring Resident #33 from his bed to his wheelchair. On 05/18/2026 at 9:35 a.m., a second observation and interview was conducted of Resident #33's care. S21CNA entered Resident #33's room and walked over to his bedside table beside his bed to feed Resident #33 his breakfast. When she was about to pick up the lid of the insulated plate on Resident #33's food tray, she was asked if she had used hand sanitizer or washed her hands before feeding Resident #33. S21CNA stated no. S21CNA stated was too busy to use hand sanitizer or wash her hands. On 05/18/2026 at 2:17 p.m., an interview was conducted with S26LPNTX. S26LPNTX confirmed Resident #33 was on EBP. S26LPNTX confirmed an EBP sign was on the wall at the entrance of Resident #33's room. S26LPNTX confirmed the EBP sign read, Enhanced Barrier Precautions, when providing high contact care. staff must wear. a gown. gloves.when transferring. S26LPNTX confirmed staff should wear a gown and gloves when providing high contact care to Resident #33. On 05/18/2026 at 2:35 p.m., an interview was conducted with S3ADON/IP. S3ADON/IP confirmed all staff should wear gowns and gloves when transferring a resident who was on EBP, and confirmed that all staff should wash their hands or use hand sanitizer before feeding residents. Resident #78 A review of Resident #78's EMR revealed an admission date of 09/05/2022 with diagnoses that included, but were not limited to, ileostomy status, encephalopathy, conjunctivitis, and urinary tract infection. A review of Resident #78's most current care plan revealed the resident had a clinical condition (i.e. chronic wound, etc.) and or medical device (i.e. urinary catheter, feeding tube, central line, tracheostomy, etc.) that warrants enhanced barrier precautions. On 05/18/2026 at 9:45 a.m., an observation and interview was conducted of care being provided to Resident #78. S29CNA was observed washing Resident #78's face, chest and stomach with a warm wash cloth. S29CNA did not wear a gown during patient care. S29CNA stated I do not consider these people as germs and I am not afraid of germs. S29CNA confirmed she should have worn a gown when providing care to Resident #78. On 05/18/2026 at 10:05 a.m., an observation was made of S29CNA and S30LPNS transferring Resident #78 from his bed to his wheelchair. S30LPNS asked S29CNA if there were any gloves in the room and S29CNA stated no. S30LPNS and S29CNA then transferred Resident #78 from his bed to his chair. S29CNA did not wear a gown when transferring Resident #78. S30LPNS did not wear a gown or gloves when transferring Resident #78. On 05/18/2026 at 2:17 p.m., an interview was conducted with S26LPNTX. S26LPNTX confirmed Resident #78 was on EBP. S26LPNTX confirmed an EBP sign was on the wall at the entrance of Resident #78's room. S26LPNTX confirmed the EBP sign read, Enhanced Barrier Precautions, when providing high contact care. staff must wear. a gown. when transferring. S26LPNTX confirmed staff should wear a gown when providing high contact care to Resident #78. On 05/18/2026 at 2:35 p.m., an interview was conducted with S3ADON/IP. S3ADON/IP confirmed all staff should use gowns and gloves when transferring, dressing, and bathing a resident who was on EBP.

Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service as evidenced by:1. S8DA failing to cover exposed facial hair while serving food to residents,2. Food items in the facility's kitchen cooler and freezer were unlabeled, opened, and undated;3. lack of cleanliness of the facility's kitchen;4. Failing to ensure kitchen equipment was in good repair; and5. Failing to ensure foods on the food service line were at appropriate temperatures.This deficient practice had the potential to affect the 102 residents who consumed foods from the kitchen.Findings:1. Review of the facility's policy titled, Employee Sanitation Practices with a last reviewed date of 09/05/2025, revealed in part .3. Proper Work Attire .b. The food service employee observes the following dress standards: i. Wears a clean hat or other hat restraint. Employees will facial hair wear a bear restraint .On 05/17/2026 at 8:25 a.m., S8DA was observed serving the breakfast meal to residents with his mustache and facial hair exposed. On 05/17/2026 at 8:38 a.m., S7DA and S8DA both confirmed S8DA's facial hair needed to be covered.2. Review of the facility's policy titled, Food Storage Labeling with a last reviewed date of 09/05/2025, revealed the facility will store and label all foods to ensure safety and quality. Procedures: 1. All temperature controlled foods and ready-to eat foods that are prepared in the facility shall be labeled with the food name, date, and time of storage and use by or discard date.7. Food is stored in containers that are sealable, leak proof, durable and undamaged.The initial kitchen tour was conducted with S12Cook on 05/17/2026 at 8:42 a.m. An observation of food storage in the facility's walk in cooler revealed one and one half bags of shredded lettuce not labeled or dated, one half bag of shredded lettuce undated, lettuce wilted with brown areas, and the cooler fan had visible lint on its exterior surface. An observation of food storage in the facility's walk in freezer revealed two opened/unlabeled clear plastic opened bag of frozen diced chicken, and one opened bag of frozen chicken. S12Cook confirmed the items should have been labeled, dated and sealed.On 05/17/2026 at 8:55 a.m., S6DM arrived and was informed of the above findings.3. On 05/17/2026 at 9:45 a.m., an observation was made of the fryer with visible particles present in grease. The fryer was on the side of the six burner stove. An observation was made of the stainless steel wall, behind the stove and fryer, with visible lint and residue on the walls.On 05/17/2026 at 11:13 a.m., an observation was made of ice machine #2. Behind the ice machine was visible lint on the wall, and two plastic resident pitchers were on observed on the floor.On 05/18/2026 at 8:38 a.m., a second observation was made of ice machine #2. Visible lint remained on the walls and floor behind the ice machine. Two plastic resident pitchers remained on the floor behind the ice machine.On 05/19/2026 at 9:10 a.m., a third observation was made of ice machine #2. Visible lint remained on the walls and floor behind the ice machine. Two plastic resident pitchers remained on the floor behind the ice machine.On 05/19/2026 at 9:15 a.m., S6DM confirmed two plastic resident pitchers were behind ice machine #2 and lint on the wall behind the ice machine was present. S6DM stated housekeeping was responsible for cleaning that area.4. On 05/17/2026 at 11:19 a.m., an observation was made of the kitchen's steam table located in the communal dining room. The steam table had six turn knobs used to regulate the temperature of food. Three of the six turn knobs were missing.On 05/17/2026 at 11:38 a.m., S6DM confirmed food items were located on the steam table where the three turn knobs were missing.On 05/19/2026 at 8:10 a.m., a follow up observation revealed S7DA serving breakfast menu items from the steam table. The steam table remained with three of the six turn knobs missing. On 05/19/2026 at 9:21 a.m., an interview was conducted with S11Maintenance. S11Maintenance reviewed work orders and confirmed there was no work order request regarding the steam table's missing knobs.5. Review of the facility's policy titled, Tray Assembly and Service, with a last reviewed date of 09/05/2025, revealed: 1. All menu items required for the meal service are placed on the steam table or serving line. 2. Hot food is placed on the steam table after being processed to the recommended temperature, and is held at minimum of 135 degrees F. (Fahrenheit)Review of the facility's policy titled, Monitoring Temperatures of Cooked Foods, with a last reviewed date of 09/05/2025, revealed:.2b. Check temperature when food is placed in hot holding equipment. If below 135 degrees F, reheat to 165 degrees F for 15 seconds and place back in the holding equipment.On 05/17/2026 at 11:30 a.m., S6DM was observed measuring the temperature of the lunch meal menu items on the steam table with a thermometer. During food temperature monitoring, S6DM identified the pureed chicken, mashed potatoes and pureed vegetables were held at 130 degrees F. On 05/19/2026 at 9:15 a.m., a final observation of identified noncompliance was reviewed with S6DM. S6DM confirmed grease in fryer with food particles, S6DM confirmed the lint and debris visible on the wall behind the stove and fryer. S6DM further confirmed the cooler fan with lint exposed on exterior of fan. S6DM reported she put in a work order for the cooler fan to maintenance on 04/24/2026 but it had not been cleaned. S6DM verified she did not request a work order for the kitchen steam table's three missing knobs and should have.

Based on observations, interviews, and record review, the facility failed to ensure services provided met nursing professional standards for medication administration by failing to ensure medications were not left at the bedside for 2 (#40 and #61) out of 42 sampled residents. Findings:Resident #40. Review of Resident #40's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, radiculopathy, lumbar region, chronic obstructive pulmonary disease, Type 2 diabetes mellitus without complications, paroxysmal atrial fibrillation, anxiety disorder, and cardiomyopathy, unspecified. Review of Resident #40's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 14, indicating the resident's cognition was intact. Review of Resident #40's MAR (Medication Administration Record) for May 2026 revealed S14LPN administered the resident's 8 a.m. (morning) medications on 05/17/2026. On 05/17/2026 at 08:50 a.m., an observation was made of S14LPN administering Resident #40's medication. S14LPN left a medication cup with the resident's morning medications on the resident's bedside table and exited the resident's room and did not observe the resident swallow the medications.05/17/2026 at 10:00 a.m., a review of Resident #40's electronic health record was conducted and revealed that Resident #40 had not been assessed and approved for self-administration of medication. 05/17/2026 at 10:21 a.m., an interview was conducted with Resident #40. The resident stated sometimes the nurses would use short cuts because they are so overwhelmed and leave her medications on her bedside table for her to take herself. Resident #61. Review of Resident #61's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unilateral primary osteoarthritis, left knee, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, generalized anxiety disorder, and dysphagia following cerebral infarction. Review of Resident #61's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident's cognition was intact. Review of Resident #61's MAR (Medication Administration Record) for May 2026 revealed S14LPN administered the resident's 8 a.m. (morning) medications on 05/17/2026. On 05/17/2026 at 08:53 a.m., an observation was made of S14LPN administering Resident #61's medication. S14LPN left a medication cup with the resident's morning medications on the resident's bedside table and exited the resident's room and did not observe the resident swallow the medications.On 05/17/2026 at 10:00 a.m., a review of Resident #61's electronic health record was conducted and revealed that Resident #61 had not been assessed and approved for self-administration of medication.On 05/17/2026 at 12:41 p.m., an interview was conducted with Resident #61. She stated that some of the nurses will leave her the cup with her medications for her to take herself. On 05/17/2026 at 10:30 a.m., an interview was conducted with S14LPN. She stated that she left Resident #40 and Resident #61's medications with the residents because she doesn't have to watch them take their medications. S14LPN stated that she was not aware of any facility policy that stated that medications cannot be left with the resident to take on their own. On 05/19/2026 at 2:50 p.m., an interview was conducted with S2DON. She confirmed that S14LPN should not have left medications with the residents to take on their own. Stated that the nurse should have remained with the residents to ensure they took all of their medications.

Based on observations, interviews and record reviews, the facility failed to implement the plan of care per the physician's orders for 1 (#18) of 42 sampled residents, by failing to change Resident #18's left arm dressing, and elevate the resident's swollen left arm while she was in bed. Findings:On 05/19/2026, a review of the facility's policy titled, Care Plan Policy and Procedure, with a last reviewed date of 09/05/2025, read in part: Purpose: The comprehensive plan of care is an interdisciplinary tool used to communicate and address care issues that are relevant to the resident's individual needs. Policy: A comprehensive plan of care will be used to communicate and address care issues that are relevant to the resident's individual needs.A review of Resident #18's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited, to end stage renal disease; chronic diastolic (congestive) heart failure; laceration without foreign body of left forearm; localized swelling, mass and lump, left upper limb; dependence on renal dialysis.A review of Resident #18's current physician's orders revealed the following in part:-04/27/2026 Elevate L (left) arm when in bed every shift for edema.-05/11/2026 WOUNDCARE: Left forearm: Cleanse with wd (wound) cleanser of choice. Pat dry. Apply tao (triple antibiotic ointment) and cover with dcd (an outer wound dressing) one time a day related to laceration without foreign body of left forearm.On 05/17/2026 at 10:11 a.m., an observation was made of Resident #18 in her room. The resident was lying in her bed. The resident's left arm was swollen and was not elevated. The resident had a white dressing with a transparent border dated 5/15 and initial DAOn 05/17/2026 at 10:18 a.m. an observation of Resident #18's arm and an interview was conducted with S9RNS. She confirmed the resident's dressing was dated 5/15 with initial DA. S9RNS stated she would check to see when the dressing was due to be changed but she did not return to the resident's room before surveyor left the resident's room. On 05/18/2026 at 8:40 a.m., a second observation was made of Resident #18 in her bed. The resident's left arm remained swollen and was not elevated.On 05/18/2026 at 8:47 a.m., an observation of Resident #18's left arm and an interview was conducted with S19CD and S22CC. They both confirmed the swelling in the resident's left arm and acknowledged the resident's left arm was not elevated. On 05/18/2026 at 9:00 a.m., an interview was conducted with S24CNA. S24CNA stated she was not aware of the swelling in Resident #18's arm or that her arm needed to be elevated. She stated the nurse was supposed to make her aware of the resident's care plan needs and the nurse did not inform her. On 05/18/2026 at 9:11 a.m., an interview was conducted with S25LPN. She stated the swelling in the resident's left arm was an ongoing problem and staff should elevate her left arm while she was in bed. She confirmed she had gone in the resident's room to administer her morning medications, but did not elevate her left arm. S25LPN was asked how Certified Nursing Assistants (CNAs) were made aware of interventions that should be carried out, and she stated through nurses communication. S25LPN stated she did not communicate to S24CNA this morning (05/18/2026) regarding the resident's arm needing to be elevated. On 05/18/2026 at 9:24 a.m., an interview was conducted with S26LPNTX who was responsible for providing the resident's wound care. She confirmed she had worked on Friday 05/15/2026 and that she changed the resident's dressing and labeled it with the date and her initial (05/15 DA). She stated that it should have been changed on 05/16/2026 and again on 05/17/2026 by the weekend treatment nurse, because it is scheduled to be changed daily. S26LPNTX further stated the resident was admitted with her arm swollen and weeping and confirmed the resident had an order to elevate her left arm while she was in bed. On 05/18/2026 at 10:12 a.m., an interview was conducted with S2DON. She stated that all staff had access to residents care plans to know what to do and carry out orders.

Based on record review and interview, the facility failed to ensure residents who had a qualifying diagnosed mental disorder were referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #29) out of 42 sampled residents. Findings: Review of Resident #29's clinical record revealed an admission date of 02/18/2017. The resident's diagnoses included bipolar disorder and major depressive disorder.Review of the resident's PASARR level I evaluation dated 06/22/2020 revealed, . The psychiatric progress note {02/03/2020}, the current diagnostic impression is major depressive disorder . A level II decision is not required . Further review revealed the resident's diagnosis of bipolar disorder was not on the form. Review of the resident's clinical record revealed there was no evidence a PASARR level II was completed with the resident's qualifying diagnosis of bipolar disorder. On 05/18/2026 at 11:02 a.m., an interview was conducted with S5SSD. S5SSD stated that a level II PASARR was not completed because the level II evaluation that was conducted on 06/22/2020 did not include the resident's diagnosis of bipolar disorder and that it should have. S5SSD confirmed that a level II evaluation was not completed.

Based on observation, record review and interview, the facility failed to ensure staffing information was complete, accurate, and posted daily. The facility's census was 105.Findings: On 05/17/2026 at 8:43 a.m., an observation was made of the staffing information posted on the bulletin board that was dated Wednesday, 05/13/2026. Daily Nursing Assignment log was dated 05/17/2026, however the posted information was not complete or accurate and failed to include a census number and the hours of services to be provided. Staff member S27CNA was listed on the day shift Daily Nursing Assignment log dated 05/17/2026 but was unaccounted for on the hall. On 05/17/2026 at 8:45 a.m., an interview was conducted with S9RNS, who revealed that she was not aware that S27CNA was not present at the facility. On 05/17/2026 at 8:57 a.m., S9RNS informed the surveyor that S27CNA called in but it was not reported to her. S9RNS further stated that an overall accurate daily staffing posting had not been posted and she had not seen one. On 05/17/2026 at 8:59 a.m., S10WC confirmed the daily staffing had not been posted. She stated that the night shift was supposed to post it and confirmed it wasn't posted.

Based on interviews and record review, the facility failed to file a grievance for a complaint of missing clothes for 1 (Resident #96) of 1 resident reviewed for grievances. Findings: A review of the facility's training, Safeguarding Resident Rights In Nursing Facilities provided to all staff during the orientation process revealed in part, If a resident reports a concern, the organization must promptly attend to and resolve the matter. Examples of complaints can include: loss of personal property. Notify your supervisor about complaints. A review of the facility's policy, Grievance Policy and Procedure with a review date of 09/05/2025 revealed in part, Procedure: take immediate action, Documentation: 1. Document grievances made by a resident. A review of Resident #96's electronic health record (EHR) revealed an admission date of 04/07/2020 with diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic nephropathy, peripheral vascular disease, and chronic obstructive pulmonary disease. A review of Resident #96's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. On 05/17/2026 at 9:40 a.m., an interview was conducted with Resident #96. He stated he could not find 3 pair of pants, 2 shirts, and 1 pair of underwear last week. He stated he told someone in laundry about the missing clothes last week, but could not remember who he told. A review of the facility's resident grievance/ complaint log for the month of May 2026 revealed no grievance filed for Resident #96. On 05/18/2026 at 10:10 a.m., an interview was conducted with S15HK. S15HK confirmed Resident #96 was missing clothes and housekeeping had been looking for his things since last week. On 05/18/2026 at 10:55 a.m., an interview was conducted with S5SSD. S5SSD confirmed there was no grievance filed on behalf of Resident #96 during the month of May 2026. On 05/18/2026 at 11:06 a.m., an interview was conducted with S17HKSUP. S17HKSUP stated she did not know Resident #96 complained of missing clothes. S17HKSUP confirmed that if a resident complained of missing clothing last week, it should have been reported to the housekeeping supervisor the same day it was reported to the staff member. On 05/17/2026 at 11:10 a.m., an interview was conducted with S13HK. S13HK confirmed Resident #96 told her he was missing clothes on Thursday, 05/14/2026. She confirmed she did not document Resident #96's complaint of missing clothes. She stated that her supervisor was at work that day but she did not tell her supervisor. On 05/18/2026 at 12:10 p.m., an interview was conducted with S1ADM. S1ADM confirmed a grievance should have been filed on the same day a complaint was made by Resident #96 for missing clothes. S1ADM confirmed housekeeping should have filed a grievance the same day the complaint was made.

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk-in cooler not labeled with the date and time, name of food; and 2. expired food in the walk-in cooler and walk-in deep freezer. This facility had a census of 106 residents. Findings: On 06/01/2025, a review of the facility's policy titled, Storage of Refrigerated Food, with a last revision date of July 2012, revealed in part . Policy Statement: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: .4. All non-hazardous, opened foods are labeled name of food and date stored. 5. All hazardous foods are labeled with name of food and date to be discarded or date stored . On 06/01/2025, a review of the facility's policy titled, Storage of Frozen Food, with a last revision date of July 2012, revealed in part . Policy Statement: The facility ensures the quality and safety of frozen foods through accepted storage practices. Procedure .5. Food taken out of original containers is put in a clean, sanitized container with a tight fitting lid. No food is left uncovered .9. Frozen foods are used or discarded on or before the expiration date . On 06/01/2025 at 8:33 A.M., a tour of the facility's kitchen was conducted with S1DS (Dietary Supervisor), who stated that she was responsible for the day to day management of the kitchen. On 06/01/2025 at 8:45 A.M., an observation of the walk-in cooler was conducted with S1DS and revealed the following items were opened and not labeled with the date and time they were opened: a large container of mayonnaise, a large bag of sliced cheddar cheese, a large bag of shredded cheddar cheese, a carton of whole milk, and a large bag of shredded lettuce. The lettuce was observed with discoloration and texture changes that indicated the food was spoiled. Further review of the walk in cooler revealed the following items: two plastic gallon bags of taco shells dated 05/18/2025, and a tray of small covered plastic containers of red liquid that was not labeled, dated 05/24/2025. At that time, S1DS confirmed the food items listed above were opened, and not labeled with the date and time they were opened, and should have been. She also confirmed the shredded lettuce, taco shells, and tray of red liquid was spoiled/expired and should have been discarded. On 06/01/2025 at 8:52 A.M., an observation of the walk-in freezer was conducted with S1DS and revealed the following: a plastic gallon bag with an opened bag of hash browns with an expiration date of 03/11/2025, and a large, unsealed, bag of cut okra with an expiration date of 05/07/2025. At that time, S1DS confirmed the food items listed above were expired and should have been discarded.

Based on records reviewed, observations, and interviews, the facility failed to ensure the resident's care plan and physician's orders were followed for 3 (#11, #91, and #102) of 34 sampled residents. This was evidenced when: 1. Facility staff failed to administer Resident #11, and Resident #102 their therapeutic diets as prescribed by the physician. 2. Facility failed to maintain right and left ear cushions to nasal cannula for Resident #91 3. Facility staff failed to ensure Resident #102 was assisted in meal set up per her comprehensive care plan, and failed to administer oxygen according to physician orders. Findings: Review of Resident #11's electronic clinical record revealed an admit date of 02/28/2022 with diagnoses that included encephalopathy, dementia, Alzheimer's disease, and dysphagia, oropharyngeal phase. Review of Resident #11's physician orders dated June 2025 revealed the following order: No added salt (NAS) pureed texture, nectar/mildly thick consistency. Review of the resident's care plan initiated 05/03/2022 read in part: resident is on a mechanical soft, NAS diet. Interventions read in part: provide/serve diet as ordered. On 06/02/2025 at 8:35 A.M., an observation of Resident #11's breakfast tray was conducted. The resident was observed eating grits, pureed scrambled eggs, pureed sausage, thickened lemon water, and milk that was not thickened. On 06/02/25 at 8:46 A.M., an observation and immediate interview was conducted with S5LPN (Licensed Practical Nurse) who stated that the milk was not the correct consistency according to the physician orders, and that the milk should have been thickened. On 06/03/2025 at 10:46 a.m. A.M., an interview was conducted with S6DM (Dietary Manager) who stated Resident #11, and was on a puree, nectar thickened liquid diet. She stated when food trays go on the hall, it was the responsibility of the certified nursing assistant to ensure the residents were receiving the correct diet and the correct fluids. Resident #102 Review of Resident #102's electronic clinical record revealed an admit date of 05/02/2025 with diagnoses which included alcoholic cirrhosis of liver with ascites, dyspnea, and chronic kidney disease stage 5. Review of Resident #102's physician's orders dated June 2025 read in part: Renal (Dialysis) diet regular texture. Further review revealed an order for oxygen via nasal cannula at 3 liters. Review of the resident's care plan dated 05/02/2025 read in part: resident requires staff assistance for Activities of Daily Living (ADL) care. Interventions included in part: assist the resident with their meal tray set up. Further review of the resident's care plan revealed the following: Oxygen therapy, with an interventions for oxygen via nasal cannula at 3 Liters continuous. On 06/01/2025 at 9:00 A.M., an interview was conducted with Resident #102's responsible party who stated that the resident had not received her breakfast tray. On 06/01/2025 at 9:33 A.M., an interview was conducted with S8CNA (Certified Nursing Assistant) who stated that Resident #102's breakfast tray was left on the food cart. She stated that the CNA who distributed the food trays was distracted by another resident and had forgotten to setup the breakfast tray for the resident. On 06/01/2025 at 9:35 A.M., S8CNA was observed assisting Resident #102 with her breakfast meal and giving her orange juice to drink. On 06/01/2025 at 9:40 A.M., an observation and immediate interview was conducted with S7LPN (Licensed Practical Nurse) who confirmed Resident #102 was on a renal diet and should not have been served orange juice. On 06/03/2025 at 11:25 A.M., an interview was conducted with S6DM who confirmed that the resident was on a renal diet, and should not have had orange juice on her meal tray. On 06/02/2025 at 7:35 A.M., an observation was conducted in Resident #102's room. The resident was observed lying in bed, awake, and alert. Further review revealed her oxygen concentrator machine was off, and the resident was not wearing her oxygen. On 06/02/2025 at 8:35 A.M., a second observation was conducted in the resident's room. The resident was alert, and awake. Further review revealed the oxygen concentrator was still off and, she was not wearing her oxygen as ordered by the physician. On 06/02/2025 at 10:14 A.M., a third observation of the resident was conducted in her room. The resident's responsible party was at the bedside. The resident was alert, and confused. On 06/02/2025 at 11:49 A.M., S11CNA checked Resident #102's oxygen saturation level which was 88% (percent) on room air. On 06/02/2025 at 11:56 A.M., S12LPN rechecked Resident #102's oxygen saturation level which was 84% on room air. After S12LPN applied the oxygen to the resident at 3 liters via nasal cannula, her oxygen saturation level increased to 94%. On 06/02/2025 at 2:35 P.M., an interview was conducted with S12LPN who stated Resident #102 had not had her oxygen on, and she should have had her oxygen on. Resident # 91 Review of Resident #91's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia and shortness of breath. Review of Resident #91's Order Summary Report revealed the following order dated 08/14/2024, Maintain right/left ear cushion q (every) shift to nasal cannula every shift. Review of Resident #91's Care Plan Report revealed the following in part, the resident has oxygen therapy r/t (related to) ineffective gas exchange. Interventions included in part, maintain bilateral ear cushions to nasal cannula. On 06/02/2025 at 11:29 A.M., an observation was conducted with Resident #91 in her room. Resident #91 was wearing a nasal cannula. There were no ear cushions were noted to the right or left side of nasal cannula. On 06/02/2025 at 12:21 P.M., a second observation was conducted with Resident #91 in her room. Resident #91 was wearing a nasal cannula. There were no ear cushions were noted to the right or left side of nasal cannula. On 06/02/2025 at 1:42 P.M., a third observation was conducted with Resident #91 in her room. Resident #91 was wearing a nasal cannula. There were no ear cushions were noted to the right or left side of nasal cannula. On 06/02/2025 at 2:09 P.M., an interview, record review and observation of Resident #91 was conducted with S10LPN (Licensed Practical Nurse). S10LPN confirmed that Resident #91 had a physician's order to maintain right and left ear cushions to nasal cannula. S10LPN confirmed that resident did not have right and left ear cushions on her nasal cannula.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received assistance with incontinent care for 2 (#61 and #72) of 8(#3, #31, #43, #57, #61, #72, #82, and #92) residents investigated for ADL care. Findings: Resident #61 On 06/03/2025, a review of the facility's policy titled Incontinence Care Policy and Procedure effective 11/17/2015, read in part: Purpose .4. To prevent infection. Policy: Incontinence care will be performed as needed .11. Replace incontinence pad or apply disposable diaper as necessary. Review of Resident #61's Electronic Health Record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to atherosclerosis of coronary artery bypass graft without angina pectoris, type 2 diabetes, and overactive bladder. Further review revealed a diagnosis of urinary tract infection with an onset date of 05/31/2025. Review of Resident #61's quarterly Minimum Data Set (MDS) dated [DATE], revealed in section C that the resident had a brief interview for mental status (BIMS) of 14, indicating her cognition was intact. Further review revealed in section H that the resident was frequently incontinent of urine and always incontinent bowel. Review of Resident #61's care plan revealed a focus area dated 12/21/2024 the resident requires staff assistance for ADL care and interventions which read in part, assist the resident with hygiene and grooming tasks. Further review revealed a focus area dated 06/01/2025 the resident has a urinary tract infection and interventions which read in part, check at least every 2 hours for incontinence. During an interview with Resident #61 on 06/02/2025 at 9:12 A.M., she stated that she was changed before she went to sleep last night (06/01/2025) and no one had changed her since then. The resident also stated that she had asked someone (unable to state who) who came in to change her roommate about an hour ago to ask her Certified Nurse Assistant (CNA) to come in and change her because her brief was wet and no one came. During an interview with S4CNA on 06/02/2025 at 9:17 A.M., she stated she started her shift at 6:00 A.M., and confirmed that she had not checked or changed Resident #61's incontinent brief. She further stated that no one told her the resident needed to be changed. During an interview with S2ADON (Assistant Director of Nursing) on 06/02/2025 at 9:36 A.M., she stated that CNAs are supposed to round on all their residents as soon as they start their shift. S2ADON stated that S4CNA should have known better. Resident #72 Resident #72 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to Parkinson's disease without dyskinesia, benign prostatic hyperplasia, muscle weakness, difficulty in walking and other lack of coordination. Review of Resident #72's Annual Minimum Data Set (MDS) dated [DATE], revealed in section C that he had a brief interview for mental status (BIMS) of 14, indicating his cognition was intact. Further review revealed in section GG that the resident was dependent in toileting hygiene, and required substantial/maximal assistance in personal hygiene. Review of Resident #72's care plan revealed a focus area dated 11/13/2024 The resident requires staff assistance for ADL care r/t (related to) Parkinson's disease with interventions in part, assist the resident with hygiene . Further review revealed a focus area dated 11/13/2024 The resident has bladder incontinence, with interventions in part: Brief use: The resident uses disposable briefs .change PRN (as needed) check as required .Incontinent: Check as required for incontinence . During an observation of Resident #72 on 06/01/2025 at 9:53 A.M., the resident was lying in bed wearing a hospital gown. The resident stated that the last time a CNA (Certified nursing Assistant) checked his brief and changed him was around 5 A.M. Resident #72 was asked if he was wet and he stated, probably. On 06/01/2025 at 9:59 A.M., an observation of Resident #72 and an interview was conducted with S5LPN (Licensed Practical Nurse). She checked the resident's brief and stated it was wet, taped the wet brief back on the resident and told him she was going to get his CNA to change him. S5LPN stated that CNAs are supposed to round on their residents every 2 hours. During a follow-up interview with S5LPN on 06/03/2025 at 11:03 A.M., she stated that she should have changed Resident #72 on 06/02/2025 at 9:59 A.M. after she opened his brief to check him. S5LPN stated she did not think about it.

Based on record review, observations, and interviews, the facility failed to provide a safe homelike environment for 1 (#100) out of 6 (#21, #24, #38, #61, #92, and #100) residents sampled for environment. Findings: A review of Resident #100's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, muscle weakness and Chronic Obstructive Pulmonary Disease. A review of Resident #100's admission MDS (Minimum Data Set) dated 03/07/2025 revealed a BIMS (Brief Interview for Mental Status) of 5, indicating her cognition was impaired. On 06/01/2025 at 9:06 A.M. an observation was conducted of Resident #100. A black wire was hanging down from the ceiling and over the resident's bed. The connector was exposed and near the resident while she was lying down in bed. Resident #100 stated the black wire has been like this since she moved into this room a few weeks ago. On 06/02/2025 at 2:36 P.M., a second observation was conducted of Resident #100's environment while she was lying in her bed. A black wire was hanging down from the ceiling and over the resident's bed. The plug in was exposed and near the resident while she was lying in bed. On 06/02/2025 at 3:16 P.M., an interview was conducted with S4CNA (Certified Nursing Assistant). S4CNA stated if there were any environmental concerns, they were instructed to notify the nurse and then put it in the maintenance log. An observation was conducted of Resident #100's environment with S4CNA. She confirmed there was a black wire hanging down from the ceiling, and the plug- in was exposed and near the resident while she was lying in bed. S4CNA was asked if she had noticed the black wire before this observation, and she stated its been there. Resident #100 stated that the wire had been there and sometimes it touched her when she laid in bed. S4CNA confirmed that she did not tell the nurse about the wire or put it in the maintenance log and should have. S4CNA confirmed this was not a homelike environment and the black wire should not have been exposed and near the resident. On 06/02/2025 at 3:17 P.M., an interview was conducted with S13MS (Maintenance Supervisor). He stated he was responsible for all repairs the facility requires regarding the environment, including checking residents' beds and anything electrical. He denied conducting rounds on residents' rooms periodically. He stated he fixed things that were listed on the maintenance log. An observation was conducted of Resident #100's room with S13MS. He confirmed that there was a black wire hanging from the ceiling that almost touched the resident's bed. He confirmed this was not a homelike environment, and the black wire should have been put in the ceiling and should not have been hanging down.

Based on interviews and record review, the facility failed to protect the residents' rights to be free from neglect by failing to provide incontinence care for a dependent resident for 1 (#3) resident out of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's policy titled Abuse- Prevention and Prohibition Policy and Procedure with a last reviewed date of 03/25/2023 read in part 6. Neglect means failure of the facility, its employees or service providers to provide adequate medical care or goods and services to a resident to avoid, physical harm, pain, mental anguish, or emotional distress. Review of Resident #3's medical record revealed she was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infraction affecting left non dominant side and aphasia following cerebral infarction. Review of Resident #3's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. Further review of the residents MDS assessment Section GG- Functional Abilities revealed the resident was coded as dependent and required the assistance of 2 or more staff for toileting. Review of Section H - Bowel and Bladder revealed the resident was always incontinent of bowel and bladder. Review of Resident #3's care plan initiated on 07/16/2024 revealed the resident required staff assistance for ADL (Activities of Daily Living) care with an intervention to assist the resident with hygiene and grooming tasks. Review of a grievance form dated 01/24/2025 completed by S2ADON (Assistant Director of Nursing) on behalf of Resident #3 revealed the following in part: On 01/23/2025, resident crying in room at approx. (approximately) 2:20 p.m.; asked resident to help describe issue by picture board or nod yes or no during questioning when trying to find out cause of resident crying. When asked if CNA (Certified Nursing Assistant) upset her she nodded yes. When asked if CNA left her wet during shift she nodded yes. Steps taken to investigate complaint: Watched facility camera, CNA did not make rounds on resident for over four hours .Summary of Pertinent Findings or Conclusions Regarding Concerns: CNA assigned to hall was S3CNA. CNA assisted resident at 9:44 a.m., and did not make scheduled 2 hr (hour) rounds. CNA went in room at 1:29 p.m. and turned light off and left room and did not return. On 02/17/2025 at 12:40 p.m., an interview was conducted with S3CNA who confirmed that she cared for Resident #3 on 01/23/2025 from 6:00 a.m.-2:00 p.m. She stated that later in the shift, the resident called for her incontinence brief to be changed, but she had no help at the time. She then explained to the resident that because she required two person assistance, she would have to get help. She turned off the call light alert in the room, exited the resident's room, and continued to complete other tasks. S3CNA stated she had gotten side-tracked as other lights were going off, and did not go back to change Resident #3. S3CNA further stated she could have asked the nurse she observed on the hallway passing medications, the DON (Director of Nursing), ADON (Assistant Director of Nursing), or other CNAs from other halls for assistance, but did not. S3CNA stated she did not go back to change the resident before clocking out at the end of her shift. On 02/17/2025 at 2:56 p.m., an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed she investigated Resident #3's grievance. Through video evidence, it was revealed S3CNA went into the resident's room at 9:44 a.m., and did not go back to the resident's room to complete two hour rounds as she was supposed to do. Also, she went into the resident's room at 1:29 p.m., turned off the call light alert, and left the room and did not return. S2ADON further stated that S3CNA told her that she was completing other tasks, did not change Resident #3, and failed to go back and change the resident before clocking out. S2ADON confirmed S3CNA was not the only CNA on the hall that shift, and another CNA or the nurse was available to assist her. On 02/17/2025 at 3:05 p.m., an interview was conducted with Resident #3. Resident #3 was nonverbal. When asked if S2ADON spoke with her about a CNA (S3CNA) leaving her wet in January 2025, she nodded yes. She also nodded yes when asked if she had to wait for extended periods of time to be changed. Resident #3 nodded yes when asked if she was upset when the S3CNA didn't come back to change her, and nodded yes when asked if that made her sad. When asked if things had improved after making the complaint with the facility, Resident # 3 shook her head no. On 02/18/2025 at 3:25 p.m., a joint interview was conducted with S1DON (Director of Nursing) and S2ADON. Both S1DON and S2ADON stated that CNAs were required to round on residents every two hours, and that S3CNA should have rounded on the resident again after her initial rounds at 9:44 a.m. They also acknowledged that when Resident #3 called to be changed at 1:29 p.m., S3CNA should not have turned the call light off in the resident's room until the task was completed. S1DON stated the CNAs were trained to leave the call light on until the task was complete so that if the task could not be completed, another staff member would be alerted that the resident still needed assistance. On 2/18/2025 at 3:25 p.m., and interview was conducted with S4CNA who stated that she worked on 01/23/2025 as a floater CNA. She stated that she was available to assist any of the nurses, CNAs, or residents if they asked for help. On 02/18/2025 at 3:35 p.m., an interview was conducted with S5LPN (Licensed Practical Nurse). S5LPN stated that she was Resident #3's nurse on 01/23/2025. She stated that she overheard S3CNA being informed that Resident #3's light was on for assistance, however S3CNA did not ask her for assistance with changing the resident. She was then told that Resident #3 had not been changed, and was informed that S3CNA had clocked out prior to changing Resident #3's soiled brief.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#77) out of 33 sampled residents. Findings: Review of Resident #77's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included but not limited to, Cerebral Infarction, Hemiplegia affecting left non dominant site, Restlessness and agitation, Generalized Anxiety Disorder, Other lack of Coordination, Cognitive communication deficit, Muscle Weakness. Review of Resident #77's electronic health record revealed on 02/18/2023, a physician order to Maintain bed alarm q (every) shift. Review of Resident #77's Quarterly MDS assessment with an ARD (Assessment Reference Date) of 01/17/2024 revealed in Section P - Restraints- Bed alarm was coded as 0 that indicated Resident #77 had no bed alarm in use. On 04/11/2024 at 10:45 a.m., an interview and record review was conducted with S8MDS (Minimum Data Set) Lead Coordinator She reviewed Resident #77's Quarterly MDS with an ARD of 01/17/2024 and confirmed that it was inaccurately coded for the use of a bed alarm.

Based on observations, interviews and record reviews, the facility failed to develop and/or implement a person centered care plan by failing to: 1. Ensure staff repositioned Resident #47 every 2 hours. 2. Develop a plan of care for the use of hand rolls for Resident #72. 3. Ensure Resident #77's bed alarm was in proper working condition. This deficient practice had the potential to affect all the residents who reside in the nursing home. Findings: 1. Resident#47 was admitted to the facility on [DATE] with a diagnoses including Muscle Weakness, Unspecified osteoarthritis, Pain, Other malaise, Dementia, unspecified severity, without behavior/psychosis/mood/anxiety. Review of the resident's care plan with a start date of 08/29/2021 revealed that she was high risk for skin breakdown r/t (related to) DM2 (Diabetes Mellitus II), Occasional Incontinence. Interventions included in part . Place me on the turn q (every) 2hr (hours) turn program. Further review of the resident's care plan revealed she required staff assistance with bed mobility. On 04/09/2024 at 08:45 a.m., Resident #47 was observed in bed lying on her back. A second observation was conducted at 10:45a.m. and the resident observed in bed lying on her back. A third observation was made at 1:00p.m. and Resident #47 was observed still lying in bed on her back. She stated that no one had turned her. An interview was conducted on 04/09/2024 at 1:15p.m.n with S6CNA. She stated that she, along with S7CNA were responsible for Resident #47's care. She stated she was familiar with the resident. She stated that staff do not have to turn the resident because she turns herself. A phone interview was conducted on 04/09/2024 at 2:10 p.m. with S7CNA. She stated that she was assigned the side of the hall Resident #47 was located from 6 a.m. to 12 p.m. because the regular scheduled CNA (Certified Nursing Assistant) called in. She stated she gave the resident a bed bath this morning between 8:30 a.m. and 9:00 a.m. After the bed bath, she positioned the resident on her back. She stated that she was aware that the resident needed to be turned every two hours. She confirmed that she had not turned/repositioned the resident during her shift. An interview was conducted on 04/11/2024 AM with S1DON (Director of Nursing). After reviewing the resident's care plan, she verified that the resident needs assistance with turning and repositioning. She confirmed that the staff should have been turned/repositioned the resident at least every two hours. 49176 2. Review of Resident #72's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia, Acute Kidney Failure, Epilepsy, Muscle Weakness, and Lack of Coordination. Review of Resident #72's April 2024 physician's orders revealed an order dated 08/30/2022 for Right Hand: Maintain hand roll as tolerated, may remove for ADLs (Activities of Daily Living) and/or split use. Review of Resident #72's care plan read in part ADLs .I require staff assistance for ADLs r/t (related to) Dementia, Epilepsy . I am mobile via staff propelled geri chair, I prefer to stay in bed. I have contractures to arms and legs. Further review of Resident #72's care plan revealed no interventions to include Right Hand: Maintain hand roll as tolerated. On 04/11/2024 at 11:47 a.m., an interview was conducted with S4MDS (Minimum Data Set Nurse) who stated that she was responsible for completing and updating the care plan for Resident #72. A review of the resident's care plan was conducted with S4MDS. S4MDS confirmed that Resident #72's care plan did not include that the resident had an order for right hand roll as tolerated. S4MDS confirmed the care plan should have been developed to include the intervention for right hand roll. 39319 3. Resident #77 was admitted on [DATE]. Her diagnoses included in part, Cerebral Infarction (Stroke), Hemiplegia following cerebral infarct affecting left non-dominant site, Restlessness and agitation, Aphasia, Generalized anxiety disorder and Muscle weakness (generalized). Review of the resident's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/17/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 15, cognitively intact. Review of the resident's April 2024 physician orders revealed an order dated 02/18/2023 that read, bed alarm q shift. Review of the resident's care plan addressed the resident's risk for falls and risk for injury/immobility. A bed alarm was used as an intervention that read, Check my device daily to make sure it is in good working condition . On 04/08/24 at 12:12 p.m., Resident #77 was observed lying in bed. Her bed alarm was observed hanging from the bed's right upper side rail. The wire connected to the alarm box was freely hanging and frayed on one end. Resident #77 communicated by nodding her head up and down that her bed alarm was not working. On 04/08/24 at 1:06 p.m., an interview with S5CNA (Certified Nursing Assistant). She verified that the resident should have a bed alarm. She observed the resident's bed alarm and confirmed that the wire had been cut. She stated the bed alarm wire should be connected to a bed alarm mat. S5CNA turned the resident on her right side and confirmed that there was no bed alarm mat under the resident. She confirmed that the bed alarm was not functioning correctly. On 04/08/24 at 1:14 p.m., an interview and observation with S1DON (Director of Nursing) was conducted. S1DON observed the bed alarm with the frayed wire on the resident's bed side rail. She verified that the bed alarm should be connected to a bed alarm mat under the resident. S1DON and another staff member turned the resident on her left side and then on her right side. S1DON confirmed that there was no bed alarm mat present under the resident. She stated that the bed alarm should be monitored by the nurses every shift to ensure it was working properly. She confirmed that the resident's bed alarm was not functioning properly.

Based on record review, observations and interview, the facility failed to ensure that a resident's enteral feeding was properly changed for 1 (#61) resident out of 1 (#61) sampled resident reviewed for tube feeding. Findings: Review of Resident #61's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Traumatic Subdural Hematoma, Alzheimer's Disease, Abnormal Weight Loss, Aphasia, Dysphagia, Other Epilepsy, Gastro-Esophageal Reflux Disease, and Gastrostomy status. Review of Resident #61's April 2024 physician's orders revealed an order dated 02/01/2024 that read in part, . Isosource 1.5 at 45 ml/hr (milliliter per hour) continuously . On 04/08/2024 at 9:35 a.m., an observation of Resident #61's tube feeding bag and administration set revealed the formula bag label listed a date of 04/07, and a time of 8:00 a.m. On 04/08/2024 at 12:35 p.m., a second observation of Resident #61's tube feeding bag and administration set revealed the formula bag label listed a date of 04/07, and a time of 8:00 a.m. On 04/08/2024 at 12:37 p.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN stated that tube feeding bags are changed every 24 hours and should be labeled with the formula type and rate, the resident's name, date, time and nurse's initial. An observation was made with S3LPN of Resident #'s 61's tube feeding bag. S3LPN confirmed the resident's feeding bag was dated 04/07 and confirmed the bag was not changed every 24 hours. S3LPN called S1DON (Director of Nursing) on her personal cell, and S1DON confirmed that tube feeding bags are changed every 24 hours and the bag should have been changed before 8:00 a.m. on 04/08/2024.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, on a weekend for 2 days on the dates of 10/21/2023 and 10/22/2023. Findings: Review of the facility's PBJ (Payroll Based Journal) Data time sheet for the dates of 10/21/2023 and 10/22/2023 revealed that there were no staffing hours for the RN. There was no evidence the RN worked 8 consecutive hours on those dates. On 04/11/2024 at 1:40 p.m., an interview was conducted with S1DON (Director of Nursing). She reviewed the PBJ Data time sheets and confirmed that there were no staffing hours for the RN for the dates of 10/21/2023 and 10/22/2023. S1DON stated that she could not provide evidence that an RN worked on the dates of 10/21/2023 and 10/22/2023.

Based on record review and interview, the facility failed to coordinate care as evidenced by failing to obtain pertinent information from the hospice agency for 1 (#152) out of 2 (#3, #152) residents investigated for hospice. Findings: Resident #152. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction and Pneumonitis due to Inhalation of Food and Vomit. Review of the resident's clinical record revealed that there was no evidence of a hospice election form, no hospice plan of care and no evidence of the physician's certification of the resident's terminal illness. On 04/11/2024 at 9:15 a.m., S2ADON (Assistant Director of Nursing) reviewed the resident's clinical record and confirmed that there was no evidence of a hospice election form, no hospice plan of care and no physician's certification of the resident's terminal illness available in the clinical record.

Based on observation and interview, the facility failed to maintain cleanliness of medication carts for 1 (MC#1) of 4 (MC1, MC2, MC3, MC4) medication carts observed. Findings: On 04/09/2024 at 9:59 a.m., an observation of MC1 (Medication Cart) with S7LPN (Licensed Practical Nurse) revealed the left 2 lower drawers of the medication cart contained bottles of medication in plastic bags. In the second to last drawer, there were 4 bottles of medication in plastic bags. The bags were stuck to the bottom of the drawer and around the bottles. The bottom of the drawer was covered with a reddish gold sticky substance. When the bottles and plastic bags were picked up, the thick, sticky liquid stuck to the surveyor's fingers. In the bottom drawer, there were 3 bottles of medication in plastic bags. The plastic bags were stuck to the bottles of medication and the bottom of the drawer was covered with a thick reddish sticky substance. S1DON was called to MC1 and she confirmed that the left two lower drawers of the medication cart were not clean and sanitary and needed to be cleaned.

Based on record review and interviews the facility failed assure the nursing staff were competent to ensure 1 (#3) of 33 sampled residents that was allergic to morphine did not receive this medication. Record review of Resident #3's face sheet (document that gives a resident's information at a quick glance) revealed she was admit to the facility on [DATE]. She was on Hospice care with diagnosis of End Stage Parkinson's disease. Her face sheet further revealed she was allergic to the medication, Morphine. Record review of Resident #3's care plan read in part, I am at risk for complications r/t (related to) my allergy. I am allergic to MORPHINE. I have no complications at this time r/t my allergy. My clinical record will be labeled to alert everyone to my allergies. Record review of Resident #3's physician orders revealed she was admitted to Hospice on 02/06/2024. On 03/04/2024, Morphine Sulfate 100 milligrams per 5 milliliter concentration to give 0.25 milliliters orally every 4 hours as needed for shortness of breath was ordered. Record review of Resident #3's MAR (Medication Administration Record) for February 2024, March 2024 and April 2024 revealed an order for Morphine Sulfate to administer 100 milligrams per 5 milliliter Concentrated to give 0.25 milliliters orally every 4 hours as needed for shortness of breath. Review of these MARs confirmed S12LPN, S13LPN, and S14LPN had administered Resident #3 Morphine Sulfate on various days during all three months. On 04/09/24 at 2:37 p.m., S12LPN stated the resident is on Hospice and is not cognizant and does not respond to verbal stimulation. She stated she gave the resident morphine for pain and discomfort at least once a day. S12LPN stated the hospice nurse told her to give her morphine to keep her comfortable as needed. On 04/11/2024 at 10:52 a.m., surveyor asked S12LPN how she would determine if Resident #3 was allergic to Morphine. She stated the resident's allergies were on the residents face sheet and on the MAR. At this time, S12LPN reviewed the MAR and stated Resident #3 was allergic to Morphine. S12LPN stated the nurses have gave Resident #3 morphine from February 2024 till present but has had no adverse effects to the Morphine. On 04/11/2024 at 11:02 a.m., S9MDS (Minimum Data Set) reviewed Resident #3's electronic record and confirmed the hospice physician wrote an order to administer Morphine as needed for shortness of breath on 03/04/2024. S9MDS reviewed the resident's electronic chart and confirmed the resident was allergic to Morphine. She stated the allergy to morphine was documented in the computer and on the Medication Administration Record. She also stated Resident #3's care plan listed that she was allergic to Morphine. She stated the nurses should have reviewed the allergies before giving the resident Morphine and notified the physician to get a clarification order prior to giving the medication. On 04/11/2024 at 2:02 p.m., S2DON (Director of Nursing) confirmed Resident #3 was allergic to Morphine and that nurses had administered it to the resident morphine despite the listed allergy. She stated the procedure for administering medications should have included reviewing the resident's allergies at the top of MAR to assure the resident was not allergic to the medications prior to administration. She also stated that nurse's should call the physician to get a clarification if the resident was ordered medication to which they were allergic.

Based on record review and interview, the facility failed to ensure that each resident ' s physician was notified after a significant weight loss for 1 (#1) of 5 (#1 - #5) resident records reviewed. This resulted in an actual harm for Resident #1 after she was hospitalized from [DATE] through 11/3/16 for [DIAGNOSES REDACTED]. Resident #1 had a significant weight loss of 18 pounds in 7 days on 11/15/16, resulted in an additional weight loss of 8 pounds on 11/22/16 and 2 pounds on 11/30/16. Resident (#1) continued to lose weight and sustained a total weight loss of 28 pounds in a 3 week time period. There was no communication and discussion among disciplines concerning Resident #1's significant weight loss so that new interventions could be put in place to prevent continued weight loss. FINDINGS: Resident #1 A review of Resident #1 ' s clinical record revealed that she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #1 ' s admit weight was 130 pounds. The resident's BIMs (Brief Interview for Mental Status) score on 11/3/16 was a 4, which indicated the resident's cognition was severely impaired. While the resident was being interviewed, she was unable to answer questions appropriately. Resident #1 was hospitalized [DATE] for [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on a regular, low salt and low fat diet. Resident #1 ' s readmit weight on 11/3/16 was noted to be 137 pounds. A review of Resident #1 ' s weights, documented on computerized printout provided by the facility on 11/29/16, revealed that her weights were as follows: 10/25/16 - 133 pounds 11/4/16 - 137 pounds 11/8/16 - 138 pounds at 1:16 p.m. and 138 pounds again at 1:23 p.m. 11/18/16 - 120 pounds There were no weights listed after the weight of 11/18/16. A review of Resident #1 ' s weights documented on handwritten Hall Monthly Weights, provided later on 11/29/16 at 2:00 p.m., by S2, ADON, revealed the following: 11/15/16 - 120 pounds 11/22/16 - 112 pounds. There were no other weights available when requested from S1, DON on 11/29/16 at 2:00 p.m. A review of Resident #1 ' s physician's order [REDACTED]. Further review of Resident #1 ' s physician's order [REDACTED]. Resident #1 had been on this prescribed diet and supplements since admit on 8/22/16. A review of Resident #1 ' s Nurse ' s Notes for 10/30/16 through 11/30/16 failed to reveal notification of the Physician of the weight losses on 11/15/16, 11/18/16, 11/22/16, or 11/30/16. Further review failed to reveal new orders addressing the weight loss during this timeframe. A review of Resident #1 ' s Dietary Manager Notes dated 10/30/16 through 11/30/16 revealed a note dated 11/14/16, in which she documented that the resident was on a regular, low fat, and no added salt diet, and that she was tolerating well. Further review revealed that the resident was on a house supplement and that her current weight was 138 pounds. A review of Resident #1 ' s Registered Dietician notes for 10/31/10 through 11/30/16 revealed a note dated 11/25/16, in which she documented that the resident had returned from the hospital on [DATE] with [MEDICAL CONDITION] and was on diuretics. Further review revealed that Resident #1 had a significant weight loss since her return from the hospital, but there was no documentation to indicate total weight loss and/or percentages. Resident #1 was noted to be on a house supplement, and the Dietician ' s recommendations at that time, were for staff to exclude the low fat dietary restriction and weigh the resident weekly till stable, at least 4 weeks. A review of Resident #1 ' s Physician ' s Progress Note dated 11/8/16, after readmit from hospitalization for Gastroenteritis, revealed that her status since admit was unchanged and that the resident was eating well. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/8/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to discontinue the medication [MEDICATION NAME], began Losartan 25 milligrams daily and to continue her present management, which was appropriate for the resident. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/9/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/10/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to add the medication [MEDICATION NAME] intramuscular 20 milligrams now, to initiate Zaroloxyn 5 milligrams daily and to insert a Foley catheter to monitor urine output. Additional interventions were to hold her Potassium Chloride for 2 days and repeat BMP lab on Monday. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/15/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/22/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to continue present treatment. A review of Resident #1 ' s Care Plan failed to reveal documentation and/or updating of the weight losses noted 11//15/16, 11/18/16, 11/22/16 or 11/30/16. An interview was conducted with S1, DON on 11/29/16 at 2 p.m. and she provided the Hall Monitoring Weight that included Resident #1 ' s weights from 11/18/16 (120 pounds) and 11/22/16 (112 pounds). She stated that she obtained the additional weights of 11/18/16 and 11/22/16 in S2, ADON ' s paperwork, as he was not present in the facility at this time. She stated that she was not aware of the resident ' s weight loss after 11/15/16, and she was uncertain as to why it was not in the computer. She stated that S2, ADON was responsible for monitoring and management of the resident weights in the facility. An additional interview was conducted with S1, DON on 11/30/16 at 11:30 a.m. and she stated that she was aware that Resident #1 had some weight loss but was unsure of how much until this time. She stated that S2, ADON was responsible for monitoring the weights and that she would have expected him to act upon any additional weight losses after 11/15/16. An interview was conducted with S2, ADON on 11/30/16 at 11:10 a.m. and he stated that Resident #1 was on weekly weights and that S3,Restorative CNA obtained all of the weekly weights. He stated that these weights were reviewed daily and new interventions were not put in place on 11/15/16, when Resident #1 had an 18 pound weight loss, because he attributed this to her being on new diuretics. S2, ADON stated that he did have the resident moved to the assisted dining room at some point, but was uncertain as to the date. He stated that he discussed the weight loss with S3, Restorative CNA, but that she was uncertain as to how much the resident was eating at that time. He stated that he had the resident reweighed 3 days later, on 11/18/16, and confirmed that her weight remained at 120 pounds. S2, ADON confirmed that Resident #1 ' s weight on 11/22/16 was 112, and this would indicate that she had an additional 8 pound weight loss. He added that S3, Restorative CNA informed him that the resident was refusing to eat at this time. S2, ADON stated that he thought that he informed S6, NP, Resident #1 ' s Nurse Practitioner, at some point but was unable to recall the date and he had no documentation regarding this. He added that obviously moving Resident #1 to the assisted dining room had not made a difference in her weights since she continued to lose weight. He also added that he was aware of Resident ' s weight loss total of 26 pounds in two weeks, on 11/22/16, but that he, couldn 't force her to eat since she is refusing, and that he did not know what else to do. He provided additional documentation dated 11/16/16 entitled Weight Evaluation Form. A review of the Weight Evaluation Form dated 11/16/16 revealed that it was completed by S2, ADON and that he was aware of Resident #1 ' s 18 pound weight loss over a 1 week period. Further review of the documentation revealed that Resident #1 was placed in the small dining room for monitoring of every meal and that she had been refusing to eat or drink, even when prompted/reminded or assisted. An interview was conducted with S2, ADON at 3:00 p.m. and he stated that Resident #1 ' s weight today was 110 pounds and confirmed that she had a 2 pound weight loss this week for a total of 28 pound weight loss in the last 3 weeks. An interview was conducted with S3, Restorative CNA on 11/10/16 at 11:40 a.m. and she confirmed that she was responsible for resident weights and inputting them into the computer. She stated that she was aware of Resident #1 ' s weight loss and had discussed this with S2, ADON. She stated that she had no documentation of having notified nursing staff of the resident ' s weight loss and added that Resident #1 had been moved to the small assisted dining room because of her poor appetite and she added that the resident had been taking very little fluids. A phone interview was conducted with S4, Registered Dietician on 11/30/16 at 12:50 p.m. who confirmed that she had evaluated Resident #1 once during the month of November, on 11/25/16. She stated that she reviewed the resident ' s Weight Change Comparison Forms in order to determine the resident ' s weights and any interventions/recommendations that she would need to make for the resident. S4, Registered Dietician stated that she was aware of Resident #1 ' s weight loss from 11/8/16 to 11/18/16 but assumed that this was due to her having diuretic medication changes during that time. S4, Registered Dietician stated that she had no other weight available to her until today, 11/30/16, at 110 pounds. She stated that she was not notified of Resident #1 ' s additional 8 pound weight loss on 11/22/16. She stated that she should have been notified of this weight loss and that she would have recommended that Resident #1 have an increase in her supplements, as well as the addition of an appetite stimulant. She stated that she was informed that the resident was consuming 50-75% of her meals and was not aware that the resident was refusing to eat or drink and that she should have been notified in order to make additional recommendations to address the weight loss. An interview was conducted with S5, Dietary Manager, on 11/30/16 at 1:35 p.m. and she stated that she was not aware that Resident #1 ' s appetite had decreased, but that the nursing staff had moved her into the assisted dining room for monitoring sometime last week. She added that she was not aware that Resident #1 had sustained a weight loss and that the last weight she noted was 11/14/16, when her weight was stable at 138 pounds. She stated that she had not been notified by any staff that the resident had sustained a weight loss and that if she had, that she would have recommended frozen supplements for the resident. She added that the resident ' s meal intake percentages were input in the computer by the ward clerks and stated that it was everyone ' s responsibility to review them for changes in a resident ' s intake. An interview was conducted with S6, Nurse Practitioner for Client #1 on 11/30/16 at 3:15 p.m. and he stated that he was aware that the resident had some weight loss but that he was not notified of the amount. He stated that if had he been notified of the significant weight losses, he would have input this on his Progress Notes, as he documented weight stable at 137 pounds. He stated that he should have been notified that Resident #1 had an 18 pound weight loss on 11/15/16, an 8 pound weight loss on 11/22/16 and an additional 2 pound weight loss on 11/30/16. He stated that he could have added nutritional supplement changes for the resident if he had known the extent of her weight loss. Based on record review and interview, the facility failed to notify the primary physician or nurse practitioner of a resident's low capillary blood glucose for 1 (#4) of 5 (#1-#5) sampled residents out of a total of 36 residents receiving accuchecks in the facility. Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #4's cumulative physician's orders [REDACTED]. (ounces) of orange juice or glucose gel (24 gm.) and repeat a CBG in 15 minutes, if the CBG was <64 mg/dL (if unable to swallow, give [MEDICATION NAME] 1 mg (milligram) IM (intramuscular) stat and call MD. A review of the Medication Administration Record [REDACTED]. The nurse's notes dated 9/27/16 at 6:24 a.m., by S7LPN read At 0500 CBG check was obtained on resident reading was 42. Resident was cold clammy and lethargic. 1ml (milliliter) of [MEDICATION NAME] was administered IM to right upper thigh. Five minutes after IM injection resident started to respond and was given clear ensure to help bring the CBG up at 0520 CBG was then rechecked with a reading of 71. Resident was responding to verbal questions. Will continue to monitor for changes (SIC) During an interview with S1DON on 12/1/16 at 1 p.m., she reviewed Resident #4's physician's orders [REDACTED].#4's CBG reading and there should have been.

Based on record review and interview, the facility failed to ensure that each resident maintained acceptable parameters of nutritional status by not addressing and adding new interventions for a significant weight loss for 1 (#1) of 5 (#1 - #5) resident records reviewed during the survey. This resulted in an actual harm for Resident #1 after she was hospitalized [DATE] through 11/3/16, for [DIAGNOSES REDACTED]. Resident #1 had a weight loss of 18 pounds in 7 days on 11/15/16, an additional 8 pounds on 11/22/16 and 2 pounds on 11/30/16. Resident (#1) continued to lose weight and sustained a total weight loss of 28 pounds in a 3 week time period. Three was no communication and discussion among disciplines concerning resident #1's significant weight loss so that new interventions could be put in place to prevent continued weight loss. FINDINGS: Resident #1 A review of Resident #1 ' s clinical record revealed that she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #1 ' s admit weight was 130 pounds. Resident #1 was not interviewable during the survey due to cognition. Resident #1 was hospitalized [DATE] for [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on a regular, low salt and low fat diet. Resident #1 ' s readmit weight on 11/3/16 was noted to be 137 pounds. A review of Resident #1 ' s weights, documented on computerized printout provided by the facility on 11/29/16, revealed that her weights were as follows: 10/25/16 - 133 pounds 11/4/16 - 137 pounds 11/8/16 - 138 pounds at 1:16 p.m. and 138 pounds again at 1:23 p.m. 11/18/16 - 120 pounds. There were no weights listed after the weight of 11/18/16. A review of Resident #1 ' s weights documented on handwritten Hall Monthly Weights, provided later on 11/29/16 at 2:00 p.m., by S2, ADON, revealed the following: 11/15/16 - 120 pounds 11/22/16 - 112 pounds. There were no other weights available when requested from S .DON at 2:00 p.m. A review of Resident #1 ' s physician's order [REDACTED]. Further review of Resident #1 ' s physician's order [REDACTED]. Resident #1 had been on this prescribed diet and supplements since admit on 8/22/16. A review of Resident #1 ' s Nurse ' s Notes for 10/30/16 through 11/30/16 failed to reveal notification of the Physician of the weight losses 11/15/16, 11/18/16, 11/22/16, or 11/30/16. Further review failed to reveal new interventions for weight loss during this timeframe. A review of Resident #1 ' s Dietary Manager Notes dated 10/30/16 through 11/30/16 revealed a note dated 11/14/16, in which she documented that the resident was on a regular, low fat, and no added salt diet, and that she was tolerating well. Further review revealed that the resident was on a house supplement and that her current weight was 138 pounds. A review of Resident #1 ' s Registered Dietician notes for 10/31/10 through 11/30/16 revealed a noted dated 11/25/16, in which she documented that the resident had returned from the hospital on [DATE] with [MEDICAL CONDITION] and was on diuretics. Further review revealed that Resident #1 had a significant weight loss since her return from the hospital, but there was no documentation to indicate total weight loss and/or percentages. Further reveal also revealed that there was no significant weight change desired at that time. Resident #1 was noted to be on a house supplement, and the Dietician ' s recommendations at that time, were for staff to exclude the low fat dietary restriction and weigh the resident weekly till stable, at least 4 weeks. A review of Resident #1 ' s Physician ' s Progress Note dated 11/8/16, after readmit from hospitalization for Gastroenteritis, revealed that her status since admit was unchanged and that the resident was eating well. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/8/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to discontinue the medication [MEDICATION NAME], began Losartan 25 milligrams daily and to continue her present management, which was appropriate for the resident. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/9/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to add the medication [MEDICATION NAME] 500 milligrams, 2 tablets twice a day, for 24 hours, and to obtain a BMP lab. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/10/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to add the medication [MEDICATION NAME] intramuscular 20 milligrams now, to initiate Zaroloxyn 5 milligrams daily and to insert a Foley catheter to monitor urine output. Additional interventions were to hold her Potassium Chloride for 2 days and repeat BMP lab on Monday. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/15/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to initiate bladder training to remove the Foley catheter and to obtain CBC and CMB labs. A review of Resident #1 ' s Medical/Nurse Practitioner Progress Notes dated 11/22/16 revealed that she had no [MEDICAL CONDITION] and that her weight was stable at 137 pounds. Further review revealed the treatment plan was to continue present treatment. A review of Resident #1 ' s Care Plan failed to reveal documentation and/or updating of the weight losses noted 11//15/16, 11/18/16, 11/22/16 or 11/30/16. An interview was conducted with S1, DON on 11/29/16 at 2 p.m. and she provided the Hall Monitoring Weight that included Resident #1 ' s weights from 11/18/16 (120 pounds) and 11/22/16 (112 pounds). She stated that she obtained the additional weights of 11/18/16 and 11/22/16 in S2, ADON ' s paperwork, as he was not present in the facility at this time. She stated that she was not aware of the resident ' s weight loss after 11/15/16, and she was uncertain as to why it was not in the computer. She stated that S2, ADON was responsible for monitoring and management of the resident weights in the facility. An additional interview was conducted with S1, DON on 11/30/16 at 11:30 a.m. and she stated that she was aware that Resident #1 had some weight loss but was unsure of how much until this time. She stated that S2, ADON was responsible for monitoring the weights and that she would have expected him to act upon any additional weight losses after 11/15/16. An interview was conducted with S2, ADON on 11/30/16 at 11:10 a.m. and he stated that Resident #1 was on weekly weights and that S3,Restorative CNA obtained all of the weekly weights. He stated that these weights were reviewed daily and new interventions were not put in place on 11/15/16, when Resident #1 had an 18 pound weight loss, because he attributed this to her being on new diuretics. S2, ADON stated that he did have the resident moved to the assisted dining room at some point, but was uncertain as to the date. He stated that he discussed the weight loss with S3, Restorative CNA, but that she was uncertain as to how much the resident was eating at that time. He stated that he had the resident reweighed 3 days later, on 11/18/16, and confirmed that her weight remained at 120 pounds. S2, ADON confirmed that Resident #1 ' s weight on 11/22/16 was 112, and this would indicate that she had an additional 8 pound weight loss. He added that S3, Restorative CNA informed him that the resident was refusing to eat at this time. S2, ADON stated that he thought that he informed S6, NP, Resident #1 ' s Nurse Practitioner, at some point but was unable to recall the date and he had no documentation regarding this. He added that obviously moving Resident #1 to the assisted dining room had not made a difference in her weights since she continued to lose weight. He also added that he was aware of Resident ' s weight loss total of 26 pounds in two weeks, on 11/22/16, but that he, couldn ' t force her to eat since she is refusing, and that he did not know what else to do. He provided additional documentation dated 11/16/16 entitled Weight Evaluation Form. A review of the Weight Evaluation Form dated 11/16/16 revealed that it was completed by S2, ADON and that he was aware of Resident #1 ' s 18 pound weight loss over a 1 week period. Further review of the documentation revealed that Resident #1 was placed in the small dining room for monitoring of every meal and that she had been refusing to eat or drink, even when prompted/reminded or assisted. An interview was conducted with S2, ADON at 3:00 p.m. and he stated that Resident #1 ' s weight today was 110 pounds and confirmed that she had a 2 pound weight loss this week for a total of 28 pound weight loss in the last 3 weeks. An interview was conducted with S3, Restorative CNA on 11/10/16 at 11:40 a.m. and she confirmed that she was responsible for resident weights and inputting them into the computer. She stated that she was aware of Resident #1 ' s weight loss and had discussed this with S2, ADON. She stated that she had no documentation of having notified nursing staff of the resident ' s weight loss and added that Resident #1 had been moved to the small assisted dining room because of her poor appetite and she added that the resident had been taking very little fluids. A phone interview was conducted with S4, Registered Dietician on 11/30/16 at 12:50 p.m. who confirmed that she had evaluated Resident #1 once during the month of November, on 11/25/16. She stated that she reviewed the resident ' s Weight Change Comparison Forms in order to determine the resident ' s weights and any interventions/recommendations that she would need to make for the resident. S4, Registered Dietician stated that she was aware of Resident #1 ' s weight loss from 11/8/16 to 11/18/16 but assumed that this was due to her having diuretic medication changes during that time. S4, Registered Dietician stated that she had no other weight available to her until today, 11/30/16, at 110 pounds. She stated that she was not notified of Resident #1 ' s additional 8 pound weight loss on 11/22/16. She stated that she should have been notified of this weight loss and that she would have recommended that Resident #1 have an increase in her supplements, as well as the addition of an appetite stimulant. She stated that she was informed that the resident was consuming 50-75% of her meals and was not aware that the resident was refusing to eat or drink and that she should have been notified in order to make additional recommendations to address the weight loss. An interview was conducted with S5, Dietary Manager, on 11/30/16 at 1:35 p.m. and she stated that she was not aware that Resident #1 ' s appetite had decreased, but that the nursing staff had moved her into the assisted dining room for monitoring sometime last week. She added that she was not aware that Resident #1 had sustained a weight loss and that the last weight she noted was 11/14/16, when her weight was stable at 138 pounds. She stated that she had not been notified by any staff that the resident had sustained a weight loss and that if she had, that she would have recommended frozen supplements for the resident. She added that the resident ' s meal intake percentages were input in the computer by the ward clerks and stated that it was everyone ' s responsibility to review them for changes in a resident ' s intake. An interview was conducted with S6, Nurse Practitioner for Client #1 on 11/30/16 at 3:15 p.m. and he stated that he was aware that the resident had some weight loss but that he was not notified of the amount. He stated that if had he been notified of the significant weight losses, he would have input this on his Progress Notes, as he documented weight stable at 137 pounds. He stated that he should have been notified that Resident #1 had an 18 pound weight loss on 11/15/16, an 8 pound weight loss on 11/22/16 and an additional 2 pound weight loss on 11/30/16. He stated that he could have added nutritional supplement changes for the resident if he had known the extent of her weight loss.

Based on record reviews and interviews the facility failed to ensure that the residents skin conditions and physical functional needs were assessed by failing to: 1. assess the resident skin to prevent a resident who entered the facility without pressure sores from developing a Stage III pressure sore to the coccyx on 07/03/12, Stage III pressure sore to the right inner thigh on 07/09/12, Stage II's to the left and right buttocks on 7/9/12, and Deep Tissue Injury to left and right heels; 2. accurately assess the resident's pain and continue monitoring of the effectiveness of the medication, which prevented the resident from participating in physical therapy/occupational therapy and resulting in refusal of care/repositioning; and notiyfing physician of the inability to manage the resident's increased pain and anxiety; This deficient practice resulted in an actual harm to resident #4 who was admitted to the facility on [DATE] for skilled services The facility did not appropriately assess the resident's skin condition which resulted in two pressure sores which developed into Stage III's prior to the facility identifying them and the resident being admitted to a long term acute care at a local hospital on [DATE] , manage, monitor, and treat the resident's pain/anxiety which interfered with the resident's participation in Physical Therapy/Occupational Therapy and ultimately leading to a decline in PT/OT. Further failure to manage, monitor and treat resident #4's pain/anxiety led to refusal to co-operate with ADL's resulting in increased incontinent episodes and further development of Stage II's to the left and right buttocks on 7/9/12 in 1 (#4) out of 40 residents on the pain managed program according to Resident Census and Conditions of Residents Report. Findings: 1. Review of medical records revealed resident #4 was admitted to the facility on [DATE] for skilled services with the following Diagnoses: [REDACTED]. Review of the Initial Nursing Admission Assessment revealed resident #4 required extensive assistance when resident is involved in activity (staff provide weight-bearing support), one person physical assist with bed mobility required extensive assistance for bed mobility self-performance and total assist-full staff performance every time during entire 7-day period with toilet use. The Initial Skin assessment revealed surgical incision/sutures to left leg with no other skin complications noted. In the nurse admission note regarding the condition of resident #4's skin a notation is made stating: " See Skin Notes. " The assessment was completed on 6/19/2012 at 4:00 PM by S7, LPN. Review of the Braden Scale for 06/20/12 at 9:33 AM indicated the following for resident # 4: ? Moisture: Degree in which skin is exposed to moisture - Rarely Moist ? Activity: Degree of physical Activity - Chair fast ? Mobility: Ability to change and control body position - Slightly Impaired ? Nutrition: Usual food intake pattern - Adequate ? Friction and Shear: Potential Problem ? Resident risk as determined by score: MILD RISK - Total Score 15 - 18 Resident # 4 is at risk for skin breakdown related to occasional incontinence, current surgical incision and limited mobility. Resident # 4 has a pressure reducing mattress to her bed. She will also be on a turn and reposition program to prevent pressure related breakdown. Nurses will perform full skin assessments weekly and CNA's will monitor skin daily while assisting with care. Review of resident #4's Physician order [REDACTED]. On 06/20/2012, an order to apply Medseptic qd (every day) and prn (as needed) incontinent episodes to excoriations to the right posterior thigh and to paint the blisters to the left lateral thigh with [MEDICATION NAME] qd (every day) was noted. Review of the treatment nurse notes revealed skin assessments and all treatments were performed by S16, LPN/Wound Care Nurse and Co-signed by S17 RN DON: Review of the treatment notes of 06/20/2012 at 4:40 PM skin assessment by S16, LPN/Wound Care Nurse revealed resident #4 was noted to have a closed surgical incision to the left hip measuring 28 inches in length, with 35 staples in place, surrounding noted with multiple fluid filled blisters, no drainage or S/S (signs/symptoms) of infection. Documentation continues, noting multiple excoriations to the right posterior thigh with no drainage noted. Review of the Body Audit Roster documented by the nursing staff revealed that on 06/24/12 at 1:33 PM, S20, LPN documented " No Skin Concerns. " On 06/24/2012 at 1:35 PM, a weekly skin assessment was performed by S20, LPN that revealed a left hip dressing dry and intact with no drainage and staples intact. A notation was made regarding right thigh excoriations with treatments in progress daily and no new skin concerns. On 06/26/2012 at 3:09 PM, S16, LPN/Wound Care Nurse documented the resident #4 was noted with closed surgical incision to left hip. Resident #4 was noted with excoriations to left posterior thigh scabbed over with small open blisters near incision site, dry no drainage resolving well. Review of the CNA Completed Care Task revealed skin checks were performed every shift for the period of 06/19/12 starting at 8:45 PM thru 06/30/12 at 9:06 PM. The skin documentation's revealed the CNA's documented "No New Skin Concerns. " Review of the Body Audit Roster documented by nursing staff revealed on 07/01/12 at 7:42 AM, S28, LPN both documented " No Skin Concerns. " Further review of the Body Audit Roster revealed there was no additional assessment or documentation of resident #4's skin condition. Review of the Departmental Nurses Notes dated 07/02/12 at 4:37 PM documented by S6, LPN revealed wound care treatment in progress to coccyx pressure wound. Further review of the Departmental Notes dated 07/03/12 at 3:04 PM revealed Nurse Practitioner made rounds today, new orders noted Stage III to coccyx treatment orders noted. Review of the CNA Completed Care Task document for the 10 - 6 shift revealed on 07/03/12 at 02:12 AM the CNA documented " No New Skin Concerns." Further review revealed that on the 6 -2 shift on 07/03/12 at 1:06 PM the documentation on the CNA Completed Care Task revealed " New Skin Concern - Nurse Notified. " Review of resident # 4's Physician order [REDACTED]. On 07/03/2012, an order was noted to clean Stage III to coccyx with wound cleaner, apply santyl and cover with a dry dressing qd (every day) and prn (as needed). On 07/03/2012, an order was noted for a low air loss mattress and a pressure reducing cushion to wheelchair. On 07/03/2012, an order to apply [MEDICATION NAME] to SDTI (Suspected Deep Tissue Injury) to left and right heels was ordered. On 07/03/2012, an order to resolve blisters to left, lateral thigh is noted. On 07/03/2012 at 2:37 PM, S16, LPN/Treatment Nurse documented resident #4 was noted with a Stage III to coccyx measuring 7.2 x 1.5 x 0.01 cm (addendum of 07/04/12 correction indicated Stage III to coccyx measured 2.2 x 1.5 x 0.1). Notation was made that multiple excoriations to right thigh, resolving well. Documentation revealed suspected deep tissue injury to the right and left heel with the left heel boggy. Review of the CNA Completed Care Task documents revealed skin checks every shift for the period of: on the 2 - 10 shifts on 07/03/12 at 08:18 PM and 07/04/12 at 7:33 PM was documented as " No New Skin Concerns. " On 07/04/2012 at 1:17 PM, S16, LPN/Treatment Nurse documented Wound Care Company made rounds and assessed resident #4 Stage III coccyx wound measuring 2.2 x 1.0 x 0.1, 60% slough and 40% granulation. The wound was debrided by Wound Care Company. Additional documentation indicated the right lateral heel was 2.8 x 2.9 x 0.01 and the left medial heel was 3.8 x 5.9 x 0.02. Review of the CNA Completed Care Task documents revealed skin checks every shift for the period of: on the 10 - 6 shift on 07/05/12 at 12:17 AM thru the 10 - 6 shift on 07/08/12 at 11:50 PM were documented as " No New Skin Concerns. " On 07/09/2012 at 9:28 PM, S28, LPN made a late entry for 07/08/2012 indicating a long, thin open area on the right leg that was to be reported to the treatment nurse. Review of the CNA Completed Care Task on the 6 - 2 shift on 07/09/12 at 11:29 AM and on the 2 -10 shift on 07/09/12 at 08:27 PM revealed " New Skin Concern - Nurse notified. Review of Physician order [REDACTED]. Cleanse the Stage III to right inner thigh with wound cleaner, apply hydrogel and cover with a dry clean dressing. Clean Stage II to right posterior thigh with wound cleaner, apply santyl and apply a dry dressing qd (every day). Clean Stage II to right and left buttocks with wound cleaner, apply santyl and apply a dry dressing qd (every day). On 07/09/2012 at 11:43 AM, S16, LPN/Treatment Nurse documented resident #4 was noted with a Stage III to right inner thigh measuring 14 x 2 cm draining serous draining 90% slough and 10% granulation; Stage II to right posterior thigh 2 x 0.5 cm draining moderate serosanguineous fluid 100% granulation; Stage II right buttock measuring 2.5 x 3 cm draining moderate serosanguineous fluid 100% granulation; and Stage II left buttock measuring 7 x 1.5 cm draining moderate serosanguineous fluid 100% granulation. Additional documentation indicated treatment continues to bilateral heels and coccyx wound. Record review of the copied Care Plan, submitted by the facility, revealed there was no documented Care Plan for the Stage II to right buttocks. Review of Physician order [REDACTED]. On 07/10/2012, resident #4 was transferred to a long term acute care at a local hospital for wound care. In an interview on 03/12/2013 at 3:05 PM with S1, RN/DON revealed that the LPN ' s on the medicine carts do a weekly " head to toe assessment " . She confirmed that S16, LPN was previously the wound care nurse and S17, RN/DON, (the former DON) assessed the skin each week. S17, RN/DON was present during the assessment and co-signed the documentation because the LPN treatment nurse could not stage a wound. S1, RN/DON stated that regarding the Stage III wound that was discovered on 07/03/2012, on resident #4's coccyx, the deep tissue injury was already there and there should have been documentation of the site before the Stage III was found. . In an interview on 03/12/2013 at 03:25 PM an interview with S3, RN/Corporate Nurse confirmed that the LPN ' s on the medicine cart are responsible for a weekly " head to toe assessment " on the residents. She also confirmed that S16, LPN wound care nurse and S17, RN/DON both performed skin assessments together because an LPN can ' t stage a wound. She stated that S17, RN/DON co-signs all of the LPN treatment notes. S3, RN/Corporate Nurse stated the CNA ' s do a skin assessment each time they perform ADL's, turn and reposition resident. She stated the CNA ' s document in the facility computerized system and report findings to the nurse. In an interview on 03/14/2013 at 10:00 AM with S8, LPN stated that if a resident was on a turn schedule and was refusing to turn, she would tell her supervisor, call the doctor and talk with the family. S8, LPN states that part of her duties as an LPN is to perform head to toe skin assessment, however if a resident is refusing to turn she indicated she would assess the skin on a daily basis. S8, LPN also indicated she would speak with the CNA ' s and have them call her when they are changing/performing care with the resident so she could assess the skin. In an interview on 03/14/2013 at 10:20 AM with S6, LPN revealed that the facility requires residents with skin issues to be assessed on a weekly basis but she would assess a resident from head to toe more frequently to see if there are any skin breakdowns. In an interview on 03/14/2013 at 1:35 PM with S3 RN/Corporate Nurse revealed that the reason resident #4 had all the skin breakdown was because she was incontinent all the time, having diarrhea, refused to be turned/repositioned, and changed. 2. Review of the Physician order [REDACTED]. [MEDICATION NAME] 10 mg tablet one po (by mouth) Q (every) 6 hr. prn (as needed) for pain [MEDICATION NAME] 10 mg tablet take two tablets po Q 6 hr. prn severe pain Review of the Nurse Notes revealed resident #4 complained of pain when either being moved/being turned in bed/refusing to turn/or being touched on the following days and times: The Departmental Nursing Notes failed to reveal documentation that the physician was notified of the inability to manage the resident's pain on a PRN interval: 06/21/12 at 3:28 PM, 06/24/12 at 11:37 AM, 06/24/12 at 11:48 AM, 06/28/12 at 3:13 PM, 06/29/12 at 12:57 AM, 06/29/12 at 11:10 AM, 06/30/12 at 2:47 PM, 07/02/12 at 4:47 PM, 07/04/12 at 1:44 AM, 07/04/12 at 3:03 PM, 07/05/12 at 1:13 PM, 07/05/12 at 5:17 PM, 07/06/12 at 5:48 AM, 07/09/12 at 2:53 PM, 07/10/12 at 1:23 AM, 07/10/12 at 6:10 PM. Review of the Departmental Nurses Notes and MARs for resident #4 revealed the following documentation: On 06/19/12, 1 dose [MEDICATION NAME] 2 tablets was administered at 09:11 PM. 06/20/12 at 7:11 AM resident complained of left hip pain graded at #10 on the 1-10 pain scale for which she received [MEDICATION NAME] 10/500 two tablets for severe pain. Further review of MAR indicated [REDACTED]. On 06/20/19, [MEDICATION NAME] 2 tablets were administered at 6:40 AM, 2:16 PM, and 9:13 PM. 06/21/12 at 3:28 PM resident complained of pain when in bed and when moving at which time she was medicated for pain. On 06/21/12, [MEDICATION NAME] 2 tablets were administered at 7:16 AM, 2:02 PM, and 8:58 PM. 06/22/12 at 2:14 PM, resident complained of pain to left hip and was administered pain medication. On 06/22/12, [MEDICATION NAME] 2 tablets were administered at 7:53 AM, 2:30 PM, and 9:31 PM. 06/23/12 at 7:09 AM,1:55 PM, 10:36 PM, 11; 37 PM resident complained of left hip pain and medicated for pain. Further review of MAR indicated [REDACTED]. The resident was medicated three times. On 06/23/12, [MEDICATION NAME] 2 tabs adminstered at 06:08 AM, 12:42 PM, 8:52 PM. 06/24/12 at 11:48 AM PRN pain medication given, at 02:22 PM resident complained of pain and was given pain medication. Further review of MAR indicated [REDACTED]. On 06/24/12, [MEDICATION NAME] 2 tablets administered at 05:41 AM, and 1 tablet at 11:40 AM & 10:29 PM. 06/25/12 resident is medicated at 7:42 AM with no narrative or follow up of effective of medication. Resident was medicated one time. On 06/25/12, [MEDICATION NAME] 2 tablets administered at 7:41 AM. 06/26/12 at 4:39 PM resident complained of pain to left hip and medicated, 10:57 PM, it is noted resident #4 has frequent complaints of pain with PRN ' s (as needed pain medications) and PRN ' s given as ordered with minimal relief noted. Resident medicated 4 times and effectiveness was not documented for the AM and Evening dose. On 06/26/12, [MEDICATION NAME] 1 tablet administered at 10:50 AM and 06:15 PM and 2 tablets were administered at 4:31 AM and 11:58 PM. 06/27/12 there was no documentation of complaints. The resident was medicated 3 times and there was no documentation of effectiveness of medication. On 06/27/12, [MEDICATION NAME] 1 tablet was administered at 7:00 AM and 2 tablets at 11:00 AM and 5:33 PM. 06/28/12 at 3:13 AM resident complained of pain to left hip graded at #10 on 0-10 scale and [MEDICATION NAME] 2 tablets given for severe pain. At 5:18 PM documentation revealed PRN [MEDICATION NAME] in progress. No documentation of effectiveness for AM dose. On 06/28/12, [MEDICATION NAME] 2 tablets at 12:19 AM, 8:47 AM and 6:25 PM. 06/29/12 resident medicated 2 times with a time span interval of 8 1/2 hours between morning and evening doses. Physician made rounds and no documentation that he was notified that the resident's pain was difficult to be managed on a PRN interval. On 06/29/12, [MEDICATION NAME] 2 tablets at 7:27 AM and 3:56 PM. 06/30/12 resident medicated 2 times with a time span interval of 9 hours between morning and evening dose. On 06/30/12, [MEDICATION NAME] 1 tablet at 10:13 PM and 2 tablets at 8:08 AM. 07/01/12 at 11:51 PM, it is noted resident #4 is complaining of pain to the left hip area. Resident #4 was medicated twice during the shift. The time span interval between AM and PM dose was 7.75 hours. On 07/01/12, [MEDICATION NAME] 2 tablets at 9:55 AM and 5:44 PM. 07/02/12 at 6:01 PM documentation revealed resident #4 stated she does experience pain to her hip which is relieved some by medications, however pain is severe at time she states and adds that therapy and movement does increase her pain. Further review revealed there was no documentation that the physician was notified of unable to manage pain with PRN intervals. On 07/02/12, [MEDICATION NAME] 1 tablet at 9:35 AM and 2 tablets at 7:06 PM. 07/03/12 at 3:35 PM documentation indicated resident #4 continues to complain of her left hip pain frequently. Further review revealed that there was no documentation that the physician was notified of unable to manage pain with PRN intervals.. 07/03/12 at 5:10 PM documentation indicated resident #4 continues to frequently complain of left hip pain with prn (as needed) [MEDICATION NAME] in progress and states the medicine is effective short term. Further review revealed there was no documentation that the physician was notified of unable to manage pain. On 07/03/12, [MEDICATION NAME] 1 tablet at 8:54 AM and 2 tablets at 4:21 PM. On 07/04/12, [MEDICATION NAME] 1 tablet at 1:25 AM and 2 tablets at 8:01 AM. 07/05/12 at 5:17 PM, documentation indicates that resident #4 moans and screams in pain prior to staff or PT (physical therapy) touching her. Resident #4 was not medicated for pain and no documentation that the physician was notified of unable to manage pain with PRN intervals. On 07/05/12, [MEDICATION NAME] 2 tablets at 4:09 AM and 1 tablet at 8:55 AM 07/06/12 at 10:48 PM documentation indicated resident #4 was complaining of pain and rating pain at 8/10. Further review of MAR indicated [REDACTED]. The nurses notes did not have documentation of continued pain assessment. On 07/06/12, [MEDICATION NAME] 2 tablets at 12:35 AM and 5:11 PM. On 07/07/12, [MEDICATION NAME] 2 tablets at 2:45 AM. On 07/08/12, [MEDICATION NAME] 1 tablet at 4:14 PM. 07/09/12 at 3:01 AM documentation indicated complaints of pain to left hip. 07/09/12 at 2:53 PM documentation indicated resident continues to request and receive prn (as needed) [MEDICATION NAME] for frequent complaints of left hip pain and states medication is effective short term. Review of MAR indicated [REDACTED]. The nurses notes did not have documentation of continued pain assessment. Further review revealed there was no documentation that the physician was notified of unable to manage pain. On 07/09/12, [MEDICATION NAME] 2 tablets at 12:04 AM and 1 tablet at 9:36 AM. On 7/10/12, No pain medication was administered. Review of Departmental Nurses Notes revealed documentation of resident #4's difficulty in participating in PT/OT as follows: 06/28/12 at 5:18 resident #4 was cooperative with therapy tolerating with moderate difficulty due to pain. 07/03/12 at 5:10 PM document revealed resident #4 continues to participate in therapy, tolerating with moderate difficulty due to pain with movement. 07/05/12 at 5:17 PM, documentation revealed resident #4 continues to participate in therapy, tolerating with moderate difficulty due to pain with movement. 07/06/12 at 4:26 PM, documentation indicates resident #4's fear of pain preventing progress of therapy. 07/09/12 at 2:53 PM documentation indicated resident #4 tolerates therapy with moderate difficulty due to pain in left hip. 07/10/12 at 6:10 PM documentation indicated resident #4 is tolerating therapy with moderate difficulty due to pain in left hip and movement. Review of the PT (Physical Therapy) Evaluation and Plan of Treatment dated 06/20/2012 revealed: Clinical Impression: Morbidly obese female who was anxious and in extreme pain. Resident #4 was defensive of any movement and totally dependent for all mobility. She required firm guidance to perform requested tasks. Resident #4 was independent at home prior to the [MEDICAL CONDITION] and needs therapy to return to PLOF (Prior Level Of Function). Risk Factors: Due to the documented physical impairments and associated functional deficits, the resident #4 is at risk for: anxiety, immobility, increased pain, increased dependency upon caregivers and falls. Review of Physical Therapy notes revealed the following documentation: 06/28/2012 resident #4 was apprehensive about weight being through left hip during sitting balance. 07/04/2012 the physical therapy notes reveal that maximum improvement is yet to be attained and resident #4 resists any movement and is extremely fearful. 07/06/2012 the physical therapy notes reveal the resident #4 did not participate well in therapy, made little progress and was inhibited by fear and pain. Review of the OT (Occupational Therapy) Evaluation and Plan of Treatment dated 06/20/2012 revealed: Clinical Impression: Resident #4 is with decreased UE (upper extremity) strength, mobility, ADL ' s (Activities of Daily Living) and t/fs (Transfers) Risk Factors: Due to the documented physical impairments and associated functional deficits, the resident #4 is at risk for falls and increased pain. Review of Occupation Therapy Notes revealed the following documentation: 06/26/2012 revealed maximum improvement is yet to be attained. S4, OT (Occupational Therapist) documented that patient was complaining of pain in the left hip with bed mobility and required extensive assistance at times for static sitting EOB (Edge of Bed) secondary to pain and positioning. 07/03/2012 the S4, OT revealed maximum improvement is yet to be attained and resident #4 is with continued increase in complaint of pain. 07/04/12 revealed resident #4 was ill with vomiting and complaints of severe pain with all movements. S4, OT notified nursing of resident ' s condition. In an interview on 03/13/2013 at 12:00 PM, an with S4, OT (Occupational Therapy) revealed resident #4 was in a lot of pain and therapy was limited by the pain. She stated resident #4 declined in OT, at times due to pain. S4, OT indicated that she recalled resident #4 as being in " pain, pain, pain and then declined. " In an interview on 03/13/2013 at 12:40 PM with S5, PTA (Physical Therapy Assistant) confirmed resident #4 was in a lot of pain and needed a lot of encouragement. She revealed resident #4 was a " Maximum Assist Patient " and often exhibited guarding because she was in a lot of pain. S5, PTA stated she made nursing aware of the pain resident #4 was experiencing and she stated the nurses told her " We Know. " In an interview on 03/14/2013 at 09:42 AM with S9, CNA/Restorative Aide revealed resident #4 was in a lot of pain while she was a resident in the facility. She stated resident #4 would cry when she was being bathed or turned. In an interview on 03/14/13 at 10:00 AM S8, LPN stated if a resident is receiving pain medications and it appears that resident is still in pain she would notify the doctor to see if the doctor would increase the medication. In an interview on 03/14/2013 at 10:20 AM an interview with S6, LPN stated if a resident was on a turn schedule and was refusing to turn even though the resident was medicated for pain she would notify the doctor and document this in her nurse notes. S6, LPN indicated that if a resident can ' t talk, she would be able to see if the resident was in pain by assessing for facial grimacing, moans, screams, refusing to turn, refusing ADL ' s or refusing to get out of bed. S6, LPN verified that she recalls caring for resident #4 and remembers her being in excruciating amount of pain. In an interview on 03/14/13 at 10:35 AM with S7, LPN revealed that resident #4 had difficulties with therapy because of her pain level and had some days that were worse than other days. S7, LPN stated that if a resident was on pain medication but still continued to complain of pain she would get a set of vital signs and call the doctor. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg tid (three times a day) prn (as needed) for anxiety. Review of the eMar (Medication Administration Record) for June 2012 and July 2012 revealed the only dose of [MEDICATION NAME] 0.5 mg 1 tablet tid prn anxiety was administered on 07/03/2012 at 10:29 AM for behavior #1. Review of the Departmental Nurses Notes revealed the following documentation: S17, RN/DON (former DON) documentation on 07/03/2012 at 5:47 PM revealed the resident #4 was often combative, refusing to eat and very anxious with transfers. The documentation indicated the resident #4 revealed she is more fearful of pain than she is in pain and that the pain is relieved with the medication. Documentation revealed resident #4 was refusing to get OOB (out of bed), refusing to turn or reposition, refusing to all staff to float heels thus in turn leading to resident #4 acquiring skin impairments that are difficult to prevent with her not cooperating with getting out of bed or repositioning. In an interview on 03/14/2013 at 1:35 PM with S3, RN/Corporate Nurse stated S17, RN/DON (former DON) documented on 07/03/12 the resident #4 was more fearful of pain than she was in pain. S3, RN/Corporate Nurse stated she agreed with S17, RN/DON (former DON) in regards to resident #4 being more fearful of pain than actually being in pain and that the facility obtained an order from S18, Medical Director for [MEDICATION NAME] 0.5 tid (three times a day) prn (as needed) for anxiety on 06/29/12. In an interview on 03/14/2013 at 4:50 PM with S2, LPN/ADON confirmed she worked with resident #4 on 06/22/2012 and 06/29/2012. She reviewed her documentation for 06/29/2012 at 11:10 AM and confirmed resident #4 often complained when the left lower extremity was being touched or moved. She stated she gave the resident [MEDICATION NAME] 2 tablets by mouth at 7:27 AM on 06/29/2012 for pain graded at 8 on a scale of 0-10. S2, LPN/ADON stated that she did not speak to the doctor about changing the pain medication to see if the pain medication could be administered on a regular basis and administered more frequently than every 6 hours. She indicated that she believed resident #4 was more fearful than in pain. The orders and MAR (medication administration record) were reviewed with S2, LPN/ADON and she confirmed that [MEDICATION NAME] 0.5 mg 1 tablet by mouth every 8 hours prn (as needed) was ordered on [DATE]. Upon review of the records, she confirmed that [MEDICATION NAME] 0.5 mg was administered only one time during resident #4 stay at the facility that being on 07/03/2012 at 10:29 AM.

Based on record review and interview the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing by failing to: 1. Prevent resident #4 who entered the facility without pressure sores from developing a Stage III pressure sore to the coccyx on 07/03/12, Stage III pressure sore to the right inner thigh on 07/09/12, Stage II's to the left and right buttocks on 7/9/12, and Deep Tissue Injury to left and right heels; This deficient practice resulted in an actual harm to resident #4 who was admitted to the facility on [DATE] for skilled services and was found with two pressure sores which developed into Stage III's prior to the facility identifying them and resulting in resident being admitted to a long term acute care at a local hospital on [DATE] in 1 (# 4) of 2 (# 2, # 3) investigated for pressure sores. This deficient practice had the potential to affect 6 residents with pressure ulcers according to Resident Census and Conditions of Residents Report. Findings: 1. Review of medical records revealed resident #4 was admitted to the facility on [DATE] for skilled services with the following Diagnoses: [REDACTED]. Review of the Initial Nursing Admission Assessment revealed resident #4 required extensive assistance when resident is involved in activity (staff provide weight-bearing support), one person physical assist with bed mobility required extensive assistance for bed mobility self-performance and total assist-full staff performance every time during entire 7-day period with toilet use. The Initial Skin assessment revealed surgical incision/sutures to left leg with no other skin complications noted. In the nurse admission note regarding the condition of resident #4's skin a notation is made stating: " See Skin Notes. " The assessment was completed on 6/19/2012 at 4:00 PM by S7, LPN. Review of the Braden Scale for 06/20/12 at 9:33 AM indicated the following for resident # 4: ? Moisture: Degree in which skin is exposed to moisture - Rarely Moist ? Activity: Degree of physical Activity - Chair fast ? Mobility: Ability to change and control body position - Slightly Impaired ? Nutrition: Usual food intake pattern - Adequate ? Friction and Shear: Potential Problem ? Resident risk as determined by score: MILD RISK - Total Score 15 - 18 Resident # 4 is at risk for skin breakdown related to occasional incontinence, current surgical incision and limited mobility. Resident # 4 has a pressure reducing mattress to her bed. She will also be on a turn and reposition program to prevent pressure related breakdown. Nurses will perform full skin assessments weekly and CNA's will monitor skin daily while assisting with care. Review of resident #4's Physician order [REDACTED]. On 06/20/2012, an order to apply Medseptic qd (every day) and prn (as needed) incontinent episodes to excoriations to the right posterior thigh and to paint the blisters to the left lateral thigh with [MEDICATION NAME] qd (every day) was noted. Review of the treatment nurse notes revealed skin assessments and all treatments were performed by S16, LPN/Wound Care Nurse and Co-signed by S17 RN DON: Review of the treatment notes of 06/20/2012 at 4:40 PM skin assessment by S16, LPN/Wound Care Nurse revealed resident #4 was noted to have a closed surgical incision to the left hip measuring 28 inches in length, with 35 staples in place, surrounding noted with multiple fluid filled blisters, no drainage or S/S (signs/symptoms) of infection. Documentation continues, noting multiple excoriations to the right posterior thigh with no drainage noted. Review of the Body Audit Roster documented by the nursing staff revealed that on 06/24/12 at 1:33 PM, S20, LPN documented " No Skin Concerns. " On 06/24/2012 at 1:35 PM, a weekly skin assessment was performed by S20, LPN that revealed a left hip dressing dry and intact with no drainage and staples intact. A notation was made regarding right thigh excoriations with treatments in progress daily and no new skin concerns. On 06/26/2012 at 3:09 PM, S16, LPN/Wound Care Nurse documented the resident #4 was noted with closed surgical incision to left hip. Resident #4 was noted with excoriations to left posterior thigh scabbed over with small open blisters near incision site, dry no drainage resolving well. Review of the CNA Completed Care Task revealed skin checks were performed every shift for the period of 06/19/12 starting at 8:45 PM thru 06/30/12 at 9:06 PM. The skin documentation's revealed the CNA's documented "No New Skin Concerns. " Review of the Body Audit Roster documented by nursing staff revealed on 07/01/12 at 7:42 AM, S28, LPN both documented " No Skin Concerns. " Further review of the Body Audit Roster revealed there was no additional assessment or documentation of resident #4's skin condition. Review of the Departmental Nurses Notes dated 07/02/12 at 4:37 PM documented by S6, LPN revealed wound care treatment in progress to coccyx pressure wound. Further review of the Departmental Notes dated 07/03/12 at 3:04 PM revealed Nurse Practitioner made rounds today, new orders noted Stage III to coccyx treatment orders noted. Review of the CNA Completed Care Task document for the 10 - 6 shift revealed on 07/03/12 at 02:12 AM the CNA documented " No New Skin Concerns." Further review revealed that on the 6 -2 shift on 07/03/12 at 1:06 PM the documentation on the CNA Completed Care Task revealed " New Skin Concern - Nurse Notified. " Review of resident # 4's Physician order [REDACTED]. On 07/03/2012, an order was noted to clean Stage III to coccyx with wound cleaner, apply santyl and cover with a dry dressing qd (every day) and prn (as needed). On 07/03/2012, an order was noted for a low air loss mattress and a pressure reducing cushion to wheelchair. On 07/03/2012, an order to apply [MEDICATION NAME] to SDTI (Suspected Deep Tissue Injury) to left and right heels was ordered. On 07/03/2012, an order to resolve blisters to left, lateral thigh is noted. On 07/03/2012 at 2:37 PM, S16, LPN/Treatment Nurse documented resident #4 was noted with a Stage III to coccyx measuring 7.2 x 1.5 x 0.01 cm (addendum of 07/04/12 correction indicated Stage III to coccyx measured 2.2 x 1.5 x 0.1). Notation was made that multiple excoriations to right thigh, resolving well. Documentation revealed suspected deep tissue injury to the right and left heel with the left heel boggy. Review of the CNA Completed Care Task documents revealed skin checks every shift for the period of: on the 2 - 10 shifts on 07/03/12 at 08:18 PM and 07/04/12 at 7:33 PM was documented as " No New Skin Concerns. " On 07/04/2012 at 1:17 PM, S16, LPN/Treatment Nurse documented Wound Care Company made rounds and assessed resident #4 Stage III coccyx wound measuring 2.2 x 1.0 x 0.1, 60% slough and 40% granulation. The wound was debrided by Wound Care Company. Additional documentation indicated the right lateral heel was 2.8 x 2.9 x 0.01 and the left medial heel was 3.8 x 5.9 x 0.02. Review of the CNA Completed Care Task documents revealed skin checks every shift for the period of: on the 10 - 6 shift on 07/05/12 at 12:17 AM thru the 10 - 6 shift on 07/08/12 at 11:50 PM were documented as " No New Skin Concerns. " On 07/09/2012 at 9:28 PM, S28, LPN made a late entry for 07/08/2012 indicating a long, thin open area on the right leg that was to be reported to the treatment nurse. Review of the CNA Completed Care Task on the 6 - 2 shift on 07/09/12 at 11:29 AM and on the 2 -10 shift on 07/09/12 at 08:27 PM revealed " New Skin Concern - Nurse notified. Review of Physician order [REDACTED]. Cleanse the Stage III to right inner thigh with wound cleaner, apply hydrogel and cover with a dry clean dressing. Clean Stage II to right posterior thigh with wound cleaner, apply santyl and apply a dry dressing qd (every day). Clean Stage II to right and left buttocks with wound cleaner, apply santyl and apply a dry dressing qd (every day). On 07/09/2012 at 11:43 AM, S16, LPN/Treatment Nurse documented resident #4 was noted with a Stage III to right inner thigh measuring 14 x 2 cm draining serous draining 90% slough and 10% granulation; Stage II to right posterior thigh 2 x 0.5 cm draining moderate serosanguineous fluid 100% granulation; Stage II right buttock measuring 2.5 x 3 cm draining moderate serosanguineous fluid 100% granulation; and Stage II left buttock measuring 7 x 1.5 cm draining moderate serosanguineous fluid 100% granulation. Additional documentation indicated treatment continues to bilateral heels and coccyx wound. Record review of the copied Care Plan, submitted by the facility, revealed there was no documented Care Plan for the Stage II to right buttocks. Review of Physician order [REDACTED]. On 07/10/2012, resident #4 was transferred to a long term acute care at a local hospital for wound care. In an interview on 03/12/2013 at 3:05 PM with S1, RN/DON revealed that the LPN ' s on the medicine carts do a weekly " head to toe assessment " . She confirmed that S16, LPN was previously the wound care nurse and S17, RN/DON, (the former DON) assessed the skin each week. S17, RN/DON was present during the assessment and co-signed the documentation because the LPN treatment nurse could not stage a wound. S1, RN/DON stated that regarding the Stage III wound that was discovered on 07/03/2012, on resident #4's coccyx, the deep tissue injury was already there and there should have been documentation of the site before the Stage III was found. . In an interview on 03/12/2013 at 03:25 PM an interview with S3, RN/Corporate Nurse confirmed that the LPN ' s on the medicine cart are responsible for a weekly " head to toe assessment " on the residents. She also confirmed that S16, LPN wound care nurse and S17, RN/DON both performed skin assessments together because an LPN can ' t stage a wound. She stated that S17, RN/DON co-signs all of the LPN treatment notes. S3, RN/Corporate Nurse stated the CNA ' s do a skin assessment each time they perform ADL's, turn and reposition resident. She stated the CNA ' s document in the facility computerized system and report findings to the nurse. In an interview on 03/14/2013 at 10:00 AM with S8, LPN stated that if a resident was on a turn schedule and was refusing to turn, she would tell her supervisor, call the doctor and talk with the family. S8, LPN states that part of her duties as an LPN is to perform head to toe skin assessment, however if a resident is refusing to turn she indicated she would assess the skin on a daily basis. S8, LPN also indicated she would speak with the CNA ' s and have them call her when they are changing/performing care with the resident so she could assess the skin. In an interview on 03/14/2013 at 10:20 AM with S6, LPN revealed that the facility requires residents with skin issues to be assessed on a weekly basis but she would assess a resident from head to toe more frequently to see if there are any skin breakdowns. In an interview on 03/14/2013 at 1:35 PM with S3 RN/Corporate Nurse revealed that the reason resident #4 had all the skin breakdown was because she was incontinent all the time, having diarrhea, refused to be turned/repositioned, and changed.

Based on record reviews and interviews, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical and mental well-being in accordance with the comprehensive assessment and plan of care by failing to: 1. Manage the resident's pain and to continue monitoring of the effectiveness of the medication, which prevented the resident from participating in physical therapy/occupational therapy and resulting in refusal of care/repositioning; and notiyfing physician of the inability to manage the resident's increased pain and anxiety; 2. Follow the facility initiated bowel/bladder program to prevent incontinent episodes to prevent further development of skin conditions. This deficient practice resulted in an actual harm to resident #4 who was admitted to the facility on [DATE] for skilled services The facility did not appropriately assess, manage, monitor and treat the resident's pain/anxiety which interfered with the resident's participation in Physical Therapy/Occupational Therapy and ultimately leading to a decline in PT/OT. Further failure to manage, monitor and treat resident #4's pain/anxiety led to refusal to co-operate with ADL's resulting in increased incontinent episodes and further development of a Stage II pressure sore to the left and right buttocks on 7/9/12 in 1 (#4) out of 40 residents on the pain managed program according to Resident Census and Conditions of Residents Report. Findings: 1. Review of the Physician order [REDACTED]. [MEDICATION NAME] 10 mg tablet one po (by mouth) Q (every) 6 hr. prn (as needed) for pain [MEDICATION NAME] 10 mg tablet take two tablets po Q 6 hr. prn severe pain Review of the Nurse Notes revealed resident #4 complained of pain when either being moved/being turned in bed/refusing to turn/or being touched on the following days and times: The Departmental Nursing Notes failed to have documentation that the physician was notified of the inability to manage the resident's pain on a PRN interval. 06/21/12 at 3:28 PM, 06/24/12 at 11:37 AM, 06/24/12 at 11:48 AM, 06/28/12 at 3:13 PM, 06/29/12 at 12:57 AM, 06/29/12 at 11:10 AM, 06/30/12 at 2:47 PM, 07/02/12 at 4:47 PM, 07/04/12 at 1:44 AM, 07/04/12 at 3:03 PM, 07/05/12 at 1:13 PM, 07/05/12 at 5:17 PM, 07/06/12 at 5:48 AM, 07/09/12 at 2:53 PM, 07/10/12 at 1:23 AM, 07/10/12 at 6:10 PM. Review of the Departmental Nurses Notes and MARs for resident #4 revealed the following documentation: On 06/19/12, 1 dose [MEDICATION NAME] 2 tablets was administered at 09:11 PM. 06/20/12 at 7:11 AM resident complained of left hip pain graded at #10 on the 1-10 pain scale for which she received [MEDICATION NAME] 10/500 two tablets for severe pain. Further review of MAR indicated [REDACTED]. On 06/20/19, [MEDICATION NAME] 2 tablets were administered at 6:40 AM, 2:16 PM, and 9:13 PM. 06/21/12 at 3:28 PM resident complained of pain when in bed and when moving at which time she was medicated for pain. On 06/21/12, [MEDICATION NAME] 2 tablets were administered at 7:16 AM, 2:02 PM, and 8:58 PM. 06/22/12 at 2:14 PM, resident complained of pain to left hip and was administered pain medication. On 06/22/12, [MEDICATION NAME] 2 tablets were administered at 7:53 AM, 2:30 PM, and 9:31 PM. 06/23/12 at 7:09 AM,1:55 PM, 10:36 PM, 11; 37 PM resident complained of left hip pain and medicated for pain. Further review of MAR indicated [REDACTED]. The resident was medicated three times. On 06/23/12, [MEDICATION NAME] 2 tabs adminstered at 06:08 AM, 12:42 PM, 8:52 PM. 06/24/12 at 11:48 AM PRN pain medication given, at 02:22 PM resident complained of pain and was given pain medication. Further review of MAR indicated [REDACTED]. On 06/24/12, [MEDICATION NAME] 2 tablets administered at 05:41 AM, and 1 tablet at 11:40 AM & 10:29 PM. 06/25/12 resident is medicated at 7:42 AM with no narrative or follow up of effective of medication. Resident was medicated one time. On 06/25/12, [MEDICATION NAME] 2 tablets administered at 7:41 AM. 06/26/12 at 4:39 PM resident complained of pain to left hip and medicated, 10:57 PM, it is noted resident #4 has frequent complaints of pain with PRN ' s (as needed pain medications) and PRN ' s given as ordered with minimal relief noted. Resident medicated 4 times and effectiveness was not documented for the AM and Evening dose. On 06/26/12, [MEDICATION NAME] 1 tablet administered at 10:50 AM and 06:15 PM and 2 tablets were administered at 4:31 AM and 11:58 PM. 06/27/12 there was no documentation of complaints. The resident was medicated 3 times and there was no documentation of effectiveness of medication. On 06/27/12, [MEDICATION NAME] 1 tablet was administered at 7:00 AM and 2 tablets at 11:00 AM and 5:33 PM. 06/28/12 at 3:13 AM resident complained of pain to left hip graded at #10 on 0-10 scale and [MEDICATION NAME] 2 tablets given for severe pain. At 5:18 PM documentation revealed PRN [MEDICATION NAME] in progress. No documentation of effectiveness for AM dose. On 06/28/12, [MEDICATION NAME] 2 tablets at 12:19 AM, 8:47 AM and 6:25 PM. 06/29/12 resident medicated 2 times with a time span interval of 8 1/2 hours between morning and evening doses. Physician made rounds and no documentation that he was notified that the resident's pain was difficult to be managed on a PRN interval. On 06/29/12, [MEDICATION NAME] 2 tablets at 7:27 AM and 3:56 PM. 06/30/12 resident medicated 2 times with a time span interval of 9 hours between morning and evening dose. On 06/30/12, [MEDICATION NAME] 1 tablet at 10:13 PM and 2 tablets at 8:08 AM. 07/01/12 at 11:51 PM, it is noted resident #4 is complaining of pain to the left hip area. Resident #4 was medicated twice during the shift. The time span interval between AM and PM dose was 7.75 hours. On 07/01/12, [MEDICATION NAME] 2 tablets at 9:55 AM and 5:44 PM. 07/02/12 at 6:01 PM documentation revealed resident #4 stated she does experience pain to her hip which is relieved some by medications, however pain is severe at time she states and adds that therapy and movement does increase her pain. Further review revealed there was no documentation that the physician was notified of unable to manage pain with PRN intervals. On 07/02/12, [MEDICATION NAME] 1 tablet at 9:35 AM and 2 tablets at 7:06 PM. 07/03/12 at 3:35 PM documentation indicated resident #4 continues to complain of her left hip pain frequently. Further review revealed that there was no documentation that the physician was notified of unable to manage pain with PRN intervals.. 07/03/12 at 5:10 PM documentation indicated resident #4 continues to frequently complain of left hip pain with prn (as needed) [MEDICATION NAME] in progress and states the medicine is effective short term. Further review revealed there was no documentation that the physician was notified of unable to manage pain. On 07/03/12, [MEDICATION NAME] 1 tablet at 8:54 AM and 2 tablets at 4:21 PM. On 07/04/12, [MEDICATION NAME] 1 tablet at 1:25 AM and 2 tablets at 8:01 AM. 07/05/12 at 5:17 PM, documentation indicates that resident #4 moans and screams in pain prior to staff or PT (physical therapy) touching her. Resident #4 was not medicated for pain and no documentation that the physician was notified of unable to manage pain with PRN intervals. On 07/05/12, [MEDICATION NAME] 2 tablets at 4:09 AM and 1 tablet at 8:55 AM 07/06/12 at 10:48 PM documentation indicated resident #4 was complaining of pain and rating pain at 8/10. Further review of MAR indicated [REDACTED]. The nurses notes did not have documentation of continued pain assessment. On 07/06/12, [MEDICATION NAME] 2 tablets at 12:35 AM and 5:11 PM. On 07/07/12, [MEDICATION NAME] 2 tablets at 2:45 AM. On 07/08/12, [MEDICATION NAME] 1 tablet at 4:14 PM. 07/09/12 at 3:01 AM documentation indicated complaints of pain to left hip. 07/09/12 at 2:53 PM documentation indicated resident continues to request and receive prn (as needed) [MEDICATION NAME] for frequent complaints of left hip pain and states medication is effective short term. Review of MAR indicated [REDACTED]. The nurses notes did not have documentation of continued pain assessment. Further review revealed there was no documentation that the physician was notified of unable to manage pain. On 07/09/12, [MEDICATION NAME] 2 tablets at 12:04 AM and 1 tablet at 9:36 AM. On 7/10/12, No pain medication was administered. Review of Departmental Nurses Notes revealed documentation of resident #4's difficulty in participating in PT/OT as follows: 06/28/12 at 5:18 resident #4 was cooperative with therapy tolerating with moderate difficulty due to pain. 07/03/12 at 5:10 PM document revealed resident #4 continues to participate in therapy, tolerating with moderate difficulty due to pain with movement. 07/05/12 at 5:17 PM, documentation revealed resident #4 continues to participate in therapy, tolerating with moderate difficulty due to pain with movement. 07/06/12 at 4:26 PM, documentation indicates resident #4's fear of pain preventing progress of therapy. 07/09/12 at 2:53 PM documentation indicated resident #4 tolerates therapy with moderate difficulty due to pain in left hip. 07/10/12 at 6:10 PM documentation indicated resident #4 is tolerating therapy with moderate difficulty due to pain in left hip and movement. Review of the PT (Physical Therapy) Evaluation and Plan of Treatment dated 06/20/2012 revealed: Clinical Impression: Morbidly obese female who was anxious and in extreme pain. Resident #4 was defensive of any movement and totally dependent for all mobility. She required firm guidance to perform requested tasks. Resident #4 was independent at home prior to the [MEDICAL CONDITION] and needs therapy to return to PLOF (Prior Level Of Function). Risk Factors: Due to the documented physical impairments and associated functional deficits, the resident #4 is at risk for: anxiety, immobility, increased pain, increased dependency upon caregivers and falls. Review of Physical Therapy notes revealed the following documentation: 06/28/2012 resident #4 was apprehensive about weight being through left hip during sitting balance. 07/04/2012 the physical therapy notes reveal that maximum improvement is yet to be attained and resident #4 resists any movement and is extremely fearful. 07/06/2012 the physical therapy notes reveal the resident #4 did not participate well in therapy, made little progress and was inhibited by fear and pain. Review of the OT (Occupational Therapy) Evaluation and Plan of Treatment dated 06/20/2012 revealed: Clinical Impression: Resident #4 is with decreased UE (upper extremity) strength, mobility, ADL ' s (Activities of Daily Living) and t/fs (Transfers) Risk Factors: Due to the documented physical impairments and associated functional deficits, the resident #4 is at risk for falls and increased pain. Review of Occupation Therapy Notes revealed the following documentation: 06/26/2012 revealed maximum improvement is yet to be attained. S4, OT (Occupational Therapist) documented that patient was complaining of pain in the left hip with bed mobility and required extensive assistance at times for static sitting EOB (Edge of Bed) secondary to pain and positioning. 07/03/2012 the S4, OT revealed maximum improvement is yet to be attained and resident #4 is with continued increase in complaint of pain. 07/04/12 revealed resident #4 was ill with vomiting and complaints of severe pain with all movements. S4, OT notified nursing of resident ' s condition. In an interview on 03/13/2013 at 12:00 PM, an with S4, OT (Occupational Therapy) revealed resident #4 was in a lot of pain and therapy was limited by the pain. She stated resident #4 declined in OT, at times due to pain. S4, OT indicated that she recalled resident #4 as being in " pain, pain, pain and then declined. " In an interview on 03/13/2013 at 12:40 PM with S5, PTA (Physical Therapy Assistant) confirmed resident #4 was in a lot of pain and needed a lot of encouragement. She revealed resident #4 was a " Maximum Assist Patient " and often exhibited guarding because she was in a lot of pain. S5, PTA stated she made nursing aware of the pain resident #4 was experiencing and she stated the nurses told her " We Know. " In an interview on 03/14/2013 at 09:42 AM with S9, CNA/Restorative Aide revealed resident #4 was in a lot of pain while she was a resident in the facility. She stated resident #4 would cry when she was being bathed or turned. In an interview on 03/14/13 at 10:00 AM S8, LPN stated if a resident is receiving pain medications and it appears that resident is still in pain she would notify the doctor to see if the doctor would increase the medication. In an interview on 03/14/2013 at 10:20 AM an interview with S6, LPN stated if a resident was on a turn schedule and was refusing to turn even though the resident was medicated for pain she would notify the doctor and document this in her nurse notes. S6, LPN indicated that if a resident can ' t talk, she would be able to see if the resident was in pain by assessing for facial grimacing, moans, screams, refusing to turn, refusing ADL ' s or refusing to get out of bed. S6, LPN verified that she recalls caring for resident #4 and remembers her being in excruciating amount of pain. In an interview on 03/14/13 at 10:35 AM with S7, LPN revealed that resident #4 had difficulties with therapy because of her pain level and had some days that were worse than other days. S7, LPN stated that if a resident was on pain medication but still continued to complain of pain she would get a set of vital signs and call the doctor. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg tid (three times a day) prn (as needed) for anxiety. Review of the eMar (Medication Administration Record) for June 2012 and July 2012 revealed the only dose of [MEDICATION NAME] 0.5 mg 1 tablet tid prn anxiety was administered on 07/03/2012 at 10:29 AM for behavior #1. Review of the Departmental Nurses Notes revealed the following documentation: S17, RN/DON (former DON) documentation on 07/03/2012 at 5:47 PM revealed the resident #4 was often combative, refusing to eat and very anxious with transfers. The documentation indicated the resident #4 revealed she is more fearful of pain than she is in pain and that the pain is relieved with the medication. Documentation revealed resident #4 was refusing to get OOB (out of bed), refusing to turn or reposition, refusing to all staff to float heels thus in turn leading to resident #4 acquiring skin impairments that are difficult to prevent with her not cooperating with getting out of bed or repositioning. In an interview on 03/14/2013 at 1:35 PM with S3, RN/Corporate Nurse stated S17, RN/DON (former DON) documented on 07/03/12 the resident #4 was more fearful of pain than she was in pain. S3, RN/Corporate Nurse stated she agreed with S17, RN/DON (former DON) in regards to resident #4 being more fearful of pain than actually being in pain and that the facility obtained an order from S18, Medical Director for [MEDICATION NAME] 0.5 tid (three times a day) prn (as needed) for anxiety on 06/29/12. In an interview on 03/14/2013 at 4:50 PM with S2, LPN/ADON confirmed she worked with resident #4 on 06/22/2012 and 06/29/2012. She reviewed her documentation for 06/29/2012 at 11:10 AM and confirmed resident #4 often complained when the left lower extremity was being touched or moved. She stated she gave the resident [MEDICATION NAME] 2 tablets by mouth at 7:27 AM on 06/29/2012 for pain graded at 8 on a scale of 0-10. S2, LPN/ADON stated that she did not speak to the doctor about changing the pain medication to see if the pain medication could be administered on a regular basis and administered more frequently than every 6 hours. She indicated that she believed resident #4 was more fearful than in pain. The orders and MAR (medication administration record) were reviewed with S2, LPN/ADON and she confirmed that [MEDICATION NAME] 0.5 mg 1 tablet by mouth every 8 hours prn (as needed) was ordered on [DATE]. Upon review of the records, she confirmed that [MEDICATION NAME] 0.5 mg was administered only one time during resident #4 stay at the facility that being on 07/03/2012 at 10:29 AM. 2. Potential for Bowel and Bladder Retraining document of 06/20/12 was reviewed and revealed: ? Voids correctly without incontinence: Yes, Always ? Is incontinent of stool: No, Never ? Can resident walk to bathroom or transfer to toilet/commode including, manage clothing, cleaning self, etc.: Immobile or needs assistance x 1 ? Mental Status: Alert and Oriented ? Mentally aware of toileting needs: Always ? Condition of skin on genitals, perineal or buttock area: No redness ? Predisposing Disease: Minor ? Summary (Total Score); 15-21 Good Candidate for individualized training ? Was resident added to program: No Summary of Findings: Resident is a new admission from hospital. She reports that she was previously continent of bowel and bladder, however is now experiencing some bladder incontinence. Resident will attempt toileting trial to determine benefits of program. Review of the Care Plan revealed problem need identified for problem onset 06/19/12: On 06/19/12, " I am incontinent of urine. " Interventions: 1. Initiate scheduled toileting plan based on my assessment (specify) 2. Initiate bladder retraining plan based on my assessment (specify) 3. Observe my skin daily for irritation and redness. 4. Assist me with perineal cleansing as needed. 5. Observe me for behavioral changes that may indicate UTI 6. Assist me to bathroom or commode as needed. 7. I use a bedside commode at night. Review of the Care Plan revealed problem need identified for problem onset 06/19/12: On 06/19/12, " I am incontinent of bowel. " Interventions: 1. Observe my skin daily for irritation and redness. 2. Assess my bowel pattern 3. Provide me verbal cueing 4. Assess me for abdominal distention. 5. Assess me for constipation/impaction. 6. Teach me about factors affecting bowel control. 7. Observe me for acute behavioral changes that may indicate constipation/discomfort. 8. Assess my bowel sounds. 9. Administer my laxative or stool softener as ordered. 10. Assist me to bathroom or commode as needed. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the following: Functional Status: ? Bed Mobility: Self Performance (# 3, Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Bed Mobility: Support Provided (# 3 Two + persons physical assist) ? Transfer: Self-Performance (# 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Transfer: Support Provided (# 3Two person physical assist) ? Toilet Use: Self-Performance ((# 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Toilet Use: Support Provided (# 3Two + person physical assist) ? ROM Limited Lower Extremity: Impairment on one side Review of the 14-Day Minimum Data Set (MDS) revealed the following: Functional Status: ? Bed Mobility: Self Performance (# 3, Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Bed Mobility: Support Provided (# 3 Two + persons physical assist) ? Transfer: Self-Performance (# 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Transfer: Support Provided (# 3Two person physical assist) ? Toilet Use: Self-Performance ((# 3 Extensive assistance - resident involved in activity, staff provide weight-bearing support) ? Toilet Use: Support Provided (# 3Two + person physical assist) ? ROM Limited Lower Extremity: Impairment on one side Review of the Departmental Notes by S35, LPN/Restorative were reviewed for 06/25/12 at 10:43 AM revealing resident completed trial program for bowel and bladder program. An individualized plan was implemented for toileting at 2 AM, 4 AM, 6 AM, 9 AM, 1 PM, 6 PM, and 10 PM. Resident #4 was oriented x 3 (awake, alert, and oriented) and wears adult diapers. The family and physician were notified of the toileting program. Staff will continue to observe weekly and adjust plan as needed. Record review of Bladder Roster from 06/01/12 - 07/31/12 revealed that the toileting schedule for resident #4 was not every 2 hours: 06/19/12: admitted , toileted at 8:43 PM/Incontinent; 06/20/12: Toileted 1 x per shift/Continent; BM lg./soft 06/21/12: Toileted 1 x per shift/Incontinent x 2 06/22/12: Toileted 1 x per shift/Incontinent x 2 06/23/12: Toileted 2 x on the night shift/Continent, No times on day and evening shift 06/24/12: Toileted 2 x on the night shift/Incontinent x 2, No times on day and evening shift 06/25/12: Toileted 2 x on day shift 1 x evening & 1 x night/Incontinent x 3; BM med./soft 06/26/12: Toileted 1 x day shift, 1 x evening & 2 x night/Incontinent x 3; BM medium/soft 06/27/12: Toileted 1 x on day shift & evening shift/Incontinent x 2; No checks on nights; BM large/soft 06/28/12: Toileted 1 x on day and evening & 2 x night/Incontinent x 2 06/29/12: Toileted 1 x on day and evening/Incontinent x 2; No checks on night 06/30/12: Toileted 2 x evening and 1 x night/Incontinent x 3; No checks on days; BM lg./soft 07/01/12: Toileted 1 x day and night/Incontinent x 2; No checks on evening 07/02/12: Toileted 1 x days and 3 x on nights/Incontinent x 3; No checks on evenings; BM x 2 medium/soft 07/03/12: Toileted 1 x on day, evening and night/Incontinent x 3 07/04/12: Toileted 1 x on day, evening and night/Incontinent x 2 07/04/12: Toileted 1 x on day, evening and night/Incontinent x 2; BM sm. & lg. soft 07/05/12: Toileted 1 x on day, evening and nights/Incontinent x 3; BM sm. soft 07/06/12: Toileted 1 x on day and evening and 2 x nights/Incontinent x 4; BM x 2 sm./lg. soft 07/07/12: Toileted 1 x on days, evenings and nights/Incontinent x 3; BM large soft 07/08/12: Toileted 1 x on days, evenings and night/Incontinent x 3; BM extra-large watery 07/09/12: Toileted 1 x on day and evening/Incontinent x 1; No checks on nights 07/10/12: Toileted 2 x on days/Incontinent x 1 In an interview on 03/14/2013 at 1:35 PM with S3 RN/Corporate Nurse revealed that a bowel and bladder program was initiated and the CNA ' s were assisting with toileting every hour. She stated that the reason resident #4 had all the skin breakdown was because she was incontinent all the time having diarrhea, refused to be turned/repositioned, and changed.