Every finding on record at Lakewood Post Acute and Rehabilitation

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews for CNA #2, CNA #4, CNA #5, CNA #6 and CNA #7 in order to determine potential training needs. Findings include: I. Facility policy and procedure The Performance Evaluations policy and procedure, revised September 2024, was provided by the regional director of clinical services (RDCS) on 3/27/25 at 1:22 p.m. It read in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be conducted on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter. Performance evaluations may be used in determining employee's promotion, shift/position transfer, demotions, terminations, wage increases and to improve the quality of the employee's work performance. The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training), and goals. II. Record review Annual performance reviews were requested on 3/25/25 at 3:59 p.m. for CNA #2 (hired 7/20/23), CNA #4 (hired on 7/30/23), CNA #5 (hired on 7/20/23), CNA #6 (hired on 7/20/23) and CNA #7 (hired on 3/18/24). -The facility was unable to provide documentation indicated CNA #2, CNA #4, CNA #5, CNA #6 and CNA #7 had annual performance evaluations. -The director of nursing (DON) said the five CNAs did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews. Cross-reference F943 for failure to ensure all staff had abuse and dementia training. III. Staff interviews The DON was interviewed on 3/26/25 at 2:11 p.m. The DON said she had become the DON six weeks prior to the survey. She said she did not know why the annual performance evaluations had not been completed.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) in contact and/or droplet precaution resident rooms; -Ensure housekeeping staff cleaned resident rooms in a sanitary manner: and, -Ensure disinfectant dwell times were followed. Findings include: I. PPE failures A. Facility policy and procedure The Infection Preventions and Control Program, revised October 2018, was received from the regional director of clinical services (RDCS) on 3/24/25 at 2:23 p.m. It revealed in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is a facility-wide effort involving all disciplines and indi-viduals and is an integral part of the quality assurance and performance improvement program. B. Observations On 3/24/25 at 12:04 p.m. resident room [ROOM NUMBER] was observed to have a sign on the door identifying the room was on droplet precautions and a PPE container was located to the left of the door. The assistant director of nursing (ADON) was applying a gown, mask, gloves and a face shield. The ADON applied PPE prior to entering the resident room with a lunch tray. The ADON exited room [ROOM NUMBER] with a mask and face shield. The ADON then removed her face shield and placed it into a blue paper bag located on the isolation cart and performed hand hygiene with an alcohol based rub. The blue paper bag was noted to have a second face shield in it. -The ADON failed to dispose of the face shield or disinfect it prior to placing it into the blue paper bag. On 3/24/25 at 10:21 a.m. an unidentified housekeeper was observed cleaning resident room [ROOM NUMBER]. The room had a sign on the outside of the door indicating the resident was on droplet precautions and an isolation cart with PPE was available outside the door in the hallway. The housekeeper entered the resident's room wearing a surgical mask and gloves. Upon her exit from the isolation room she removed her gloves and completed hand hygiene with an alcohol based hand rub. She then proceeded to the next room with the surgical mask in place. The housekeeper was observed to enter two other resident rooms with the same surgical mask worn in room [ROOM NUMBER], who was on droplet precautions per the signage on the door. -The housekeeper failed to properly apply the correct PPE when entering a resident room in isolation for droplet precautions and she failed to remove all PPE on exit of the room. On 3/25/25 at 12:09 p.m. the nutrition service manager (NSM) was brought a lunch meal tray to residents in room [ROOM NUMBER]. He came to the closed door, read the sign and looked for the PPE cart. The NSM asked the floor nurse where the PPE was to enter room [ROOM NUMBER]. Registered nurse (RN) #1 advised him it had been moved into the resident's room. The NSM then placed the room tray items on a table in the hallway approximately 10 feet from the resident's room. The NSM entered the resident's room, collected a gown, gloves and a mask. He applied the PPE then walked across the hallway to retrieve the lunch tray and entered room [ROOM NUMBER] to deliver the room tray. -The NSM failed to properly don PPE without bringing the PPE into the hallway after entering the resident room to retrieve the PPE. On 3/25/25 at 2:38 p.m. an unidentified oxygen supplier entered resident room [ROOM NUMBER]. There was a sign on the door that indicated the resident was on droplet precautions. There was a cart to the left of the door that contained PPE. The unidentified oxygen supplier did not put on PPE. He was observed to be within three feet of the resident assessing her oxygen use. The oxygen supplier exited the room, returned to the nurses station, spoke with facility personnel, returned to the resident's room and had staff assist him in retrieving an oxygen concentrator from the resident's room that was not in use. He then applied gloves in the hallway and wiped the oxygen concentrator down with a disinfectant wipe. He left the concentrator in the hallway then proceeded to several other resident rooms reviewing their oxygen needs. -The oxygen supplier failed to apply PPE prior to entering an isolation room and failed to perform hand hygiene after exiting a resident's room who was on droplet isolation room. C. Staff interviews RN #1 was interviewed on 3/25/25 at 2:22 p.m. She said the resident in room [ROOM NUMBER] was on isolation for vomiting and loose stools. RN #1 said the resident in room [ROOM NUMBER] was able to self ambulate to the restroom. RN #1 said the PPE cart was placed into the resident's room who resided in room [ROOM NUMBER] per the infection preventionist (IP) direction on 3/25/25. RN #1 said the IP informed her it could be placed inside the residents room if kept in what the facility considered a clean area in the room. RN #1 said the resident in room [ROOM NUMBER] was initially placed on droplet precautions, but was then changed to contact precautions per the IP direction. RN #1 said PPE was to be applied prior to entering the resident's room and removed prior to exiting. RN #1 said a gown and gloves were needed for contact precautions. RN #1 said if the resident was on droplet precautions the staff would have to apply a mask in addition to gown and gloves. RN #1 said regardless if the staff was providing care or not, anyone who entered a resident's room needed to apply PPE to prevent the spread of infection. The unidentified oxygen supplier was interviewed on 3/25/25 at 2:48 p.m. He said he worked for the oxygen company. He said he did not realize he entered a resident's room who was in isolation. He said he did not touch the resident, but should have performed hand hygiene on exit from the room. He said he usually applied PPE when he saw a sign on resident doors but did not apply it today. The infection preventionist (IP) was interviewed on 3/27/25 at 10:49 a.m. She said there were currently two residents in the building that were on isolation. She said one resident was on droplet precautions and the other one was on contact precautions. The IP said anyone who entered a room on droplet precautions needed to apply gloves, gown, mask and a face shield. The IP said anyone who entered a resident's room that was on contact precautions needed to apply a gown and gloves. The IP said PPE was important to help prevent the spread of infection. The IP said PPE could be stored inside a resident's room for contact precautions. She said PPE was stored outside of the room when the resident was on droplet transmission. The IP said they created a clean area within resident room [ROOM NUMBER] to place the PPE for contact isolation. She said she expected staff to enter the room to apply PPE in the deemed clean area within the room. The IP said a resident in room [ROOM NUMBER] was initially placed on droplet precautions by staff and when she arrived at the facility on 2/25/25. She said she reviewed the resident's isolation precautions and changed the precautions to contact based on the resident's symptoms. The IP said she then changed the signs and placed the isolation cart inside the resident's room. The IP said the facility had plenty of PPE and the face shield used on 3/24/25 should have been disposed of or wiped down with a disinfectant prior to being placed into the blue paper bag. The housekeeping laundry manager (HLM) was interviewed on 3/27/25 at 12:21 a.m. He said the housekeeping staff were to wear PPE when entering a resident room who was in isolation along with performing hand hygiene with soap and water. The HLM said alcohol based had rub could be used for hand hygiene, but soap and water was more effective. II. Housekeeping failures A. Professional Reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 4/2/25 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 4/2/25 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. The Profect HP Hydrogen Peroxide Disinfectant product specification sheet, undated, was retrieved on 4/2/25 from https://www.spartanchemical.com/globalassets/sharepoint/product-literature--documentation---epidocuments/product-literature/l1008_profect_hp.pdf. It revealed in pertinent part Use Profect HP daily as part of a simple and effective cleaning and disinfection program for your entire facility on hard, non-porous surfaces. Featuring patented hydrogen peroxide technology, Profect HP kills bacteria and viruses in 60 seconds. One minute contact times ensure efficacy and compliance for your most critical disinfection needs. Ideal for daily use on high-touch surfaces, Profect HP is available in a convenient ready-to-use formula. B. Facility policy and procedure The Routine Cleaning and Disinfection policy and procedure, undated, was received from the RDCS on 3/27/25 at 1:22 p.m. It revealed in pertinent part It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Cleaning considerations include, but not limited to, the following: a. Dry cleaning procedures will be conducted before wet procedures; b. Clean from areas that are visibly clean and least likely to be contaminated to areas usually visibly dirty; c. Clean from top to bottom (bring dirt from high levels down to floor levels); and, d. Clean from back to front areas. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: toilet flush handles; bed rails; tray tables; call buttons; TV (television) remote; telephones; toilet seats; monitor control panels, touch screens and cables; resident chairs; IV poles; blood pressure cuffs; sinks and faucets; light switches; and, door knobs and levers. Disinfectant solutions will be prepared fresh daily and changed frequently in order to ensure effectiveness. a. Follow manufacturer recommendations for dilution and frequency of changing of disinfectant solution. b. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection. c. Change solution after cleaning a room under transmission-based precautions. Clean and disinfect any equipment that enters the room before use in another location. d. Verify products used to clean and disinfect surfaces in rooms under transmission-based precautions are effective against the pathogen of concern. C. Observations Housekeeper (HK) #1 was observed on 3/25/25 at 9:40 a.m. cleaning resident room [ROOM NUMBER], a single occupancy room. HK #1 performed hand hygiene with alcohol based hand rub and applied gloves. She entered the room with Profect HP disinfectant spray and a rag. HK#1 sprayed a table in the room, the TV stand and dresser tops. HK#1 immediately wiped the spray on the surfaces. -HK #1 failed to allow a one minute dwell time for the Profect HP disinfectant to sit on the surface of items to ensure it was properly disinfected (see professional reference above). HK#1 removed her gloves, performed hand hygiene with alcohol based hand rub and applied new clean gloves. HK #1 then entered the bathroom with Profect HP disinfectant spray and two rags. HK #1 sprayed the sink handles, rim and bowl then she sprayed the toilet tank, rim and bowl with Profect HP disinfectant spray. HK #1 immediately flushed the toilet after she sprayed it with Profect HP disinfectant. HK #1 then returned to the sink and turned on the water. She splashed water onto the mirror and took a paper towel from the paper towel and wiped the mirror. HK#1 then took one rag and wiped the sink rim, handles and then the bowl of the sink. HK #1 then took the same rag she cleaned the sink with and wiped down all the grab bars in the bathroom. -HK #1 failed to clean the sink from cleanest to dirtiest. -HK #1 used the same rag, which had been contaminated by the sink, to clean the grab bars which were not sprayed with any Profect HP disinfectant spray. HK #1 went to the toilet with a new rag and she wiped the toilet tank, the handle, the seat and the rim of the toilet bowl. HK #1 then took the rag, dunked it into the toilet bowl water, wrung out the rag splashing water outside of the toilet. She then wiped the rim of the toilet again and the outside of the toilet to the floor with the same rag she dipped into the toilet bowl. -HK #1 failed to clean the toilet in a hygienic manner. HK#1 then returned to her cleaning cart. She removed her gloves, performed hand hygiene with alcohol based rub and applied clean gloves. She collected two mop pads from a bucket on her cart and wrung them out. HK #1 took one mop pad to clean the resident room from the window to the bathroom door. She changed the mop pad out and used the second mop pad in the bathroom. She used the same mop mad to clean the and the remaining floor from the bathroom door to the entrance of the room. -HK#1 failed to clean the floor in a hygienic manner as she finished mopping the room with the same mop pad from the bathroom. HK#1 said she was done cleaning room [ROOM NUMBER] at 9:51 a.m. -HK #1 failed to clean high touch areas in a resident room like call light, bed controls, handles to dresser, handles to doors and the bedside table. HK#1 was observed to clean room [ROOM NUMBER], a single occupancy room, on 3/25/25 at 9:54 a.m. She performed hand hygiene with alcohol based rub and applied clean gloves. HK #1 entered the resident's room with rag and Profect HP disinfectant spray. HK #1 sprayed the disinfectant on the horizontal surfaces of the TV stand, dresser, bedside table, night stands and tops of lamps. While HK #1 was spraying disinfectant spray she moved items that were on the bedside table including the resident's urinal. HK#1 immediately wiped the surface after spraying with disinfectant. The surfaces did not remain wet for one minute. -HK #1 failed to clean handles to dresser, night stand, call lights, bed controls and light switches. HK #1 failed to keep surfaces wet with disinfectant for one minute dwell time. HK #1 returned to the cleaning cart, removed her gloves, performed hand hygiene with alcohol based hand run and applied new clean gloves. HK #1 then collected two rags and entered the resident's bathroom. HK #1 sprayed disinfectant spray on the paper towel dispenser and the sink. HK #1 took one rag and wiped the paper towel dispenser. With the same rag, she wiped the sink rim and sink handle. HK #1 splashed water onto the mirror and wiped it down with a paper towel. HK #1 wiped the sink bowl and. Using the same rag she wiped down the grab bars in the bathroom without spraying them with a disinfectant. -HK #1 failed to clean the bathroom sink and grab bars in a hygienic manner. HK #1 did not apply any disinfectant to the grab bars prior to wiping them down with the solid rag from the sink. HK #1 took a second rag and began wiping the toilet by wiping the tank, handles, seat, and the rim of the toilet bowl . HK #1 then dunked the rag into the toilet bowl water and rang it out. She splashed toilet bowl water on the outside of the toilet. Using the same rag she wiped the toilet rim and the outside of the toilet base to the floor. -HK #1 failed to clean the toilet in a hygienic manner. HK #1 said she had completed cleaning the resident room at 10:09 a.m. -HK#1 failed to clean the high touch areas in the resident room: call light, door handles, light switches. D. Staff interviews HK #1 was interviewed on 3/25/25 at 10:10 a.m. She said the disinfectant spray she used was called Profect HP and had a three minute dwell time. -However, according to the manufacturer recommendations the dwell time was one minute (see manufacturer recommendations above). HK #1 said high touch areas in a resident room were cleaned only during a deep cleaning or when the resident was discharged from the facility. HK #1 said high touch areas were call lights, bed controls, light switches, handles and door handles. HK #1 said she did not clean the high touch areas as the two rooms she cleaned were regular cleans and not deep cleans. HK #1 said she had a toilet bowl brush to clean toilets but only used it when there was visible stool observed in the toilet. HK #1 said the Profect HP disinfectant she sprayed on the toilet was enough to clean it. She said she had no concerns with wiping the rim and the outside part of the toilet after dipping the rag into the toilet bowl. The housekeeping and laundry manager (HLM) was interviewed on 3/27/25 at 12:21 a.m. with the director of nursing (DON) present. The HLM said the chemicals used in the facility had a one to two minute dwell time. He said the surface had to remain wet for it to be effective in disinfecting the surface. The HLM said high touch surfaces were to be cleaned daily due to them being frequently touched by residents or staff. The HLM said high touch areas in resident rooms included call lights, door knobs and remotes. The HLM said the residents' rooms should be cleaned in a clock manner to ensure all surfaces were cleaned accordingly. The HLM said areas should be cleaned from cleanest to dirtiest areas to prevent contamination of cleaner areas. The IP was interviewed on 3/27/25 at 10:49 a.m. The IP said high touch areas in a resident's room included bedside tables, handles to drawers or doors, call lights, light switches, bed controls and any area the resident frequently touched. The IP said the high touch area should be cleaned daily with a disinfectant to help prevent the spread of infection. The IP said when cleaning a room, the cleanest areas should be cleaned first then the dirtiest last to prevent moving contamination from a dirtier area to cleaner areas. The IP said she did not know what disinfectant spray the housekeepers used to clean rooms. The IP said dwell time meant the time the surface was to remain wet for the disinfectant to be effective.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educated staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident dementia abuse prevention. Specifically the facility failed to: -Provide annual resident abuse prevention training to 17 out of 74 staff members; and, -Provide annual dementia management training for 15 out of 74 staff members. Findings include: I. Facility policy and procedure The Training Requirements policy and procedure, undated, was provided by the regional director of clinical services (RDCS) on 3/31/25 at 9:22 a.m. It read in pertinent part, It is the policy of this facility to develop, implement and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement and volunteers consistent with their expected roles. II. Staff training records A request was made for the facility's annual abuse and dementia training records for all active staff members on 3/25/25. On 3/26/25 at 11:00 a.m the RDCS provided the records for all active staff members who had completed annual abuse and dementia training. She said the training had not been completed by all the facility staff. Additionally, the records revealed 17 out of 74 staff members had not completed the facility's annual abuse training and 15 out of 74 had not completed the facility's annual dementia training. -The facility failed to ensure all active staff members completed the annual training for abuse and dementia. III. Staff interviews The director of nursing (DON) was interviewed on 3/26/25 at 2:11 p.m. The DON said she had become the DON six weeks prior to the survey. She said abuse and dementia training were completed upon hire and annually by human resources. She said she was responsible for tracking the staff abuse and dementia training and did not know why the training had not been completed.

Based on record review and interviews, the facility failed to ensure consent was obtained for the use of psychotropic medications for one (#4) of five residents reviewed for unnecessary medications out of 17 sample residents. Specifically, the facility failed to ensure informed consents, which included the risks associated with taking a psychotropic medication, were obtained for Resident #4 prior to the administration of a psychotropic medication. Findings include: I. Facility policy and procedure The Use of Psychotropic Medications policy and procedure, undated, was received from the regional director of clinical services (RDCS) on 3/27/25 at 1:22 p.m. It revealed in pertinent part, It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions were clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (written consent form, narrative note). II. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included type two diabetes mellitus (abnormal glucose control), major depressive disorder and heart failure. The 2/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The MDS assessment revealed Resident #4 received antipsychotic medications, had depression and was taking antidepressants. B. Record review The March 2025 CPO revealed the following physician's orders: -Bupropion 150 milligrams (mg), one tablet by mouth once daily for depression, ordered on 2/16/25; and, -Bupropion 300 mg, one tabled by mouth once daily for depression, ordered on 3/22/25. The 2/16/25 comprehensive care plan revealed Resident #4 was on antidepression medication due to a diagnosis of depression. Interventions included administering medications as ordered by the physician and observing the resident's mood and response to the medications. -Review of Resident #4's electronic medical records (EMR) failed to reveal an informed consent, which included the risks associated with taking the medication were discussed with the resident or resident representative prior to the administration of the medication. Review of the resident's EMR on 3/26/25 revealed the facility obtained informed consent from Resident #4 on the use of Bupropion on 3/26/25. -The facility failed to obtain informed consent from Resident #4 prior to the first administration of Bupropion on 2/16/25. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 2:10 p.m. She said it was the responsibility of the admitting nurse to obtain all consents for treatment including informed consents on psychotropic medications. LPN #1 said the resident had the right to refuse or accept taking medication and consent should be obtained from the resident or responsible party prior to the first administration. LPN #1 reviewed Resident #4's EMR and was unable to locate an informed consent for the use of Bupropion and said she would follow up on this matter. (see record review above). The social service director (SSD) was interviewed on 3/27/25 at 12:26 p.m. She said informed consent should be obtained from the resident or responsible party to ensure they knew the risks and benefits of taking the medication. The director of nursing (DON) was interviewed on 3/27/25 at 1:39 p.m. She said the floor nurses were responsible to ensure informed consent was obtained on medications during the admission process. She said the consent forms were part of the packet set-up to be completed for admissions. The DON said informed consent was important so the resident was aware of the risks and benefits of the medications they were taking . The DON said every new admit chart was audited by herself or the assistant director of nursing (ADON). The DON said she was unable to determine how the consent for this medication was missed.

Based on record review and interviews, the facility failed to develop and implement a comprehensive care plan for two (#18 and #15) of three residents reviewed for care plans out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #18's comprehensive care plan addressed his use of oxygen; and, -Ensure Resident #15 had a care plan for the use of splint and contractors. Findings include: I. Facility policy and procedure The Comprehensive Care Plan policy, undated, was provided by the regional director of clinical services (RDCS) on 3/27/25 at 1:22 p.m. It read in pertinent part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive care plan will be developed within 7 (seven) days after the completion of the comprehensive MDS (minimum data set) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included oxygen dependency, morbid (severe) obesity due to excess calories, shortness of breath and dependence on supplemental oxygen. The 1/31/25 MDS assessment revealed the resident was cognitively intact with a mental status (BIMS) score of 15 out of 15. He was independent with eating. The MDS assessment indicated he received oxygen therapy. B. Observations Resident #18 was observed three times between 3/24/25 and 3/27/25 in his room. He had a nasal cannula in place during all observation. His oxygen tubing was attached to his portable oxygen or his oxygen concentrator during observations. C. Record review Review of Resident #18`s comprehensive care plan on 3/24/25 did not reveal a care plan for oxygen therapy. Review of Resident #18's electronic medical record (EMR) revealed the resident did not have a physician's order for oxygen use. Cross-reference F695: failure to ensure a physician's order was obtained for oxygen therapy. D. Staff interviews Registered nurse (RN) #1 was interviewed on 3/26/25 at 9:37 a.m. RN #1 said if a resident was receiving oxygen therapy, there should be a physician's order and a care plan. She said she reviewed Resident #18's EMR and was not able to find the care plan for Resident #18's oxygen therapy and flow rate. The assistant director of nursing (ADON) was interviewed on 3/26/25 at 9:47 a.m. The ADON said a care plan and a physician order should be in place for oxygen therapy. She said she was not able to find a care plan for the resident's use of oxygen. The director of nursing (DON) was interviewed on 3/26/25 at 2:19 p.m. She said the use of oxygen required a physician's order as well as a care plan. She said these documents were crucial for the staff to know what the resident's plan of care was. She said the facility completed an audit to ensure all residents utilizing oxygen had a care plan in place. 46849 III. Resident #15 A. Resident status Resident #15, age 66, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included altered mental status, rheumatoid arthritis, osteoporosis, muscle weakness, chronic pain syndrome and cellulitis (infection of the skin of the right lower limb. The 1/23/25 MDS assessment documented the resident had moderate cognitive impairments with a BIMS score of nine out of 15. She had a functional range of motion deficit to her lower extremities. She required a wheelchair for mobility and required maximum assistance from staff for toileting, showering, dressing, bed mobility, transfers and ambulation. B. Resident interview and observation Resident #15 was interviewed on 3/24/25 at 10:30 a.m. The resident was unable to recall how she sustained her contractures but pointed out splints on her table. She said she could not remember how long she had been using the splints but she did not like them because the splints caused her pain. The resident said she knew she had been working with therapy for a long time and her goal was to be able to straighten her legs. During the interview Resident #15 was laying on her right side with her legs bent with her heels touching her back. C. Record review The comprehensive care plan, initiated 7/16/24, revealed the resident had an alteration in musculoskeletal status related to rheumatoid arthritis and osteoporosis. Interventions (revised 7/16/24) included anticipating and meeting the residents needs, providing heat and cold applications as needed, placing the call light within reach, monitoring for fatigue, monitoring for risk of falls and monitoring signs and symptoms or complications related to arthritis. The therapy care plan, revised on 7/16/24, revealed the resident was on physical therapy (PT) services related to a spinal surgery and metabolic encephalopathy which caused weakness and deconditioning. Interventions (revised 7/16/24) included PT five times a week for four weeks for improved independence and safety with functional mobility. -The care plan did not include the presence of contractures or a medical device to treat contractures such as a splint. The March 2025 CPO revealed the following physician's orders: A review of hospital records, dated 4/29/24, revealed the resident had bilateral knee and hip contractures. The OT evaluation, dated 5/29/24, documented the resident had bilateral contractures and spasticity (involuntary muscle stiffness). The PT evaluation, dated 5/29/24, documented the resident began using a bilateral knee extension bracing for contracture management two hours daily. The PT evaluation, dated 3/20/25, documented the resident was using knee splints for up to six hours a day to improve range of motion. -However, review of Resident #15's comprehensive care plan did not reveal the use of the splints (see care plan above). D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:09 a.m. She said she had worked with Resident #15 for over a year and the resident had contractures in her legs the entire time. LPN #1 said therapy worked with the resident and she had knee splints for the contractures. She said the nurse management wrote all the care plans and the interventions for residents for nursing treatment and services. LPN #1 said the nursing staff utilized the care plan for resident centered interventions. The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:55 p.m. She said Resident #15 was receiving services from PT and OT. The DOR said PT had just started using a splint with the resident for her contractures. She said the nursing department would be responsible for including any devices used for contractures in the resident's care plan. The DON was interviewed on 3/27/25 at 1:47 p.m. She said the therapy department took the lead on assessing and identifying devices that were needed for the residents. The DON said the nursing department added the resident diagnosis and any treatment being received from therapy into the resident's care plan. The DON said she thought Resident #15 had only used a splint one time. She said she did not know why the splint was not included in her care plan.

Based on observations, record review and interviews, the facility failed to ensure one (#15) of two residents received care and services according to acceptable standards of clinical practice out of 17 sample residents. Specifically, the facility failed to ensure residents had a physician review and order for the use of specialized medical devices for Resident #15. Findings include: I. Resident #15 A. Resident status Resident #15, age 66, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included altered mental status, rheumatoid arthritis, osteoporosis, muscle weakness, chronic pain syndrome, and cellulitis (infection of the skin) of the right lower limb. The 1/23/25 minimum data set (MDS) assessment documented the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of nine out of 15. She had a functional range of motion deficit to her lower extremities. She required a wheelchair for mobility and required maximum assistance from staff for toileting, showering, dressing, bed mobility, transfers, and ambulation. The MDS assessment failed to indicate any assistive or therapeutic devices. B. Resident interview and observations Resident #15 was interviewed on 3/24/25 at 10:30 a.m. The resident was unable to recall how she sustained her contractures but pointed out splints on her table. She said she could not remember how long she had been using the splints. The resident said she knew she had been working with therapy for a long time and her goal was to be able to straighten her legs. During the interview Resident #15 was laying on her right side with her legs bent with her heels touching her back. Resident #15 was observed on 3/25/25 at 1:15 p.m. laying in her bed on her right side with her legs bent with her heels touching her back. C. Record review The comprehensive care plan, initiated 7/16/24, revealed the resident had an alteration in musculoskeletal status related to rheumatoid arthritis and osteoporosis. Interventions included anticipating and meeting the residents' needs, providing heat and cold applications as needed, placing the call light within reach, monitoring for fatigue, monitoring for risk of falls and monitoring for signs and symptoms or complications related to arthritis. The therapy care plan, revised on 7/16/24, revealed the resident was on physical therapy (PT) services related to spinal surgery and metabolic encephalopathy which caused weakness and deconditioning. Interventions included providing PT five times a week for four weeks for improved independence and safety with functional mobility. The March 2025 CPO revealed the following physician's orders: Provide occupational therapy (OT) two times a week for four weeks, treatment may include bilateral lower extremity passive range of motion exercises, ordered on 3/18/25. Provide PT one to two times a week. The resident would tolerate knee splinting daily to improve range of motion and reduce risk of skin breakdown, ordered on 3/20/25 and effective on 3/26/25 (during the survey). -Physician visit notes dated 3/15/24 to 3/19/25 failed to reveal orders for splints or braces for contractures. A PT evaluation, dated 5/29/24, documented the resident began using a bilateral knee extension bracing for contracture management two hours daily. A PT evaluation, dated 3/20/25, documented the resident was using knee splints for up to six hours a day to improve range of motion. -Review of the March 2025 CPO revealed the resident did not have a physicians' order for splint use until 3/26/25 (during the survey), although documentation revealed PT had been using the knee splints since 5/29/24. II. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:09 a.m. She said she had worked with Resident #15 for over a year and the resident had contractures in her legs the entire time. LPN #1 said therapy worked with the resident and she had knee braces for the contractures. LPN #1 said she did not know if there was a physician's order for the use of the splints. She said there should have been a physician's order prior to the use of the splints. The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:55 p.m. She said Resident #15 was receiving services from PT and OT. The DOR said PT had just started using a splint with the resident for her contractures. -However, record review revealed the PT was using splints since 5/29/24 (see record review above). The DOR said she did not know if the physician had to write an order for the use of splints or braces for Resident #15 because the resident was paying privately and not through her insurance. The DOR said she did not know how the staff knew how to provide person-centered care without the physician's. She said the therapist working with Resident #15 had told her that she had entered the order into the electronic medical record (EMR) on 3/20/25 but there was no record of this. The director of nursing (DON) was interviewed on 3/27/25 at 1:47 p.m. She said the therapy department took the lead on assessing and identifying devices that may be needed for the residents. The DON said once a trial of the device took place, the therapy department notified the nursing department and the physician would be contacted for an order. The DON said it was important to ensure there was a physician's order prior to the use of any devices such as braces or splints for the collaboration of care with all departments. The DON said she was not aware the resident did not have a physician's order for the splint until the survey.

Based on observations, record review and interviews, the facility failed to ensure one (#18) of three residents who required respiratory care received the care consistent with professional standards of practice out of 17 sample residents. Specifically, the facility failed to: -Obtain a physician`s order for oxygen therapy was in place for Resident #18. -Ensure Resident #18`s portable oxygen tank was operating when in use. Findings include: I. Facility policy and procedure The Oxygen Administration policy, undated, was provided by the regional director of clinical services (RDCS) on 3/27/25 at 1:22 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. Personnel authorized to initiate oxygen therapy include physicians, RNs (registered nurse), LPNs (licensed practical nurse) and respiratory therapists. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. II. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included oxygen dependency, morbid (severe) obesity due to excess calories, shortness of breath and dependence on supplemental oxygen. The 1/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a mental status (BIMS) score of 15 out of 15. He was independent with eating. The MDS assessment indicated he received oxygen therapy. B. Observations On 3/24/25 at 10:21 a.m. Resident #18 was sitting in his wheelchair in his room He had a nasal cannula in his nose and the tube was attached to his portable oxygen tank. He had his portable oxygen tank on the back of his wheelchair. The portable oxygen tank was not turned on. He said he was unsure about the oxygen concentration setting. On 3/25/25 at 9:33 a.m. Resident #18 was in his room. He was sitting in his wheelchair and he had a nasal cannula in place. The oxygen tubing was attached to his oxygen concentration tank. The concentrator flow rate was set to 2.5 liters per minute (LPM). On 3/26/25 at 9:04 a.m. Resident #18 was sitting in his wheelchair in his room with the nasal cannula in his nose. The oxygen tubing was attached to the oxygen concentrator. The concentrator flow rate was set to 2 LPM. C. Record review Review of Resident #18`s March 2025 CPO revealed the resident did not have a physician's order for oxygen therapy. III. Staff interviews Certified nurse aide (CNA) # 1 was interviewed on 3/26/25 at 9:30 a.m. CNA #1 said the nurse notified the CNAs of the appropriate oxygen flow for the residents. He said they also had a report sheet that the assistant director of nursing (ADON) updated with the resident oxygen levels. He said the report sheet would show the residents oxygen flow rate. He said if a resident was using a portable oxygen tank, the resident's oxygen tubing should be reattached back to the concentrator upon returning to their room. He said the CNA might have forgotten to reattach Resident #18`s oxygen tubing to his concentrator after he returned to his room. Registered nurse (RN) #1 was interviewed on 3/26/25 at 9:37 a.m. RN #1 said the oxygen flow rate was located in the medication administration record (MAR) or on the report sheet. She said there should be a physician's order for oxygen therapy and it should be included on the resident's care plan. She was not able to find the physician`s order or the care plan for Resident #18's oxygen therapy and flow rate. She said the portable oxygen tank should be on when in use. She said residents should be switched over to the concentrator when they returned to their room. Cross- reference F656: failure to ensure Resident #18 had a care plan for the use of oxygen. The ADON was interviewed on 3/26/25 at 9:47 a.m. The ADON said a physician's order should be obtained and include the use of oxygen therapy and the flow rate. She said the hospital discharge paperwork should also tell them the correct therapies and flow rate ordered for the residents. She said a care plan and a physician's order should be in place for oxygen therapy. She was not able to find either documents in the resident's medical record. She said the portable tank should be on when in use. She said she will put the order in right away. The director of nursing (DON) was interviewed on 3/26/25 at 2:19 p.m. She said the use of oxygen required a physician's order as well as a care plan. She said these documents were crucial for the staff to know what the residents` plan of care was. She said portable oxygen should be turned on when in use.

Based on observations, record review and interviews, the facility failed to ensure one (#75) of one resident reviewed for dialysis care out of 17 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to consistently complete the pre-dialysis facility assessment section on dialysis communication form for Resident #75. Findings include: I. Facility policy and procedure The Hemodialysis policy and procedure, undated, was received from the regional director of clinical services (RDCS) on 3/27/25 at 1:22 p.m. It revealed in pertinent part, The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: -Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; -Physician/treatment orders, laboratory values, and vital signs; -Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; -Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; -Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; -Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; -Changes and/or declines in condition unrelated to dialysis; and, -The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications. II. Resident #75 A. Resident status Resident #75, age greater than 65, admitted on [DATE]. According to the March 2025 computerized physician orders (CPO) diagnoses included metabolic encephalopathy, congestive heart failure (fluids overload on the heart), end stage renal disease (abnormal kidney function) and type two diabetes mellitus (abnormal glucose control). The 3/21/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score (BIMS) score of ten out of 15. The MDS assessment revealed he had renal insufficiency, renal failure, or end stage renal disease (ESRD). B. Record review The dialysis communication book was provided for Resident #75 on 3/25/25 at 2:17 p.m. by registered nurse (RN) #1. Review of the binder revealed one communication sheet, dated 3/17/25. The post dialysis section of the form was not completed by the facility staff. The assistant director of nursing (ADON) provided a second binder for Resident #75 on 3/25/25 at 2:58 p.m. Review of the second binder revealed the dialysis center information with chair time, resident face sheet, medical orders for scope of treatment (MOST) form and current medication list. Review of the communication forms in the binder revealed the following: -The 3/17/25 communication form was placed into this binder and was l missing the post dialysis section to be completed by the facility; -The 3/19/25 communication form did not have the post dialysis section completed by facility staff; -The 3/21/25 communication form did not have the post dialysis section completed by facility staff; and, -The 3/24/25 communication form did not have the post dialysis section completed by facility staff. The March 2025 CPO revealed the following physician's orders: Obtain vital signs pre dialysis and post dialysis every shift every Monday, Wednesday and Friday, ordered on 3/24/25. Fill out pre/post dialysis form for dialysis Monday, Wednesday and Friday, name of dialysis center, location and chair time, ordered on 3/26/25 (during the survey). -Resident #75 had received four sessions of dialysis since admission to the facility. The facility failed to complete the post dialysis section of the communication form for all four dialysis sessions. III. Staff interviews RN #1 was interviewed on 3/25/25 at 3:06 p.m. She said the nurses were responsible for completing the dialysis communication forms prior to the resident leaving for dialysis and upon the resident's return. She said the nurse needed to review the form for orders or complications at dialysis and then complete the post dialysis section on the form. RN #1 confirmed the communication forms were incomplete (see record review above). The ADON was interviewed on 3/25/25 at 3:10 a.m. She said it was the floor nurses responsibility to ensure the dialysis communication forms were completed by all parties. The ADON said the missing entries on the dialysis forms were probably related to agency staff who provided care in the facility. The director of nursing (DON) was interviewed on 3/27/25 at 1:41 p.m. She said the facility was responsible for completing two of three sections on the communication forms used between the facility and the dialysis center. The DON said it was the responsibility of the floor nurse assigned to the resident to ensure the form was completed by all parties. The DON said the communication forms were important so the facility and the dialysis center were aware of the residents medical needs like if there was a change in condition or recommendations from dialysis to be discussed with the attending physician. The DON said agency staff have to review a binder prior to working to ensure they understand our policies, however it was the responsibility of the facility staff to ensure the forms were completed.

Based on record review and interviews, the facility failed to ensure residents diagnosed with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing for one (#78) of three residents out of 17 sample residents. Specifically, the facility failed to: -Ensure Resident #78, who had a history of suicide attempts and trauma, was monitored for signs and symptoms of suicidal ideation; and, -Ensure Resident #78, who had a diagnosis of depression and requested to see a therapist, was provided with mental health services. Findings include: I. Resident #78 A. Resident status Resident #78, aged 66, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included multiple fractures of ribs, myocardial infarction (heart attack), diabetes, chronic kidney disease, adjustment disorder with depressed mood and compression fracture of vertebra. The 3/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident's depression screen assessment, dated 3/25/25, revealed Resident #78had indicated she felt depressed, hopeless and bad about herself. B. Resident interview and observation Resident #78 was interviewed on 3/24/25 at 11:00 a.m. Resident #78 said she was recently admitted to the facility following a car accident. She said she had asked the social services director (SSD) if she could see a therapist because she felt she needed to talk to someone. Resident #78 said she had lost her mother a few months prior to her admission to the facility, the anniversary of her nephew's murder was coming up in a few days and she was worried she would no longer be able to care for herself without assistance. She said she had not heard anything from the SSD about a therapist appointment. During the interview, Resident #78 became tearful and cried frequently when discussing her traumatic experiences. C. Record review The trauma informed care plan, initiated 3/21/25, revealed Resident #15was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills and poor impulse control. Trauma included family issues, loss of mother in December 2024, murder of nephew in March 2022, life threatening illness, suicide attempt by overdose and recent breakup with her longterm partner. Interventions included encouraging the resident to verbalize her feelings, monitoring for signs and symptoms of decreased psychosocial wellbeing and adjustment issues and social services visits as indicated. Review of Resident #78's March 2025 CPO revealed the following physician's orders: Psychological evaluation and treatment needed, ordered 3/18/25. Bupropion (Wellbutrin) 150 milligrams (mg) tablet. Give one tablet by mouth one time per day for depression, ordered 3/18/25. Escitalopram (Lexapro) 5 mg tablet. Give one tablet one time per day for depression, ordered 3/18/25. Behavior monitoring for tearful or sad expressions, ordered 3/19/25. -The March 2025 CPO did not include a physician's order to monitor for potential signs and symptoms of suicidal ideation. The social history admission assessment, dated 3/18/25, revealed Resident #78 had indicated a history of stressful events to include a motor vehicle accident, life threatening illness or injury and a sudden, violent death. The resident lived with her sister and neither had been managing their health. Her sister was currently in the hospital and on dialysis. The discharge plan was unclear and the resident might have to move in with her brother. Social history obtained from the brother revealed the brother had concerns about the sisters being able to live together. Social services focus was to connect the resident with mental health services. Review of Resident #78's progress notes, from 3/18/25 to 3/25/25, failed to reveal documentation that referral had been sent to a psychologist for evaluation and treatment of the resident. II. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:09 a.m. LPN #1 said Resident #15 exhibited signs of depression, such as staying isolated in her room. LPN #1 said she knew the resident had lost her mother recently, but she was unaware of any other significant traumatic events or a history of suicide attempts for the resident. She said if the resident expressed signs or symptoms of depression, the nurse would document the information in the resident's medical record. Certified nurse aide (CNA) #2 was interviewed on 3/26/25 at 9:37 a.m. CNA #2 said he knew Resident #78's nephew had been murdered and the anniversary of his death was coming up. He said he was unaware of any other significant traumatic events or a history of suicide attempts for the resident. He said if the resident expressed signs or symptoms of depression, he would document it. CNA #3 was interviewed on 3/26/25 at 12:47 p.m. CNA #3 said Resident #78 cried frequently but she did not know why. The SSD was interviewed on 3/27/25 at 11:00 a.m. The SSD said she met with residents three days after admission to the facility. She said if a resident was having difficulty with coping or suffering from loss, she would check in with the resident. She said social services assessments were used to determine residents' needs. The SSD said the facility did not have any mental health providers. She said she only set up mental health services for a resident to follow up on after discharge from the facility. She said a resident with six or more traumatic events would be at higher risk for psycho social distress. She said if a resident had a history of suicidal ideations or attempts, that would warrant establishing behavior monitoring of signs and symptoms of increased depression. The SSD said she had completed a trauma assessment for Resident #78 and she was aware she had attempted suicide in the past. The SSD said she did not initiate behavior monitoring for suicidal ideations for the resident because Resident #78 said she would not attempt suicide again. She said she did not notify the facility staff that the resident had significant trauma or a history of suicide attempts. The SSD said it would be important for the staff to be aware that Resident #78 was at higher risk due for suicide due to an increase in stressors since her prior suicide attempt and staff could report to the SSD right away if there was a concern.

Based on record review and interviews, the facility failed to ensure two (#15 and #11) of five residents were free from unnecessary psychotropic medications out of 17 sample residents. Specifically, the facility failed to: -Document resident specific care plan approaches, to include medication specific target behaviors and person-centered interventions for Resident #15 and Resident #11's psychotropic medications; -Document behaviors for Resident #15 and Resident #11 to justify the use of psychotropic medications; and, -Ensure non-pharmacological interventions were offered to Resident #11 prior to the administration of an as needed (PRN) psychotropic medication. Findings include: I. Facility policy The Behavior Assessment, Interventions, and Monitoring policy, revised March 2019, was provided by the regional director of clinical services (RDCS) on 3/27/25 at 1:26 p.m. It read in pertinent part, The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include a description of the behavioral symptoms, including: frequency, intensity, duration, outcomes, location, environment, and precipitating factors or situations. The care plan will include targeted and individualized interventions for the behavioral and/or psychosocial symptoms, the rationale for the interventions and approaches, specific and measurable goals for targeted behaviors, and how the staff will monitor for effectiveness of the interventions. Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. When medications are prescribed for behavioral symptoms, documentation will include the rationale for use, potential underlying causes of the behavior, other approaches and interventions tried prior to the use of antipsychotic medications. For monitoring, if the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. Interventions will be adjusted based on the impact on behavior and other symptoms. II. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included altered mental status, chronic pain syndrome and unspecified dementia with behavioral disturbances. The 1/23/25 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) score of nine out of 15. The MDS assessment indicated the resident did not exhibit hallucinations or delusions, did not have physically or verbally abusive behaviors directed towards others, and did not display other symptoms such as disrobing in public or smearing/throwing bodily waste. B. Resident interview Resident #15 was interviewed on 3/24/25 at 10:30 a.m. Resident #15 said she could not recall the medications she was taking but she said she had a history of anxiety and depression related to chronic pain. She said when the staff provided her with interventions that alleviated physical discomfort, such as distracting her through snacks and keeping the room temperature comfortable, this decreased her anxiety and depression. C. Record review The cognitive care plan, revised 3/4/25, revealed Resident #15 had exhibited cognitive loss related to encephalopathy and altered mental status. She had delusions and hallucinations about dead family members and strangers in her room. Interventions (revised 7/16/24) included explaining all care to the resident to reduce tension, providing cognitive therapy and reality orientation, and monitoring and documenting behavior episodes to attempt to determine underlying causes considering location, time of day, person involved and situation. -The care plan failed to identify what specific person-centered interventions were effective in decreasing Resident #15's hallucinations and delusions. The psychosocial care plan, revised 7/16/24, revealed Resident #15 was at risk for behavioral symptoms (striking out, grabbing others, combative, verbally, or physically abusive, inappropriate disrobing, smears/throws food/feces/objects). Interventions (revised 7/16/24) included anticipating needs, notifying the physician of episodes of aggression and abusive behaviors, observing and documenting changes in behavior to include potential triggers, and reducing stimulation. -The care plan failed to identify which specific target behaviors Resident #15 exhibited or what specific person-centered interventions were effective for the resident's behaviors. -The care plan failed to identify potential triggers for Resident #15's behaviors. Review of Resident #15's March 2025 CPO revealed the following physician's orders: Behavior monitoring every shift for antipsychotic medication with target behaviors of combativeness, harm to self or others, delusions, and hallucinations, ordered 10/31/24. Record non-pharmological interventions used for antipsychotic medication,to include re-direction to another area of the facility, re-orientation of the resident to the current situation, providing a safe and secure environment, visits from social services, and diverging attention to an activity of choice, ordered 10/31/24. Risperdal (antipsychotic medication) 0.5 milligrams (mg). Give one tablet by mouth one time per day for dementia with behaviors, ordered 2/27/25 (original start date 9/15/24). Review of Resident #15's progress notes from 1/1/25 to 3/25/25 revealed there was no documentation regarding any behaviors for the resident. Review of Resident #15's medication administration records (MAR) and treatment admission records (TAR) from 1/1/25 to 3/25/25 revealed there were no behaviors documented for the resident during that time period. Review of the facility's psychotherapeutic meeting minutes revealed Resident #15 had been reviewed by the IDT one time, on 3/18/25. -There was no documentation to indicate the facility had concerns regarding behavior episodes for the resident and there was no documentation to indicate the justification for the continued use of the resident's antipsychotic medication. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included chronic pain, major depressive disorder and anxiety disorder. The 3/7/25 MDS assessment documented the resident had no cognitive impairments with a BIMS score of 15 out of 15. The MDS assessment indicated the resident had no behaviors. B. Resident interview Resident #11 was interviewed on 3/26/25 at 2:00 p.m. Resident #11 said she took PRN medication for anxiety. She said when she was feeling anxious, some non pharmacological interventions that helped were a cup of coffee and reading. Resident #11 said she had read three entire books since admitting to the facility and it distracted her from her anxiety. She did not recall if the staff offered her other interventions prior to giving her the PRN medication. C. Record review The medication care plan, initiated 3/13/25, revealed Resident #11 required anti-anxiety medications. Interventions included attempting non-pharmological approaches prior to medication administration and observing and recording the effectiveness of medications. -The care plan failed to identify person-centered non-pharmacological interventions that were effective for Resident #11. The psychosocial care plan, revised 3/13/25, revealed Resident #11 had a diagnoses of depression and anxiety and was at risk for tearfulness, isolation, withdrawing, restlessness, irritability and decline in mood. Interventions included observing for tearfulness, increased agitation and decreased participation in care. -The care plan failed to identify person-centered non-pharmacological interventions that were effective for Resident #11. Review of Resident #11's March 2025 CPO revealed the following physician's orders: Valium (benzodiazepine) 5 mg. Give one tablet by mouth every four hours as needed (PRN) for anxiety, ordered on 3/3/25 and discontinued 3/20/25. Valium 5 mg. Give one tablet by mouth every six hours PRN for anxiety, ordered 3/20/25. Behavior monitoring every shift for episodes of restlessness or repetitive questions. Record non-pharmological interventions, such as musical activity, empathetic listening, positive reinforcement, dim lights, social service visits, diverting attention, and encouraging the resident to express feelings or concerns, ordered 2/3/25. Review of Resident #11's MAR and TAR records from 2/3/25 to 3/25/25 revealed the following: The resident received PRN Valium five times between 2/3/25 and 2/28/25. -There was no documentation to indicate what behaviors warranted the administration of the medication. The resident received PRN Valium 102 times between 3/3/25 and 3/25/25. -There was no documentation to indicate what behaviors warranted the administration of the medication. Review of Resident #11's progress notes from 2/3/25 to 3/25/25 revealed a non pharmacological intervention was attempted or offered prior to the PRN Valium 25times out of 107 administrations of the medication. -The facility failed to consistently offer non-pharmacological interventions to Resident #11 prior to administration of her PRN Valium medication. A review of the facility's psychotherapeutic meeting minutes revealed Resident #11had been reviewed by the IDT on 3/5/25. -There was no documentation to indicate the facility had concerns regarding behaviors episodes for the resident. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:09 a.m. LPN #1 said prior to the administration of a PRN psychotropic medication, such as Valium for anxiety, the nurse should offer non-pharmacological interventions. Non-pharmacological interventions tried were documented in the resident's MAR or the TAR, as well as specific notes were put into the progress notes. She said the social services director (SSD) put standard, not individualized, interventions on the monitoring order and the nurses determined what worked most effectively through trial and error with the resident. LPN #1 said Resident #11 had behaviors of anxiety and agitation related to pain and stress over her health conditions. LPN #1 said she tried non-pharmacological interventions with Resident #11 such as one-on-one interactions, offering a book, offering a cup of coffee and offering to take the resident to the therapy department for socialization. LPN #1 said Resident #15 had behaviors of crying for staff to keep her company or agitation when she became too warm and the non-pharmacological interventions that worked for her included one-on-one visits, snacks (such as yogurt), turning on her air conditioner and putting a pillow in between her legs. She said she had not been asked by the SSD or the director of nursing (DON) what interventions she had tried for Resident #11 or Resident # 15. Certified nurse aide (CNA) #2 was interviewed on 3/26/25 at 9:37 a.m. CNA #2 said Resident #11 had behaviors of anxiety but he did not know the specifics. He said when she became anxious, he would give her a cup of coffee or offer to take her to visit the therapy department and that was effective. CNA #2 said Resident #15 cried out for attention and going to her favorite activities, such as bingo, was an effective intervention, as well as offering her a favorite snack, such as yogurt. CNA #3 was interviewed on 3/26/25 at 11:00 a.m. CNA #3 said Resident #15 was often confused but she did not have any behaviors that she knew of. CNA #1 was interviewed on 3/26/25 at 12:47 p.m. CNA #1 said Resident #15 was very vocal and cried frequently. He said he was not sure if she was crying because she was in pain or because she was depressed. He said the intervention he tried with Resident #15 was to turn on her air conditioner. CNA #1 said reorientating the resident to reality or removing her from the environment (her room) were not effective interventions because the resident required extensive assistance from staff to leave her room and this could cause her a lot of pain and reorientation would cause the resident distress. The SSD was interviewed on 3/27/25 at 11:00 a.m. The SSD said her role with psychotropic medications started at admission when she would review the hospital discharge records for background information on the resident's medications, history and diagnoses. The SSD said she assessed the residents after admission and reported back to the physician if there were any concerns with the psychotropic medications or if there needed to be changes to the medications. She said she determined the appropriate behaviors to put in the behavior tracking order based on the type of medication, or drug class, as well as the resident's diagnoses. The SSD said the nurse admitting the resident entered the physician's order for behavior tracking. She said if there were specific behaviors, the SSD would make modifications to the behavior tracking. The SSD said to determine the effectiveness of the psychotropic medications, she interviewed the nursing staff, the CNA staff and reviewed information from the morning clinical meeting. She said the nurses documented behaviors on the residents' TARs or in the progress notes. The SSD said the CNAs used the behavior tracking physician's orders to determine the specific non-pharmacological interventions to use for resident behaviors. She said the CNAs documented behaviors on the [NAME] (a tool utilized to provide consistent resident care) or in the CNA documentation system. The SSD said when there was a change to the behaviors or interventions, the DON would make updates to the physician's orders and staff were notified of the change when it came up on the resident's TAR again. She said once a month, the facility had a psychotherapeutic medication meeting where the residents' medications, behaviors and depression screens were reviewed. The SSD said the IDT reviewed the behavior monitoring documented on the TAR and the progress notes for changes to provide behavior information at the meeting. She said it was important the behaviors were being accurately captured and documented on the behavior monitoring records to reflect the necessity and efficacy of the psychotropic medications. The SSD said if a resident was taking a PRN psychotropic medication, the nurse needed to attempt a non-pharmacological intervention before offering the PRN medication and document whether the intervention was effective or not. She said the necessity for the PRN medications were reviewed in the psychotherapeutic drug meetings. The SSD said the meeting was important because the pharmacist, the medical director, social services and nurse management staff were present to review and make recommendations on medications for residents who were staying long-term in the facility. The SSD said Resident #11 was receiving Valium PRN for restlessness and fidgeting. She said she was not sure the origin of her behaviors other than the resident suffered from anxiety related to her chronic pain. The SSD said she was not aware of the specific non-pharmacological interventions listed for the PRN medication or what interventions the staff were using that were effective with Resident #11. The SSD said Resident #15 was prescribed Risperdal for combativeness, harm to self or others, delusions and hallucinations. She said Resident #15 had lived in the facility since 3/14/24 and should be reviewed in the psychotherapeutic meeting every quarter. She said the reason Resident #15 was only reviewed one time since 3/14/24 was because the facility had been having the meeting sporadically and not consistently. She said the psychotherapeutic drug meeting schedule had been disrupted with DON and assistant director of nursing (ADON) staffing changes. She said the facility did not have a process to ensure systems, such as the psychotherapeutic drug meetings were not interrupted by changes in clinical staff. The SSD said she was not aware that the current non-pharmacological interventions listed on the behavior monitoring records were ineffective and the staff were using different interventions for residents. The SSD said if the staff were not documenting correctly as to what behaviors were occurring and what interventions were being used, this affected the physician's ability to show the necessity for the medication and made it appear the facility was only using medication as an intervention for behaviors.

Based on observations, record review and interviews the facility failed to ensure for one (#5) of two residents reviewed received foods in the appropriate form as prescribed by the physician and/or assessed by the interdisciplinary team to support the treatment and plan of care. Specifically, the facility failed to consistently follow the physician's order for a renal diet for a Resident #5. Findings include: I. Professional reference The National Kidney Foundation (2023) Potassium in Your Diet, was retrieved on 4/2/25 from https://www.kidney.org/kidney-topics/potassium-your-ckd-diet It read in pertinent part, People with kidney disease are often advised to avoid high potassium foods. The body uses the potassium it needs. A person's kidneys remove the extra potassium from the blood. But when someone has kidney disease, the kidneys cannot remove extra potassium in the right way, and too much potassium can stay in the blood. When there is too much potassium in the blood, it is called hyperkalemia, or high potassium. Having too much potassium in the blood can be dangerous. Potassium affects the way a person's heart muscles work. When there is too much potassium, the heart may beat irregularly, which in the worst cases can cause heart attack. Foods high in potassium can include potatoes and tomatoes. II. Resident status A. Resident #5 Resident #5, age 80, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnosis of acute kidney failure, diabetes and protein calorie malnutrition. The 3/14/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The resident had a diagnosis of renal failure and was prescribed a therapeutic diet. B. Resident interview and observation Resident #5 was interviewed on 3/24/25 at 10:30 a.m. She said she was not aware she had kidney disease until her recent hospitalization but tried to adhere to her new renal diet. Resident #5 said she was aware she was supposed to eat foods low in potassium but frequently received foods that were not consistent with her renal diet like potatoes, tomatoes and bananas. She said she left those items on the plate and did not eat them. On 3/24/25 at 1:00 p.m. Resident #5 had her lunch tray. She had received tomatoes on the side and she had left them uneaten. C. Record review The nutrition care plan, initiated 3/15/25, revealed the resident had altered nutrition related to acute kidney failure. Interventions included to provide diet as ordered. -The care plan did not specify the resident's therapeutic diet. The March 2025 CPO revealed a physician's order for a renal protein 80 gram (g) diet with regular textures- ordered on 3/10/25. The dietary assessment, dated 3/10/25, revealed the resident was on a renal diet and was cognitively able to understand her prescribed diet. The physician's history and physical, dated 3/10/25, revealed the resident was hospitalized prior to admitting to the facility due to her kidney functioning. She reported to the physician she had lost her sense of taste but it had improved with her improving renal function. The weight note, dated 3/19/25, revealed the resident had a 4% anticipated weight loss due to diuretics. The resident reported she did not eat a lot of her meal if she received foods that she knew were high in potassium. The resident was provided education on her diet. III. Staff interviews The nutrition service manager (NSM) and the registered dietitian (RD) were interviewed together on 3/27/25 at 10:30 a.m. The RD said she reviewed the resident's prescribed diet in her evaluation and put the diet order into the electronic medical record (EMR). The RD said the NSM was notified through the EMR and entered the diet order into the electronic ticket system. The RD said the electronic ticket system printed out the resident's meal tickets with their imputed diet, texture and preferences. The RD said she worked at the facility part time and when she was in the building, she checked the tickets on the meal trays before the tray went out to the resident to ensure the order was correct and consistent with the resident's diet. The RD said for a resident on a renal diet, they received foods that were low in potassium because of the kidney's compromised functioning. The NSM said the facility started using the current electronic ticket system two months prior and he had found occasional errors in the system if too many specifics are entered into a resident's diet order. He said he had been working on how to improve the system errors and on a process to provide education to the kitchen staff on the different therapeutic diets. He said he was aware of the error with the tomatoes on the meal tray for Resident #5 on 3/24/25 but was not aware she had received high potassium foods on other days. The NSM said he would begin to work on a system to make sure the tickets are checked for accuracy for every meal, not only the meals when the RD was present.

Based on record review, observations and staff interviews, the facility failed to ensure one (#6) of three residents reviewed out of 28 sample residents, was provided the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #6, age 76, was admitted on [DATE] with diagnoses of fractured right femur (thigh bone), NPO (no food or fluids by mouth), type two diabetes, anemia, dysphagia (difficulty swallowing), and vitamin D deficiency. Resident #6 sustained a weight loss of 7.7 % (8.3 lbs) from 8/22/23 to 9/12/23, and a weight loss of 11.6 % ( 12.0 lbs) from 8/22/23 to 9/19/23, which was considered significant. Resident #6's weight was not obtained on 9/26/23, and not requested on 9/27/23 or 9/28/23. The facility failed to monitor, verify and document Resident #6's bolus tube feedings and liquid protein supplement were administered correctly and timely per the physician's orders. Findings include: I. Facility policy and procedure The Enteral Tube Feeding via Syringe (Bolus) policy, revised November 2018, was provided by the nursing home administrator (NHA) on 9/28/23 at 2:05 p.m. It read in pertinent part, Check the enteral nutrition label against the order before administration. Check the following information: type of formula, route of delivery, access site, method and rate of administration (ml/hour). The person performing this procedure should record the following information in the resident's medical record: the date and time the procedure was performed, amount of feeding and amount of water administered, the name and title of the individuals who performed the procedure, how the resident tolerated the procedure, if the resident refused the procedure, why and the intervention taken, the signature and title of the person recording the data. Report complications promptly to the supervisor and the attending physician. Notify the supervisor if the resident refuses the procedure. Report other information in accordance with facility policy and professional standards of practice. II. Resident status Resident #6, age 76, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included fractured right femur (thigh bone), NPO (no food or fluids by mouth), type two diabetes, anemia, dysphagia (difficulty swallowing) and vitamin D deficiency. The 7/11/23 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) completed. He required extensive assistance of two people with bed mobility, transfers, dressing and toilet use, and extensive assistance of one person with locomotion on and off the unit and personal hygiene. He needed the assistance of one person for bathing. The MDS assessment indicated the resident had a feeding tube and received 51% of more of his nutrition from the feeding tube. III. Resident representative interview and observations A. Resident representative interview Resident #6's wife was interviewed on 9/25/23 at 2:00 p.m. She said she did not understand how Resident #6 received 2200 calories a day and lost 10 pounds. She said she was concerned about Resident #6's weight loss. She said the facility ran out of the previous tube feeding product and changed the order to the Jevity 1.5; now the facility provided 325 ml per feeding and five bolus feedings per day instead of four and he was getting about 2400 calories a day. She said his nutrition was provided by the tube feeding and he only had food by mouth if he was working directly with speech therapy at the facility. B. Observations A continuous observation was completed on 9/26/23 from 2:30 p.m. until 4:30 p.m. -At 3:55 p.m. licensed practical nurse (LPN) #1 moved the medication cart outside the door to Resident #6's room. -At 3:58 p.m. LPN #1 entered Resident #6's room. She administered Resident #6's nystatin orally per the physician's order. LPN #1 did not administer any other medications or feedings for Resident #6. LPN #1 left Resident #6's room at 4:01 p.m. -At 4:05 p.m. Resident #6 was interviewed and he said he was unable to remember if he received his afternoon bolus feeding. LPN #1 was interviewed on 9/26/23 at 4:30 p.m. She said she administered Resident #6's bolus feeding at 2:00 p.m. on 9/26/23. A review of Resident #6's medication time stamped on 9/27/23 for medications administered 9/26/23 revealed the following: -Active critical care liquid protein was ordered to be administered at 7:00 a.m. daily and on 9/26/23 the active critical care liquid protein administration was marked completed at 3:53 p.m by LPN #1. - A 60 ml enteral tube water flush was ordered to be administered at 1:00 p.m. and on 9/26/23 the enteral water flush was marked completed at 3:55 p.m. by LPN #1. -An enteral feed of 325 ml of Jevity 1.5 with 120 ml of water flush was ordered to be administered at 3:00 p.m. and on 9/26/23 was marked completed at 5:29 p.m. by LPN #1. The active critical care liquid protein and 60 ml water tube flush were not observed to be administered at the time the medication was marked completed, or between 2:30 p.m. to 4:30 p.m. on 9/26/23. A continuous observation was completed on 9/27/23 from 2:30 p.m. until 4:50 p.m. -At 4:20 p.m. Resident #6's enteral feed of 325 ml of Jevity 1.5 with 120 ml water flush scheduled for 3:00 p.m. showed as overdue in the electronic medical record. -At 4:30 p.m. Resident #6's enteral bolus feed of 325 ml of Jevity 1.5 with 120 ml water flush was marked completed in the resident's electronic medical record. -At 4:38 p.m. LPN #2 entered Resident #6's room and told Resident #6 she wanted to administer Resident #6's bolus feeding. LPN #2 was observed measuring 237 ml of Jevity 1.5 into a measuring cylinder and LPN #2 said she measured 237 ml of Jevity 1.5. LPN #2 said she would administer his flush of 120 ml of water. LPN #2 was observed measuring 120 ml of water. LPN #2 attached a bolus syringe to Resident #6's feeding tube, poured Jevity 1.5 and partial water flush into the syringe and administered the formula into the tube. LPN #2 administered the remainder of the water flush into Resident #6's feeding tube. A review of Resident #6's electronic medical record at 5:00 p.m. revealed LPN #2 administered Resident #6's 10:00 a.m. bolus tube feeding on 9/27/23. LPN #2 was interviewed on 9/27/23 at 5:19 p.m. LPN #2 said she used a small bottle of Jevity 1.5 for Resident #6's 10:00 a.m. feeding and that must be why she thought to administer 237 ml. She said she gave Resident #6 237 ml of Jevity 1.5 for his 10:00 a.m. bolus feeding and that she could go back to his room and give Resident #6 additional Jevity to equal 325 ml. A review of the 9/27/23 daily skilled nursing note completed at 6:18 p.m. by LPN #2 documented Resident #6 received 325 ml of bolus. -The note did not provide further documentation of when or how LPN #2 returned to Resident #6's room to provide a additional bolus feeding after completing two bolus feedings incorrectly on 9/27/23 by measuring only 237 ml instead of 325 ml of Jevity 1.5 for the 10:00 a.m. and 3:00 p.m. feedings. A continuous observation was completed on 9/28/23 from 8:56 a.m. until 11:20 a.m. -At 9:54 a.m. Resident #6's enteral bolus feeding of 325 ml of Jevity 1.5 with 120 ml of water flush was marked completed in the resident's electronic medical record. -At 10:00 a.m. LPN #3 entered Resident #6's room. She asked how he was doing and told him she was checking on him. LPN #3 told Resident #6 she opened his blinds and said that she would see him in a little bit. She then told him she would put his pillows under his neck and left Resident #6's room at 10:01 a.m. -At 10:53 a.m. LPN #3 entered Resident #6's room and she said she was going to administer Resident #6's bolus feeding in a little bit and she was just bringing the containers. She carried a measuring cylinder in her hand entering the room. LPN #3 asked Resident #6 if he was doing all right. LPN #3 told Resident #6 she would be back in a little bit and she would see him in a while. -At 11:19 a.m. LPN #3 was observed administering Resident #6's enteral bolus tube feeding. LPN #3 provided 325 ml of Jevity 1.5 over two minutes with 120 ml water flush. LPN #3 was interviewed on 9/28/23 at 11:21 a.m. LPN #3 said she held Resident #6's earlier bolus feeding as a staff member from the therapy department was in Resident #6's room. IV. Record review A. Nutrition evaluation, care plan and physician orders Resident #6's 7/6/23 nutrition evaluation documented Resident #6's estimated nutritional needs to be 1470 to 1715 calories per day and 58 to 76 grams of protein per day. The evaluation documented Resident #6's initial tube feeding order provided 1785 calories and 76 grams of protein per day. Resident #6's care plan initiated 7/6/23 and revised 9/25/23 documented he was at risk for alteration in nutrition related to his NPO status and need for enteral feeding, low BMI (body mass index) and weight changes. The goal was for Resident #6 to maintain adequate nutritional status evidenced by no significant weight changes in 90 days while allowing for appropriate weight gain, meet his estimated nutritional needs at greater than 75% and tolerate his tube feeding without nausea, vomiting or diarrhea. Pertinent care plan interventions included to explain and reinforce the importance of maintaining the diet as ordered; obtain and monitor lab/diagnostic work as ordered and notify the physician of results and follow up as indicated; registered dietitian to evaluate and make diet change recommendations PRN (as needed), all initiated 7/6/23. -Resident #6's care plan interventions were not updated after his significant weight loss. Resident #6 had a care plan for cognitive loss and confusion as related to Alzheimer's disease and dementia, initiated 8/3/23. Resident #6's physician orders documented the following enteral g-tube feeding orders: -A 60 ml water flush to be administered through the feeding tube three times a day at 9:00 a.m., 1:00 p.m. and 9:00 p.m. initiated 8/17/23. -A bolus feeding (administered to the tube with a syringe) of 325 ml of liquid Jevity 1.5 (1.5 calories/ml) with a 120 ml water flush five times a day at 12:00 a.m., 5:00 a.m., 10:00 a.m., 3:00 p.m. and 7:00 p.m., initiated 9/21/23. -A 30 ml supplement of active critical care liquid protein administered through the tube feeding one time a day at 7:00 a.m. for low BMI initiated 9/9/23. B. Resident weights Resident #6's weights were documented in the resident's record as follows: -On 8/8/23 the resident weighed 110.0 lbs -On 8/15/23 the resident weighed 107.1 lbs -On 8/22/23 the resident weighed 107.5 lbs -On 8/29/23 the resident weighed 103.2 lbs -On 9/12/23 the resident weighed 99.2 lbs -On 9/19/23 the resident weighed 95.0 lbs -A weight was not obtained on 9/26/23, 9/27/23 or 9/28/23 (during the survey). From 8/22/23 to 9/12/23 Resident #6 lost 8.3 lbs, which was a 7.7 % weight loss considered significant and from 8/22/23 to 9/19/23 Resident #6 lost 12.0 lbs which was an 11.6% weight loss considered significant. There were no documented re-weighs to verify if any weight changes were incorrect. C. Progress notes Resident #6's progress notes were reviewed from 8/29/23 to 9/28/23. -The 9/8/23 registered dietitian (RD) note at 3:01 p.m. documented the RD spoke with the physician's assistant (PA) regarding the plan of care for Resident #6. Resident #6's tube feeding provided 42 calories per kilogram (kg) of body weight. A new weight was not recorded to review and adding liquid protein daily was recommended, which provided an additional 100 calories and 10 grams of protein per day. -The 9/13/23 weight change note at 11:20 a.m. documented Resident #6's weight continued to decrease despite the increased calories provided. The 8/24/23 labs showed a TSH3 (thyroid stimulating hormone) of 14 which was considered elevated. This lab result was relayed to the PA as this might have contributed to Resident #6's weight loss. Resident #6 was receiving 43 calories per kg of body weight which exceeded his estimated needs. A liquid protein supplement once daily was added on 9/9/23, and resident was reassessed as needed. -The 9/14/23 nurses note at 3:33 p.m. documented Resident #6 had a post surgical follow up at the hospital and the hospital physician reported worsening weight loss, decreased cognition and overall functional status and recommended a nutrition consult with a tube feeding adjustment for Resident #6. -The 9/15/23 nutrition narrative note at 9:40 a.m. documented the RD received a consult for Resident #6's continued weight decrease despite the increase in calories. The PA added levothyroxine for 9/16, and the facility allowed time for Resident #6's TSH to improve weight maintenance. The tube feeding exceeded estimated needs at 43 calories per kg of body weight and liquid protein was added 9/9/23. The facility would follow up with the PA and assess Resident #6 as needed. -The 9/20/23 weight change note at 9:54 a.m. documented Resident #6 continued with a weight decrease and was started on levothyroxine as an intervention. He was receiving an excess of calories and protein and was unable to maintain his weight. An additional bolus feeding was added to attempt to stabilize his weight. The RD referred to the PA regarding concerns for weight loss in presence of exceeding calories and protein needs. The new recommended tube feeding order was 325 ml of Jevity 1.5 five times a day, which provided 59 calories per kg of body weight. -The 9/22/23 nutrition narrative note at 12:57 p.m. documented Resident #6 continued on NPO; the tube feeding provided an excess of calories and protein, providing 2547 calories a day, with 59 calories per kg of body weight. The RD explained this to Resident #6's wife. Resident #6's weight continued to trend down and the PA was consulted. -There was no facility documentation of verification Resident #6's bolus tube feeding or liquid protein supplement was provided in the correct amounts. V. Staff interviews LPN #2 was interviewed on 9/26/23 at 5:06 p.m. LPN #2 said she looked at Resident #6's enteral tube feeding order again and said the bolus feeding was not late. She said it was up to the resident to choose and sometimes Resident #6 was tired and did not want his tube feeding. LPN #2 said the bolus feeding was given within the hour for administration at 4:00 p.m. when she provided it. She said it was her first day working at the facility. RD #1 and RD #2 were interviewed on 9/28/23 at 11:30 a.m. RD #1 said the interventions for Resident #6 were increased protein through his supplement, a tube feeding change from Jevity 1.2 to Jevity 1.5 and the physician was notified of Resident #6's weight loss. RD #1 said Resident #6's thyroid medication was adjusted. She said he was working with a speech therapist. RD #1 said Resident #6 was previously receiving a bolus tube feeding at home and his current tube feeding order using a bolus was based on his history. She said the facility kept Resident #6's tube feeding as a bolus instead of a continuous tube feeding to provide Resident #6 with a sense of normalcy based on what the resident used to receive at home. RD #2 said she could see if a bolus tube feeding was marked as administered by checking the resident's electronic medical record. She said if a medication in the electronic medication administration record (eMAR) was marked as completed that was the information she used. RD #2 said she was unable to check time stamps of medications that were administered. She said she assumed the bolus was administered correctly because it was marked completed in the eMAR. RD #1 and RD #2 said they were unsure if any visual verification the bolus feeding amount administered to Resident #6 was observed or completed. RD #1 and RD #2 said a visual verification of the bolus feeding should be completed and nursing staff were responsible for that. RD #2 said physicians typically recommended tube feed changes and made the changes as needed. The director of nursing (DON) and NHA were interviewed on 9/28/23 at 2:15 p.m. The DON said a medication should not be marked completed before the medication was administered and the medication should be marked completed after being administered. The DON said every resident in the building was weighed every week on Tuesday by a certified nurse aide (CNA). The DON said the RD reviewed all weights weekly on Wednesday and if a weight or re-weight of a resident was needed the RD would notify the DON and the DON would request the CNA weigh the resident. The DON said she did not receive a request from the RD a weight was needed for Resident #6. The DON said all departments were responsible for verifying the administration accuracy of the tube feeding orders and if a staff member noticed something was wrong it should be brought to a manager's attention. The DON said the physician would decide if a continuous tube feeding would be more appropriate for a resident than the bolus feeding. The DON said if a nurse administered Resident #6's tube feeding with 237 ml instead of the ordered 325 ml and then returned to the resident's room to provide an additional bolus feeding, a nurse would have to leave a written note or documentation to make the DON aware it occurred. The DON said she spoke with LPN #3 and the regional director of clinical services (RDCS) provided LPN #3 with an in-service on the correct times for medication administration. The DON said she was going to observe and monitor Resident #6's bolus feedings. The NHA said he preferred LPN #1 and LPN #2 not return to the facility. The NHA said the facility would likely keep Resident #6 on the bolus tube feeding as that was what Resident #6 received historically. VI. Facility follow up Daily weights were ordered on 9/28/23 at 12:32 p.m. for Resident #6. The NHA provided copies of facility in-services on 10/2/23 at 6:02 p.m. The in-services documented the regional director of clinical services (RDCS) provided education to licensed nursing staff at 12:30 p.m. on 9/28/23. The in-services revealed in pertinent part, Enteral tube feeding-bolus, pour, pass, sign. When administering medications, after observing the patient taking the medication sign the medications out on the eMAR (electronic medication administration record). Medications must be administered within the hour before time the medication is due or within the hour following. Do not sign medications as administered until after medication is taken by the patient.

Based on record review and interviews, the facility failed to consistently provide pain management services for one (#14) of one resident reviewed for pain out of 28 sample residents. Resident #14 was admitted on [DATE]. He had a surgical procedure on 9/25/23 to scrape infected bone out of his left foot and ankle region as a result of osteomyelitis (bone infection). Resident #14 had pain from the recent surgical procedure and phantom pain from a previous right leg above-knee amputation. He had orders for as-needed (PRN) Oxycodone which relieved his pain when given, but it was not administered in a timely manner. The facility failed to ensure Resident #14 had enough pain medication on hand to manage his pain and when it ran out failed to provide it from the facility emergency kit. The facility failed to notify the resident's physician of his unrelieved pain and need for medication and failed to conduct adequate pain assessments to determine if the pain regimen was effective and to determine whether an order for regularly scheduled pain medication was needed. Resident #14's pain management care plan was not individualized, did not include his pain management goals and was not updated after his surgery. These failures contributed to Resident #14 experiencing unrelieved severe pain rated at seven out of 10, which affected his sleep and daily activities. Findings include: I. Facility policy The Pain Management policy, revised October 2022, was provided by the nursing home administrator (NHA) on 10/2/23 at 6:02 p.m. The policy read in pertinent part: Implementing pain management strategies: 5. The following are considered when establishing that medication regimen: a. Starting with lower doses and titrating upwards (increasing the dose) as necessary; b. Administering medications around the clock rather than as needed (PRN); c. Combining long-acting medications with PRNs for breakthrough pain; d. Combining non-narcotic analgesics (pain relievers) with narcotic (opioid) analgesics; and e. Reducing or preventing anticipated adverse consequences of medications. 6. The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medication. Monitoring and modifying approaches: 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. 6. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. 7. If there is a pattern (time of day or day of the week) that the resident reports or appears to be in increased pain, consider the possibility of drug diversion and communicate the pattern to the nursing supervisor. II. Resident #14 status Resident #14, age 63, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included osteomyelitis (bone infection) of the left ankle and foot, acquired absence of right leg above the knee (amputation of right leg), a stage f4 pressure ulcer of the sacral region (above the tailbone) and depression. According to the 8/8/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive one-person assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The pain management section showed Resident #14 received a scheduled pain medication regimen as well as PRN pain medications. Resident #14 received no non-medication interventions for pain. Resident #14 had a hard time sleeping at night and his day-to-day activities were limited due to his pain. Resident #14 rated his pain as an eight (severe) on a scale of zero to 10. III. Interviews and observations Resident #14 was interviewed on 9/27/23 at 2:40 p.m. He said he had a major procedure on 9/25/23 where the surgeons had scraped the infected bone out of his left foot and ankle region. He said his pain was a seven (severe) on a scale of one to 10. Observations during the interview revealed he grimaced every time he had to move his left foot or when he attempted to fix the pillow his foot rested on. Resident #14 said he requested his as-needed (PRN) pain medication as soon as he was able to. He said he requested his Oxycodone every four hours and his Methocarbomal (a muscle relaxer used to treat acute musculoskeletal pain but does not relieve generalized pain) every six hours and he kept track of when he had taken each dose so he knew when he could request more. He said there seemed to be a problem with getting his Oxycodone (pain medication) being refilled because the facility could not get it in time from the pharmacy before he ran out. Resident #14 said it was not the first time he ran out of his Oxycodone and he was concerned because of the major surgery he had. He said it was really hard for him to sleep because of the pain and he was unable to take acetaminophen (non-narcotic pain medication) because there was concern about too much acetaminophen affecting his liver. Resident #14 said he took one to two tablets of Oxycodone every four hours PRN for pain. He said he received a dose around 10:00 a.m. on 9/27/23 and was informed by the nurse that it was his last dose. He said he believed he had a PRN order for Tramodol but the nurse told him he did not. He had an order for PRN Methocarbamol (muscle relaxer) which he said was not as effective on his pain but he was waiting for 6:00 p.m. when he would be able to receive the next dose. Licensed practical nurse (LPN) #2 was interviewed on 9/27/23 at 3:33 p.m. She said she touched base with the pharmacy for Resident #14's Oxycodone refill and was waiting for it. She said the pharmacy told her he needed a new prescription and she left a voicemail with Resident #14's physician to get the prescription sent over. She said the facility had an emergency kit with narcotics in it and it was an option for pain relief if Resident #14 needed it. She said she was an agency nurse and did not know a lot about Resident #14's pain. Resident #14 was interviewed again on 9/28/23 at 12:40 p.m. He said the nurses did not administer pain medication the night before (on 9/27/23). Resident #14 said on a scale of one to 10 his pain was a seven. He said, No one offered non-pharmacological options. I elevated my left foot on a pillow and no one has offered me ice since I returned from surgery on Monday, 9/25/23. (See record review below) He said the director of nursing (DON) worked last night, was not aware he was out of his pain medication and she said the facility was having issues with the pharmacy they used. I was told my medications would be delivered today by 9:00 a.m. I asked the nurse for an update since no one came in around that time. The nurse said my medications would be delivered between 1:00 p.m. and 3:00 p.m. so I'm waiting to see if they show up. I should not have to advocate this hard for my own pain medications, especially after just having surgery. I should just be able to recover, it gets very tiring having to advocate for myself this much. It is a daily fight to get a pain pill that I need. I had the infection scraped from my bone and it was a very painful experience. My pain today, on a scale of one to 10, is a seven. I know I probably will never be able to get the pain completely controlled but it would be great if I could get the pain down to a three or four. I experience a dull throb and sometimes it is a sharp pain on the inside of my left ankle. The pain changes depending on how I move my foot and ankle. The pain is constant and so far nothing has helped with the pain except the Oxycodone, even the Tramadol and Methocarbamol (muscle relaxers) do not help as much as the actual pain medicine. Resident #14 was tearful during the interview and winced whenever he moved or repositioned his foot. LPN #3 was interviewed on 9/28/23 at 1:05 p.m. She said she spoke to the pharmacy and they told her the medication would go out on the 1:00 p.m. medication run and usually was delivered between 1:00 p.m. and 3:00 p.m. She said Resident #14's pain was usually an eight out of 10 when he asked for his Oxycodone at 1:00 p.m. She said Resident #14 would probably want his pain brought down to a one or a two; he also had phantom pain due to his amputation. She said she ordered the medication when they were down to day six or day seven on a medication pack. Some medications came in multiple cards at a time, so it depended on the medication. She said Resident #14 should get a 30 or 90 day supply of his Oxycodone. We also have a narcotic emergency kit that typically stays in the medication cart but I am not sure where it is. It was in the cart Sunday (9/24/23) when I worked my last day and when I returned today it was not in the cart. I did not ask where the narcotic emergency kit went. LPN #3 said she administered Resident #14 a PRN Tramadol at approximately 10:00 a.m. to try to help his pain until the pharmacy delivered his medications. -LPN #3 did not notify the physician until 1:22 p.m. when discussing his PRN Tramadol not having an active order. The DON was interviewed on 9/28/23 at 1:37 p.m. She said the facility had issues with the pharmacy they used. She said, We faxed things to the pharmacy multiple times and they would say they never received it, although we received the fax confirmation sheet. The DON said she saw Resident #14's Oxycodone order was discontinued on his electronic medication administration record (EMAR) but was not able to locate the order in the CPO to discontinue it. She said when she spoke to the pharmacy she was informed the pharmacy discontinued the order because they never received the paperwork from Resident #14's doctor that they needed for a new prescription. She explained Resident #14 had surgery on 9/25/23 to scrape the infection from his bone and said it was a very painful procedure. The DON said Resident #14's pain was not being managed by the facility. She said, I tried calling the pharmacy for authorization to use the narcotic emergency kit and they said the medications were gone so they could not give the medication. The nurses called the pharmacy to see when his Oxycodone would be delivered so I was the only one to call and ask about using the emergency kit, which the pharmacy would not authorize. This is a typical problem with this pharmacy. Last night (9/27/23) he was in a lot of pain and I called the doctor to get the medication refilled and to get a new order. She said Resident #14's pain was not being managed by the facility. The NHA was interviewed on 9/28/23 at 4:40 p.m. He said the facility had been having problems since they switched pharmacies. He said, There is now an on-grounds liaison that we can call if we are having issues and she will get us the medications we need. The liaison is available to arrange medication deliveries 24/7 (24 hours a day, seven days a week). The NHA said he was unsure who the backup pharmacy was for the facility. He said non-pharmacological options should be used if appropriate. The NHA said the facility communicated with the resident's doctor or an on-call doctor if they could not reach the resident's doctor and consulted with them to determine if the best option for pain management would be the resident being sent to the emergency room . He said, If we consulted with the doctor and they indicated that a scheduled pain medication regime would work better for the resident versus PRN pain medications then we would do that. IV. Record review Resident #14's pain care plan, initiated 7/30/23 and not revised, identified, Pain (specify location) evidenced by (blank) related to (blank) which was initiated 7/30/23 and not revised. The goal was, Will express that pain management is within acceptable limits. -However, the facility did not list interventions to reach the resident's pain goal or specify where the pain was or what the pain was related to. The care plan was not individualized or person-centered and had not been updated since the resident's surgery. The September 2023 CPO read in pertinent part: Oxycodone HCI Oral Tablet 5 mg- give one tablet by mouth every four hours as needed for moderate pain (scale of one to six). Give two tablets by mouth every four hours as needed for severe pain (scale of seven to 10). The electronic medication administration record (EMAR) showed the last dose Resident #14 received of Oxycodone was two 5mg tablets administered on 9/27/23 at 11:19 a.m. It showed he received one Methocarbamol oral tablet 750 mg on 9/27/23 at 11:19 a.m. Staff documented pain levels prior to administering PRN pain medications. When he received his Oxycodone his pain levels were documented below a three out of 10 but when the Oxycodone was not received his pain level was documented at an eight out of 10. -However, no other pain medications were documented for the rest of 9/27/23 or 9/28/23 when Resident #14 said his pain was at a seven out of 10, his sleep was disrupted and the pain affected his activities of daily living. Resident #14 had no nursing progress notes in his medical record documenting his pain levels or that he was out of his pain medication. Resident #14's EMAR dated 9/1/23 to 9/28/23 directed nursing staff to document non-pharmacological pain interventions used for Resident #14. The options were listed as: -none needed -repositioning/limb elevation -reassurance/emotional support -provide distraction/diversionary activities -exercise/range of motion (ROM)/ambulation/stretching -rest period/quiet environment -Deep breathing/relaxation exercise -guided imagery/meditation -laughter/socialization -aromatherapy Additional options on Resident #14's EMAR for non-pharmacological interventions ordered 9/9/23 were documented as: -reposition -cold application -calm environment -deep breathing -relaxing technique -diversional activity Staff had documented providing Resident #14 with ice or cold applications on the EMAR as follows: 9/25/23 at 7:00 p.m. 9/26/23 at 7:00 a.m. and 7:00 p.m. 9/27/23 at 7:00 a.m. and 7:00 p.m. 9/28/23 at 7:00 a.m. -However, Resident #14 said he had not received any ice since the evening of 9/25/23. No other non-pharmacological pain interventions were documented. Staff had documented Resident #14's pain scale on the EMAR as follows: 9/25/23 for day shift, 7:00 a.m. to 7:00 p.m., one out of 10 9/25/23 for night shift, 7:00 p.m. to 7:00 a.m., two out of 10 9/26/23 for day shift zero out of 10 9/26/23 for night shift eight out of 10 9/27/23 for day shift three out of 10 9/27/23 for night shift one out of 10 9/28/23 for day shift one out of 10 Staff documented Resident #14's pain when he requested a PRN Oxycodone as follows: On 9/25/23: 12:00 a.m. pain was an eight out of 10 and the PRN Oxycodone was effective 11:37 a.m. pain was a seven out of 10 and the PRN Oxycodone was effective On 9/26/23: 4:16 a.m. pain was an eight out of 10 and the PRN Oxycodone was effective 8:55 a.m. pain was a five out of 10 and the PRN Oxycodone was effective 1:24 p.m. pain was a six out of 10 and the PRN Oxycodone was effective 6:46 p.m. pain was an eight out of 10 and the PRN Oxycodone was effective 11:23 p.m. pain was an eight out of 10 and the PRN Oxycodone was effective On 9/27/23: 11:19 a.m. pain was a five out of 10 and the PRN Oxycodone was effective -However, Resident #14 said during interviews on 9/27/23 at 2:40 p.m. and 9/28/23 at 12:40 p.m. that his pain level was seven out of 10. His nurses said on 9/27/23 at 3:33 p.m. and 9/28/23 at 1:05 p.m. that they were awaiting a refill of his Oxycodone. Interviews on the afternoon of 9/28/23 with the DON and the NHA and record review revealed the physician was not notified in a timely manner of the resident's unmanaged pain and there was still no plan to relieve Resident #14's pain. -Resident #14 had one comprehensive pain assessment completed on 8/8/23 and the facility failed to complete another pain assessment after he had surgery 9/25/23.

Based on observations, record review and interviews, the facility failed to store, prepare and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure a system was in place to monitor the internal temperature of the dish machine and ensure proper functioning of a high temperature dish machine; -Ensure staff washed and dried hands appropriately while plating and serving resident meals; and, -Ensure proper bistro refrigerator temperatures were maintained in two of two resident snack refrigerators that contained ready to eat perishable food. Findings include: I. Dish machine temperatures A. Professional reference The 2022 Food and Drug Administration (FDA) Food Code was accessed on 10/4/23 from https://www.fda.gov/media/164194/download?attachment and revealed in pertinent part, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160 degrees fahrenheit. Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 degrees fahrenheit. The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 degrees fahrenheit. B. Facility policy and procedure The Sanitization policy, revised November 2022, was provided by the nursing home administrator (NHA) on 9/27/23 at 3:59 p.m. It revealed in pertinent part, Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat sanitization for a high-temperature dish machine are: Wash temperature 150 to 165 degrees fahrenheit and rinse temperatures 180 degrees fahrenheit. One hundred and sixty degrees fahrenheit at the rack/dish surface reflects 180 degrees fahrenheit at the manifold, which is the area just before the final rinse nozzle where the temperature of the dish machine is measured. Temperature logs are to be kept for each meal (breakfast, lunch and dinner). If temperatures are not up to manufacturers regulations, notify the maintenance director and administrator. If the machine is cold or has not run for an extended period, run it a few times to bring it up to temperature. In the event the gauges are not reading correctly, temperature stips are to be run through to acquire temperature checks. Dishwashers are considered out of order and cannot be used if temperatures are not met. C. Observations At 9:25 a.m. the high temperature dish machine log for September 2023 was observed on the wall in the dish room. The dish machine log contained three columns for dish machine wash and rinse temperatures to be recorded three times a day. -There were no dish machine wash or rinse temperatures recorded from 9/12/23 to 9/25/23. The high temperature dish machine was observed during a wash and rinse cycle on 9/25/23 at 9:28 a.m. The first rinse cycle reached a maximum of 100 degrees fahrenheit. The dish machine was started for a second cycle and the rinse cycle reached a maximum 102 degrees fahrenheit. -The manufacturing instruction label on the side of the dish machine documented the required rinse temperature of the high temperature dish machine was 180 degrees fahrenheit. At 9:45 a.m. dish machine log was observed to have wash and rinse temperatures written on the temperature log from 9/12/23 to the breakfast shift on 9/25/23. All recorded temperatures were 180 degrees fahrenheit in the rinse temperature column. The environmental services director (ESD) asked the dietary manager (DM) if she had any of the temperature indicator strips to check the dish machine internal rinse temperature. The DM was interviewed on 9/25/23 at 9:46 a.m. The DM said she was aware the dish machine log was not filled out correctly and told the dietary aide to make sure dish machine temperatures were recorded. The DM said she thought the machine was a high temperature dish machine but was unsure. She said she was going to go find some temperature indicator strips to check the internal rinse temperature of the dish machine. At 9:50 a.m. the NHA was alerted that the logs were filled in from 9/12/23 to 9/25/23. The NHA said he was going to get a temperature indicator strip to check the internal temperature of the dish machine from another facility within their cooperation. At 10:04 a.m. the DM said she was trying to find the paperwork from the dish machine service company on their last facility visit that verified the dish machine worked and find a temperature indicator strip. She said the dietary staff would wash dishes in a three compartment sink until the the dish machine fixed. -A copy of the verification from the dish machine service company was requested but not provided. -On 9/27/23 at 11:20 a.m. the dish machine was observed running through a wash and rinse cycle and reached a maximum of 182 degrees fahrenheit on the rinse cycle. The NHA said the dish machine had been fixed Monday. D. Staff interviews The ESD was interviewed on 9/25/23 at 9:45. He said a dish machine service company was at the facility a couple weeks ago and the company verified the machine was working correctly and he would provide the documentation. The NHA and DM were interviewed on 9/28/23 at 1:00 p.m. The DM said the facility did not have internal measuring devices in house for the dish machine on Monday, but ordered some and the new temperature indicator monitoring strips were in the kitchen. The DM said her staff knew the importance of the dish machine rinse temperature being 180 degrees fahrenheit for sanitation purposes. The DM said monitoring the dish machine temperatures was the responsibility of all staff working but recording the temperatures was the responsibility of whomever was washing dishes that day. The DM said she had the documentation the dish machine service company paper verified the machine worked correctly and she would check the date the company was at the facility. The DM and the NHA said the rinse gauge was fixed Monday, tested and was running correctly. The NHA said he provided an inservice regarding the correct dish machine temperatures, recording the dish machine temperatures and not to use the dish machine if it was not working correctly. He said he provided the in-service to the DM and needed to provide the inservice to the remainder of the dietary staff. E. Facility follow-up The NHA provided sanitization inservice documentation on 10/2/23 at 6:02 p.m. that was provided to the dietary staff on 9/25/23. A new dish machine log was provided that included a column with a corrective action section to complete if the dish machine was not working properly. II. Proper handwashing A. Professional reference The Colorado Retail Food Regulations, effective 1/1/2019, were retrieved 10/4/23 from https://cdphe.colorado.gov/environment/food-regulations. It read in pertinent part, Food employees shall keep their hands and exposed portions of their arms clean. Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. Food employees shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: rinse under clean, running warm water; apply an amount of cleaning compound recommended by the cleaning compound manufacturer; rub together vigorously for at least 10 to 15 seconds while paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, and creating friction on the surfaces of the hands and arms or surrogate prosthetic devices for hands and arms, finger tips, and areas between the fingers; thoroughly rinse under clean, running warm water; and immediately follow the cleaning procedure with thorough drying method. Food employees shall clean their hands and exposed portions of their arms as specified under immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning gloves to initiate a task that involves working with food; after engaging in other activities that contaminate the hands. B. Facility policy and procedure The Handwashing/Hand Hygiene policy, revised August 2019, was provided by the NHA on 9/27/23 at 3:59 p.m. It revealed in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand washing is the best practice for preventing healthcare-associated infections. C. Observations Meal service was observed on 9/27/23 from 11:25 a.m. to 12:00 p.m. The hot foods were placed in the preheated steam table. The main server, cook (CK) #1, started the meal service by washing his hands with soap and water and applying disposable plastic gloves, but failed to perform proper hand hygiene during meal service while preparing resident meal plates. -At 11:36 a.m. CK #1 used utensils to scoop food onto a plate. CK #1 then touched the food on the plate with his gloved hands. He placed the plate in the serving window, a lid was placed over the plate and the plate was placed in the resident meal cart. CK #1 then used utensils to scoop food onto two more plates. He then used his gloved hand to place a roll on each of the two plates. The two plates were placed in the serving window, covered with a lid and placed in the resident meal cart. A pair of tongs were observed in the pan of rolls and remained there for the duration of meal service. -At 11:40 a.m. CK #1, while wearing the same gloves, touched two dry towels on the side of the steam table, used utensils to scoop food onto a plate and then touched the food on the plate with his gloved hands. He then put the plate in the window, a lid was placed over the plate and the plate was put in the resident meal cart. -At 11:42 a.m. CK #1, while wearing the same gloves, used utensils to scoop food onto two plates. He then used his gloved hand to place a roll on each of the two plates. The two plates were placed in the serving window, covered with a lid and placed in a resident meal cart. -At 11:45 a.m. CK #1 while wearing the same gloves, opened the microwave, placed a bowl of food inside, closed the door and pushed the microwave buttons to heat the food inside. He then opened the microwave, took the bowl out of the microwave and scooped the food onto a plate. He added a roll to the plate using his gloved hand. CK #1 then used his gloved hands and pushed the vegetables off the plate and back into the hot pan on the steam table. He placed the plate in the serving window, a lid was placed over the plate and the place was placed in the resident meal cart. -At 11:48 p.m. CK #1, while wearing the same gloves, guided cooked pasta onto a plate with his hands. He placed the plate in the serving window, a lid was placed over the plate and the plate was placed in the resident meal cart. -At 11:50 a.m. CK #1, while wearing the same gloves, used tongs to remove sliced turkey from the hot steam table pan and carried the sliced turkey to a cutting board. He started chopping the turkey with a knife and used his gloved hands to push the chopped turkey together on the cutting board and continued chopping. He then wiped his gloved hands on his pants, and grabbed a new pair of gloves and set them on the table next to the cutting board he was using. CK #1 then used the knife he chipped with and his gloved hand to scoop the chopped turkey off the cutting board and carried the turkey back to the steam table and placed the chopped turkey in the hot steam table pan. He then removed his gloves, did not wash his hands and put on the gloves he placed on the table. -At 11:55 a.m. CK #1 used utensils to scoop food onto a plate. He used his gloved hand to place a roll on the two plates. The plate was placed in the serving window, covered with a lid and placed in a resident meal cart. -At 12:00 p.m. CK #1 said he would use tongs for rolls in the future. D. Staff interviews The NHA and DM were interviewed on 9/28/23 at 1:00 p.m. The DM said she corrected CK#1 on a regular basis during his shifts to wash hands and perform hand hygiene correctly. She said she did not correct CK #1 during the meal service observation during the survey because she was not aware she was able to. The DM said she verbalized previous hand washing inservices to the dietary staff and did not have any written inservices she could provide. The NHA said moving forward the inservices would be documented or it was considered the in-service did not occur. The DM said she provided regular hand washing training. The DM said to properly wash your hands, after you turn on the water, add soap to your hands, sing the happy birthday song twice, dry your hands with a towel grab another towel and shut the water off. The DM said CK #1 was trained to wash his hands in between glove changes previously. The DM said she followed up with CK #1 again after meal service, he apologized and the DM told CK #1 had to be on top of his hand washing. The DM said she worked with the dietary staff on proper handwashing daily. The NHA said the infection preventionist (IP) provided handwashing inservices for all facility staff that attended the all staff meeting. The NHA said the IP did a demonstration for the staff but staff have not previously had to do a handwashing demonstration themselves. The NHA said he would look for some staff to sign in sheets that verified hand washing training. The IP was interviewed on 9/28/23 at 2:15 p.m. The IP said she had not completed a handwashing inservice for the building yet and had not yet provided any written handwashing education materials to the staff. III. Cold food holding of ready to eat food and unit refrigerators A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 10/4/23 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed 3/27/23 and retrieved 10/5/23 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Facility policy and procedure The Refrigerators and Freezers policy, revised November 2022, was provided by NHA on 9/27/23 at 3:59 p.m. It read in pertinent part, The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Refrigerators and/or freezers are maintained in good working conditions. Refrigerators keep foods at or below 41 degrees fahrenheit. Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCS food, initials, and 'action taken.' The last column will be completed only if temperatures are not acceptable. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and /or department contacted. C. Observations -On 9/25/23 at 11:03 a.m. a refrigerator was observed in the east hall bistro area. The refrigerator contained 10 half pint cartons of milk. There was no evidence of a temperature monitoring log on the refrigerator. -On 9/25/23 a.m. at 11:06 a.m. a refrigerator was observed in the west hall bistro area. The refrigerator contained 12 half pint cartons of milk and four individual yogurts. There was no evidence of a temperature monitoring log on the refrigerator. -On 9/27/23 at 10:55 the east hall bistro refrigerator was observed to have a temperature log on the outside of the refrigerator. The temperature log contained a morning temperature column and a evening temperature column. There were refrigerator temperatures recorded 9/26/23 and 9/27/23 and no temperatures recorded from 9/1/23 to 9/25/23. -On 9/27/23 at 11:00 a.m. the west hall bistro refrigerator was observed to have a temperature log on the outside of the refrigerator. The temperature log contained a morning temperature column and a evening temperature column column. There were refrigerator temperatures recorded 9/26/23 and 9/27/23 and no temperatures recorded from 9/1/23 to 9/25/23. D. Staff interviews The NHA and DM were interviewed on 9/28/23 at 1:00 p.m. The NHA said nursing staff should monitor and record refrigerator temperatures on the bistro logs. The NHA said typically floor staff or a certified nurse aide (CNA) should monitor and record the bistro refrigerator temperature at shift change which was twice a day at 6:00 a.m. and 6:00 p.m. The NHA said the bistro refrigerators might have food items for the night shift such as yogurts or anything residents requested. The NHA said there were no August 2023 refrigerator temperature logs for the bistro. The NHA said previously it was kitchen staff who monitored the bistro refrigerators but a CNA would monitor the refrigerators going forward. The DM said she thought nursing staff monitored the bistro refrigerator logs. The DON and NHA were interviewed on 9/28/23 at 2:15 p.m. The DON said her understanding was the kitchen staff monitored the bistro refrigerators. The DON said she was unsure who put refrigerator temperature logs on the bistro refrigerators during the survey. The DON said the kitchen staff placed product in the bistro refrigerator and were responsible for removing outdated products from the bistro refrigerators.

Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive based on the residents wishes for five (#23, #181, #6, #233 and #14) of five residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure: -Resident #23's physician order matched his Medical Orders for Scope of Treatment (MOST) advance directives form; -Resident #181 and Resident #233 had the MOST form completed upon admission; -Resident #6's physician order matched his MOST form and was readily accessible to nursing staff; and, -Resident #14 had a MOST form completed upon admission and reviewed with him. Findings include: I. Facility policy The Advanced Directives policy, revised [DATE], provided by the nursing home administrator (NHA) on [DATE] at 8:50 a.m., read in pertinent part: The resident has the right to formulate an advanced directive, including the right to accept or refuse medical or surgical treatment. Advanced directives are honored in accordance with state law and facility policy. If the resident or representative indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. Information about whether or not the resident has executed an advanced directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. II. Staff interviews Certified nurse aide (CNA) #2 was interviewed on [DATE] at 2:00 p.m. and said she did not know where the MOST form binder was located. She said she had worked at the facility for seven years and just checked the residents for medical bracelets. If the resident had a bracelet they were a do not resuscitate and if the resident did not have a bracelet they received cardiopulmonary resuscitation (CPR). Licensed practical nurse (LPN) #5 was interviewed on [DATE] at 2:00 p.m. and said he checked the resident's face sheet in the facility's charting system for CPR status when a medical emergency occurred. He was not aware of a binder that contained the residents' MOST forms but he would check with the charge nurse. LPN #1 was interviewed on [DATE] at 3:30 p.m. She said code status would be documented under the resident's face sheet or in the resident's computerized physician orders (CPO). She said if it was not in the facility's charting system then it would be located in the MOST forms binder. LPN #1 also said if the MOST form was not in the computer or the binder, the staff treated it as a full code and provided CPR to the resident. LPN #5 was interviewed again on [DATE] at 3:41 p.m. He said if the code status was not in the facility's charting system he would check the MOST form binder. If he was unable to locate the MOST form in the binder he said, I guess I would call a code and start CPR and inform the charge nurse or the director of nursing (DON) so they could make the final decision of what to do for the resident. LPN #2 was interviewed on [DATE] at 3:33 p.m. and said, We check the MOST form binder because that is the paperwork that the resident and the doctor have signed. We check to see if the computer orders match, too. If the resident does not have a MOST form then they are a full code, I think, until the form is signed. The social services director (SSD) was interviewed on [DATE] at 10:00 a.m. She said the social services team completed an audit on the MOST forms on Mondays and Fridays. She said her team checked the binder but not the orders in the computer. The MOST forms were initially completed by nursing staff and the social services team reviewed them during interdisciplinary team (IDT) meetings and care conferences and checked to see if the residents' wishes were still the same or had changed. She said the residents received a MOST form with their admission packet and was filled out by the admitting nurse. The facility did not use DNR bracelets of any kind, especially if information or wishes changed and the bracelet was not removed, or if the bracelet fell off and staff provided CPR to a resident who had a DNR in place. She said the bracelets caused a lot of problems and having the MOST form with a matching doctor's order was what the facility used. The DON was interviewed on [DATE] at 1:37 p.m. and said the MOST form was what the facility used for their residents. The MOST forms were expected to be completed upon admission with the admitting nurse. She said, We noticed issues with the MOST forms before where they were not being filled out completely. She said when a MOST form was signed by the resident or their representative then it was flagged for their doctor to sign the next time they were at the facility. The nursing home administrator (NHA) was interviewed on [DATE] at 4:40 p.m. He said the MOST forms were discussed at a previous quality assurance and performance improvement (QAPI) meeting. An audit was completed and the MOST forms were checked to see if everything was uploaded in the facility's system, coded correctly, and filled out accurately. He said, I think it failed because some MOST forms were completed and uploaded into the system but the paper MOST forms were not correct. I think too many people have their hands on the MOST forms. The NHA said a MOST form was completed upon admission and the social services team would follow up to ensure it was completed. The nursing staff should use the MOST form uploaded in the facility's charting system or the code status at the top of the resident's face sheet. He said the MOST forms went through their internal system which should have ensured the forms and orders matched. III. Resident #23 A. Resident status Resident #23, age 56, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), depression, gout (a form of severe arthritis), and hemiplegia (paralysis) of the left side of his body. According to the [DATE] minimum data set (MDS) assessment the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. He required minimum assistance for bed mobility. He required extensive assistance of one person transfers, toileting, dressing, and personal hygiene. B. Record review Resident #23 had a MOST form filled out and signed by himself and his physician on [DATE] as a DNR. An order was entered into his CPO as a full code on [DATE] and his face sheet showed full code as well. C. Resident interview Resident #23 was interviewed on [DATE] at 1:00 p.m. He said his DNR was extremely important to him. Resident #23 said his DNR was even entered into his will and everyone he knew understood his wishes. He said I would not just be mad that they provided me CPR and brought me back to life but I would be livid if I was brought back to life worse than I already am. IV. Resident #181 A. Resident status Resident #181, age 69, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included fusion of cervical spine (neck), fusion of lumbar spine (lower back), and spinal stenosis (space in the back bones are too small). According to the [DATE] MDS assessment the resident was cognitively intact with a BIMS score of 15 out of 15. He required very limited one person assistance with most activities of daily living (ADLs) but required extensive one person assistance with dressing and toileting. B. Record review Neither a MOST form or a physician's order regarding advance directives could be located in Resident #181's records or in the MOST forms binder. C. Resident interview Resident #181 was interviewed on [DATE] at 2:17 p.m. and said no one at the facility had asked what his wishes were if there was an emergency. He said his family understood he wanted to be a full code and all life saving treatments provided. Resident #181 said, It would upset me if I needed CPR and did not receive it and my family would be upset and probably sue someone if I needed help and it was not provided. V. Resident #6 A. Resident status Resident #6, age 76, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included osteomyelitis (bone infection), cervicalgia (neck pain), post-traumatic osteoarthritis (arthritis caused by an injury or trauma), chronic respiratory failure with hypoxia (not enough oxygen), and osteomyelitis of vertebra (bone infection in the spine). According to the [DATE] MDS a BIMS assessment had not been completed. Resident #6 required extensive two person assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. B. Record review An unsigned MOST form was placed in the MOST form binder under Resident #6's tab that said DNR. There was nothing regarding advance directives in his CPO or on his face sheet. Under the resident's documents uploaded in the facility's charting system a full code MOST form, signed on [DATE] by Resident #6's legal decision-maker and signed by his physician on [DATE] (almost two months after admission), was located. V. Resident #233 A. Resident status Resident #233, age 76, was admitted on [DATE]. According to the September CPO diagnoses included epilepsy (seizures), atrial fibrillation (irregular heartbeats), muscle weakness, and chronic fatigue. According to the [DATE] MDS a BIMS assessment had not been completed. B. Record review Resident #233 had an order in his CPO and on his face sheet that said full code. A MOST form could not be located in the binder under Resident #233's tab. VI. Resident #14 A. Resident status Resident #14, age 63, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included osteomyelitis (bone infection) of the left ankle and foot, acquired absence of right leg above the knee, a stage four pressure ulcer of the sacral region (above the tailbone), and depression. According to the [DATE] MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He required extensive one-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. B. Record review A MOST form or a physician's order could not be located in Resident #14's records initially. A new order was entered on [DATE] for Resident #14 to be a full code by the DON. (However, see the resident's and DON's interviews below.) C. Resident interview Resident #14 was interviewed on [DATE] at 2:17 p.m. He said no one had asked him what his wishes were since he had been admitted back in July. He said his wishes were to be a DNR due to having his leg amputated and dealing with a bone infection in his other leg. He said, It would just be best to let me go if something happened. D. Staff interview The DON was interviewed on [DATE] at 1:37 p.m. and said the MOST form was what the facility used for their residents. The MOST forms were expected to be completed upon admission with the admitting nurse. She said, We noticed issues with the MOST forms before where they were not being filled out completely. She said when a MOST form was signed by the resident or their representative then it was flagged for their doctor to sign the next time they were at the facility. -However, the DON said she did not know what Resident #14's advance directive wishes were and she did not recall entering any code status for him into the facility's charting system.

Based on observations, record review and interviews, the facility failed to ensure two (#183 and #14) of three residents reviewed out of 28 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to: -Document narcotic medication on the narcotic sheet and in the medication administration record (MAR) at the time of administration for Resident #183; and, -Document narcotic medication on the narcotic sheet and in the MAR at the time of administration and have physician order prior to administering the narcotic for Resident #14. Findings include: I. Professional reference According to Treas, L.S., [NAME], K.L. and [NAME], M.H. (2022). Davis Advantage for Basic Nursing: Thinking, Doing and Caring (3rd ed): Most nurses consider documentation the sixth right. After administering a medication, document it immediately on the patient ' s MAR. II. Facility Policy The Administering Medications policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 10:49 a.m. The policy read in pertinent part: Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication initials the resident ' s MAR on the appropriate line after giving each medication. III. Resident #183 A. Resident status Resident #183, age 69, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), her diagnoses included right femur (upper leg) fracture, osteoarthritis, head injury, anemia, congestive heart failure, diabetes and chronic pain. The minimum data set (MDS) assessment had not yet been completed due to the resident being newly admitted . B. Observation On [DATE] at 11:45 a.m., the medication cart was reviewed with licensed practical nurse (LPN) #2. The count of the resident ' s oxycodone 10 milligram pills revealed 37 pills remained and the documentation on the narcotic log for these pills revealed 38 pills remained. The LPN stated she needed to document on the narcotic log the administration of a dose that she had given earlier to the resident. LPN #2 documented the dose she administered earlier that morning. C. Record review The CPO included an order for oxycodone 10 milligrams, every four hours with a start date of [DATE] at 12:00 p.m. On [DATE] at 12:45 p.m., the nursing home administrator (NHA) provided a record that revealed the LPN documented administration on [DATE] at 11:10 a.m. for the dose of Oxycodone which was scheduled at on [DATE] at 8:00 a.m. D. Staff interviews LPN #2 was interviewed on [DATE] at 11:45 a.m. The LPN said that she gave Resident #183 her scheduled dose of oxycodone at 8:00 a.m. on that day and she had not documented the removal of the narcotic from the medication cart. The director of nursing (DON) was interviewed on [DATE] at 12:50 p.m. The DON said the nurse should document administration of medication immediately after the resident took the medication. She said the nurse should document on the narcotic log as soon as the narcotic was removed from the cart. 48412 IV. Resident #14 A. Resident #14 Resident #14, age 63, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included osteomyelitis (bone infection) of the left ankle and foot, acquired absence of right leg above the knee (amputation of right leg), a stage four pressure ulcer of the sacral region (above the tailbone), and depression. According to the [DATE] MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He required extensive one-person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS pain management section showed Resident #14 received a scheduled pain medication regimen as well as PRN pain medications. Resident #14 received no non-medication interventions for pain. Resident #14 had a hard time sleeping at night and his day-to-day activities were limited due to his pain. Resident #14 rated his pain as an eight (severe) on a scale of one to 10. C. Resident interview Resident #14 was interviewed on [DATE] at 2:40 p.m. and he said he believed he had a PRN order for Tramadol but the night nurse on [DATE] told him he did not. He had an order for PRN Methocarbamol (muscle relaxer) which he said was not as effective on his pain but he was waiting for 6:00 p.m. when he would be able to receive the next dose. Resident #14 was interviewed again on [DATE] at 12:40 p.m. He said the nurses did not administer pain medication the night before (on [DATE]). Resident #14 said on a scale of one to 10 his pain was a seven. He said licensed practical nurse (LPN) #3 administered a Tramadol to him but he did not know where the medication came from since a previous nurse informed Resident #14 that he did not have an order for it. (Cross-reference F697, pain management.) D. Staff observations and interviews LPN #3 was interviewed on [DATE] at 1:05 p.m. and said she spoke to the pharmacy about Resident #14 being out of his Oxycodone. She said his pain was usually an eight by the time he requested his Oxycodone at 1 p.m. She said she worked on getting his pain medication delivered. -However, LPN #3 failed to mention she provided Resident #14 a Tramadol for his pain. LPN #3 was interviewed again on [DATE] at 1:14 p.m. and said, Shoot, yes I did give Resident #14 a PRN Tramadol around 10:00 a.m. He has a card in the narcotic lock box of Tramadol. She provided the Tramadol's count sheet but said she needed to sign out his 10:00 a.m. dose first. She said she was unable to locate the order in Resident #14's electronic medication administration record (EMAR) to sign off the medication as administered, just an old order that expired on [DATE]. She reached out to the physician's assistant (PA) to obtain an order during the interview. -LPN #3 said she administered the Tramadol on [DATE] at 10:00 a.m. however she signed the narcotic count sheet for [DATE] at 11:00 a.m. as administered and did not sign the count sheet until 1:14 p.m. (two hours and 15 minutes after she administered the medication). The DON was interviewed on [DATE] at 1:37 p.m. She said a medication should not be administered if there was not an order for it. The DON said when nurses passed medications they located the resident, located the right medication, signed the narcotic count sheet when the narcotic medication was put into a medication cup, administered the medication, and then marked the successful administration on the EMAR. She confirmed the PRN Tramadol order expired for Resident #14 on [DATE] and a new order was needed to continue administering it. -A one-time order was entered for Resident #14 on [DATE] in his CPO and on the EMAR at 1:45 p.m. E. Record review Resident #14 had an order for PRN Tramadol which expired on [DATE]. The narcotic count sheet for the Tramadol said to discard the medication after [DATE]. The narcotic count sheet showed the following administrations to Resident #14: [DATE] at 9:30 a.m. by LPN #6 [DATE] at 5:50 p.m. by LPN #6 [DATE] at 11:30 a.m. by LPN #3 [DATE] at 6:20 p.m. by LPN #3 [DATE] at 11:00 pm by an unidentified nurse [DATE] at 10:00 a.m. by LPN #3 -Each time the medication was administered it was documented on the paper count sheet but not on the resident's EMAR because there was no active order in the CPO to make it accessible for administration documentation. V. Facility follow-up On [DATE] at 6:02 p.m., after the survey, the NHA provided the following documentation of nursing education: -On [DATE] When administering medications, after observing the patient taking the medications, sign the medications out on the EMAR. When administering narcotics, sign the medication out at the time the medication is removed. -On [DATE] Logging controlled substances- when administering controlled substances, medication must be signed out of the EMAR immediately after the administration to patient. Any controlled substance that is not signed out on the EMAR is considered diversion. All staff must sign in and out when handing off the keys on the staff sheet (oncoming/off-going). All controlled substances must be signed in and out of the controlled substances binder with a dual sign off between two nurses. -On [DATE] Medications must be administered within the hour before time the medication is due or within the hour following. Do not sign medications as administered until after medication is taken by the patient. With controlled substances, sign narcotic out of controlled binder at the time of removing medication. If medications are not available, pharmacy must be contacted, medical director (MD) notified medication not given, and a progress note entered.

Based on staff interviews and record review, the facility failed to ensure certified nurse aides and licensed nurses were able to demonstrate competency skills and techniques necessary to care for residents' needs. This placed all residents at the facility at risk of receiving inadequate care. Specifically, the facility failed to conduct staff competency evaluations for certified nurse aides (CNAs), licensed practical nurses (LPNs) and registered nurses (RNs). Cross-reference F658, professional standards for failure to sign out narcotic medications at the time of administration. Cross-reference F692, nutrition/hydration for failure to administer bolus tube feedings and water flushes per physician orders resulting in significant weight loss. Cross-reference F695, respiratory care for failure to ensure physician orders and baseline care planning for tracheostomy care. Cross-reference F697, pain management for failure to provide pain medications resulting in severe pain. Cross-reference F760, significant medication errors for failure to ensure a resident was not administered an intravenous antibiotic with properties she was allergic to, and which was ordered for a different resident. Cross-reference F880, infection control for failure to follow enhanced barrier precautions for residents with indwelling medical devices and failure to use proper personal protective equipment when entering a COVID-positive room. Findings include: I. Facility assessment The facility assessment, reviewed 9/11/23, identified the staff training provided by the facility to meet the needs of the residents, which read in pertinent part: Staff training/education and competencies Training Topics: Communication - effective communications for direct care staff Resident's rights and facility responsibilities - ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents Abuse, neglect, and exploitation - training that at a minimum educates staff on- (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse prevention. Infection control - a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program Culture change (that is, person-centered and person-directed care) Required in-service training for nurse aides. In-service training must: -Be sufficient to ensure the continuing competence of nurse aides and all staff but must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. -For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired. Required training of feeding assistants - through a State-approved training program for feeding assistants Identification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life Cultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents) Person-centered care - This should include but not be limited to person-centered care planning, education of resident and family /resident representative about treatments and medications, documentation of resident treatment preferences, end-of-life care, and advance care planning Activities of daily living - bathing (e.g., tub, shower, sitz, bed), bed-making (occupied and unoccupied), bedpan, dressing, feeding, nail and hair care, perineal care (female and male), mouth care (brushing teeth or dentures), providing resident privacy, range of motion (upper or lower extremity), transfers, using gait belt, using mechanic lifts Disaster planning and procedures - active shooter, elopement, fire, flood, power outage, tornado Infection control- hand hygiene, isolation, standard universal precautions including use of personal protective equipment, precautions, environmental cleaning Medication administration - injectable, oral, subcutaneous, topical Measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone Resident assessment and examinations - admission assessment, skin assessment, pressure injury assessment, neurological check, lung sounds, nutritional check, observations of response to treatment, pain assessment Caring for persons with Alzheimer's or another dementia Specialized care - catheterization insertion/care, colostomy care, diabetic blood glucose testing, oxygen administration, suctioning, pre-op and post-op care, trach care/suctioning, ventilator care, tube feedings, wound care/dressings, dialysis care Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, and implementing nonpharmacological interventions. II. Competency records The training records were requested on 9/27/23 at 12:00 p.m. The facility was not able to provide documentation of competency or training for certified nurse aide (CNA) #1, CNA #2, CNA #3, licensed practical nurse (LPN) #5, and registered nurse (RN) #1. III. Staff interviews The human resources staff person (HR) was interviewed on 9/27/23 at 12:20 p.m. HR said she did not have access to the annual competency checks. She said the company was bought out in July 2023 and all of their files were sent off either for storage or to be shredded. She said she would reach out to the former company and try to obtain the records. HR was interviewed again on 9/27/23 at 3:40 p.m. She said, I have no competency checks or annual reviews for any staff. Unfortunately, the last company did not complete them at all and I reached out to see if I could get a written statement but their HR person is on vacation. We should have completed the competencies when we took over but we did not and I understand we dropped the ball. HR provided a copy of the blank competency checks that would be used going forward for CNAs, LPNs, and RNs. The director of nursing (DON) was interviewed on 9/28/23 at 1:37 p.m. She said processes were not in place when the corporation change occurred in July 2023. She said We are working on a process now. Whichever nurse provided the training would complete the competencies. We completed an audit shortly after the buyout and I attempted to go through the employees' files but I did not see them. I assumed they were already sent to the storage facility. We have not completed the competencies but we have been talking about it and I just received access to the system with our forms to do that. -As of 10/2/23, no further information regarding nursing competencies was provided by the facility.

Based on record review, observations and interviews, the facility failed to ensure proper storage of medications for two of three medication storage carts. Specifically, the facility failed to: -Ensure a medication cart that was no longer in use did not contain medications from residents who had discharged and over the counter medications were kept locked; and. -Ensure medication was properly labeled with open dates. Findings include: I. Professional reference According to [NAME] Lilly and Company, revised August 2023, Humalog-Insulin Lispro Injection, obtained from https://uspl.lilly.com/humalog/humalog.html#ug. Per manufacturer instructions, opened lispro (Humalog) vials must be thrown away 28 days after first use, even if they still contain insulin and opened vials can be stored in refrigerator or at room temperature up to 28 days. II. Facility policy and procedure The Medication Storage policy, revised November 2020, was provided by the nursing home administrator (NHA) on 10/2/23 at 6:02 p.m. It read in pertinent part: Drugs and biologicals used in the facility are stored in locked compartments. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing drugs and biologicals) are locked when not in use. Unlocked medication carts are not left unattended. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. III. Observations and interviews On 9/26/23 at 11:06 a.m., licensed practical nurse (LPN) #5 prepared to administer Lispro insulin to Resident #17. LPN #5 obtained the insulin vial from the medication cart. The medication was unrefrigerated and was labeled with the resident's name. The label indicated the pharmacy had dispensed the medication on 8/9/23. The package had been previously opened and the vial or package did not contain a label which indicated the date it was opened. LPN #5 was ineterviews and said it did not matter that a date opened label was on the package because the manufacturer expiration date had not been reached. On 9/28/23 at 12:35 p.m., there were two medication carts located on the 1st floor east hallway which was accessible to the public, and residents, near the nurses station. One of the medication carts was unlocked. At 1:05 p.m., the medication cart that had been unlocked at 12:35 p.m. continued to be unlocked. LPN #3 opened drawers in the medication cart. There were 50 bottles of pills in the cart including over the counter medications. Five medications with resident labels were affixed to packages, which the LPN said belonged to discharged residents. The cart contained an insulin pen and a box of lancets. LPN #3 was interviewed and said the cart was not actively being used and she did not know if anything was in the cart. She said every time she has seen this medication cart when she worked, it was unlocked. She said the medications from discharged residents should have been removed from the cart. IV. Administrative interviews The director of nursing (DON) was interviewed on 9/27/23 at 3:46 p.m. The DON said an opened vial of lispro insulin should be labeled after opening with the date opened and should be discarded if found to not have a label with the date opened. The DON was interviewed again on 9/28/23 at 1:30 p.m. The DON identified the unlocked cart as the facility's surplus medication cart and said the cart should have been locked unless someone was actively administering medications from it. V. Facility follow-up On 10/2/23 at 6:02 p.m., the NHA provided in-service documentation dated 9/29/23, entitled Nursing Education-Med Storage. The document read: All medication carts must remain locked when unattended. This includes carts that are not in use. Any medications for patients that have been discharged must be placed in the med rooms. No expired medications can be in the medication carts at any time. All OTCs (over the counter) and insulins upon opening must be dated.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to provide isolation signage, appropriately apply and remove (donning and doffing) personal protective equipment (PPE) and assure the resident's door remained closed for Resident #232 on isolation precautions. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During Coronavirus Disease 2019, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html : Place a patient with suspected or confirmed SARS-CoV-2 infection in a single person room. The door should be kept closed. Healthcare personnel who enter the room should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or face shield that covers front and side of face. According to the CDC, revised 8/8/21, Coronavirus Disease 2019 (COVID-19) Factsheet entitled Use Personal Protective Equipment When Caring for Patients with Confirmed or Suspected COVID -19, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf: PPE must be donned correctly before entering the patient area. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. Do not wear respirator/face mask under your chin. Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). When wearing an N95 respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection, and the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. Doffing-taking off the gear- 1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 2. Remove gown. Untie all ties (or unsnap all buttons). Dispose in trash receptacle. 3. May now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or goggles. 6. Remove and discard respirator (or facemask if used instead of respirator). 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse. II. Facility policy The Infection Prevention and Control Program policy, revised October 2018, was provided by the nursing home administrator (NHA) on 9/25/23. It read in pertinent part: Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures. Following established general and disease- specific guidelines such as those for the Centers for Disease Control (CDC). III. Observations On 9/25/23 at 10:00 a.m., an isolation sign was not present on Resident #232's door, who was diagnosed with COVID-19 on 9/22/23. At 11:05 a.m., an unidentified housekeeper was observed cleaning the resident's room. There was not an isolation sign on the door. The housekeeper was in the room wearing an N95 respirator, a gown, gloves and no eye protection. At 11:07 a.m. the housekeeper exited the room wearing a gown and gloves. She took off the gloves, reached out to her pants pocket, located a key and unlocked the cart. She removed a bottle of sanitizer, locked the cart, put clean gloves on and entered the room again. At 11:10 a.m. the housekeeper wiped her wet hands on the gown. She later approached the exit of the room, removed her gown, removed N95 mask and then gloves. She did not remove her mask last. She exited the room, sanitized her hands and donned a new N95 mask. At 11:14 a.m., certified nurses aide (CNA) #1 moved an isolation sign from another resident room to Resident #232's door. She was wearing her N95 mask with the top string security around her head. The bottom string was under her chin. At 11:46 a.m., an unidentified CNA donned a gown, gloves and put a N95 mask on. She did not wear a face shield. She was wearing her own glasses. She left her surgical mask hanging under her neck. She went in the room with a vital sign machine. At 11:57 a.m., the CNA exited the room wearing a N95 mask, surgical mask still under her chin. She did not replace her N95 mask after leaving the room. At 11:57 a.m., the speech language pathologist (SLP) entered the room and donned a gown, gloves, N95 mask and face shield. At 12:28 p.m., the CNA entered the room again with PPE, but continued to wear a surgical mask under her chin. She exited a minute later. She did not change her N95 after she exited the room and she still had her surgical mask under her chin. At 12:28 p.m., an unidentified staff entered the room. He donned a gown only. He wore his existing N95 mask into the room. He did not wear gloves or eye protection. He exited the room a minute later and did not remove his N95 mask. At 12:36 p.m., the SLP exited the room. She was wearing a N95 mask and she did not remove it upon exiting. On 9/26/23 at 10:25 a.m., an unidentified staff member holding a clipboard left the resident room, removed her gown and gloves and kept her N95 mask on after she left the resident room. She left the door of the resident's room completely open. IV. Staff interviews CNA #1 was interviewed on 9/25/23 at 11:15 a.m. She said Resident #232 should have had a sign on his door because resident was on isolation and she said she was removing the one from resident who was no longer in isolation and was going to place on the door of Resident #232. The director of nursing (DON), who was in charge of infection control for the facility, was interviewed on 9/25/23 at 2:56 p.m. She said the facility had a COVID outbreak that started on 9/2/23. The DON said since testing began, several residents and staff members have tested positive for COVID. She said the most recent testing was completed on 9/23/23 which revealed a staff member tested positive for COVID. The DON said two residents were positive for COVID at the time of the interview. The NHA was interviewed on 9/26/23 at 10:30 a.m. He said the door to Resident #232's room should not be left open (he then closed the resident's door). The DON was interviewed on 9/27/23 at approximately 12:30 p.m. The DON stated she had asked all staff providing direct resident care to be wearing N95 masks at all times due to recent COVID infections. V. Facility follow-up On 10/2/23 at 6:02 p.m. the NHA provided a copy of educational staff in-service completed on 9/29/23. The education included proper donning and doffing (addition and removal) of PPE, hand hygiene, isolation cart information and isolation signage.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for four (#232, #230, #16 and #229) of seven residents reviewed for immunizations out of 28 sample residents. Specifically, the facility failed to: -Offer Resident #232 and #16 the pneumococcal vaccine upon admission; and, -Offer additional doses of the pneumococcal vaccine to Resident #229 and #230. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 9/28/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes) -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. -Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy The Pneumococcal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 9/25/23. It read in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, wil be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. III. Resident #230 A. Resident #230 Resident #230, age 78, was admitted on [DATE]. According to the 9/21/23 minimum data set (MDS) assessment diagnosis included atrial fibrillation. The 9/21/23 MDS revealed Resident #230 had moderately impaired cognitive status with a brief interview for mental status (BIMS) score of 10 out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record review A review of Resident 230's electronic medical record (EMR) revealed the resident received the pneumococcal vaccine,pneumococcal 23-valent polysaccharide vaccine (PPSV23) on 6/8/22. -The EMR failed to show that the resident had not been offered an additional dose since. IV. Resident #232 A. Resident #232 Resident #232, age 88, was admitted on [DATE]. According to the 9/29/23 MDS assessment diagnoses included heart failure, hypertension and renal insufficiency. The 9/29/23 MDS revealed Resident #232 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented the resident was up to date on the pneumonia vaccination. B. Record review A review of Resident 232's EMR revealed the resident received the pneumococcal vaccine PPSV23 on 9/2/21. -The EMR failed to show that the resident had not been offered an additional dose on admission. The Colorado Immunization Information System (CIIS) showed the resident was due for the PVR 15 on 9/24/23. V. Resident #16 A. Resident #16 Resident #16, age under 65, was admitted on [DATE]. According to the 7/17/23 MDS assessment diagnoses included deep venous thrombosis, pneumonia and cancer. The 7/17/23 minimum data set assessment (MDS) revealed Resident #16 was cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. -The MDS inaccurately coded that the resident was up to date on the pneumococcal vaccination. B. Record review The resident's immunization record showed the resident was offered and refused the pneumococcal vaccination. -However, the EMR showed a consent form which was marked as a refusal, however, there was no signature from the resident or responsible party. VI. Resident #229 Resident #229, age 82, was admitted on [DATE] According to the 9/21/23 MDS diagnoses included heart failure, arterial fibrillation, and anemia. The 9/21/23 minimum data set assessment (MDS) revealed Resident #229 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. -The MDS inaccurately coded that the resident was up to date on the pneumococcal vaccination B. Record review The resident's immunization record showed the resident received the Prevnar 13 on 5/26/22. -However, the EMR failed to show the resident was offered an additional vaccination on admission. VII. Interview The director of nurses (DON) was interviewed on 9/28/23 at 4:00 p.m. The DON said the facility offered residents pneumonia vaccinations. She said at admission the resident's vaccination record was obtained. She said that Colorado Immunization Information System (CIIS) was utilized. She said it should be downloaded to ensure accurate information was obtained in regard to the resident's vaccination record. She said the admitting nurse would then offer and provide education to the resident in regard to the importance of being vaccinated against pneumonia. She said if the resident accepted the pneumonia vaccination then the consent was signed and the vaccination was administered after receiving the physician's order. She said that if the resident refused then the resident signed the consent form. She said that the resident should be asked again within a year. The DON said the facility followed the CDC guidance. The DON reviewed the records and confirmed the CIIS records were not utilized as should be. She confirmed that the consents were not signed and that the residents were not offered the pneumococcal vaccination as should be. She said Prevenar 20 should be offered.

Based on record review and staff interviews, the facility failed to ensure one (#1) resident reviewed out of nine sample residents received treatment and care in accordance with professional standards of practice. The facility failed to consistently monitor the blood sugar for Resident #1 as written in the provider's orders. The facility failed to notify the provider for the change in condition. Resident #1 sustained blood sugar was below the normal range multiple times on 1/10/23. Record review revealed that the diabetic interventions were not implemented and the provider was not notified to modify the plan of care to prevent further complications. Findings include: I. Professional reference According to the American Diabetes Association, January 2023, accessed on 5/2/23 from https://diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia: Hypoglycemia symptoms occur when blood glucose levels fall below 70 mg/dL. As unpleasant as they may be, the symptoms of low blood glucose are useful. These symptoms tell you that your blood glucose is low and you need to take action to bring it back into a safe range. From milder, more common indicators to the most severe, signs and symptoms of low blood glucose include: coordination problems, clumsiness, confusion, feeling shaky, and feeling weak or having no energy. II. Facility policy and procedure The Diabetes: Care Management Clinical Guideline policy, revised November 2023, was provided by the director of nursing (DON). It includes in pertinent part: Establish a current status of blood glucose management including: current medication use, blood glucose baselines, stability of blood glucose levels, and current level of activity associated with glucose stability. III. Resident #1 A. Resident status Resident #1, age 75, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included type two diabetes mellitus. The 1/10/23 minimum data set (MDS) assessment revealed the resident had no cognitive impairment. She had limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record review According to the April 2023 CPO, the resident had the following orders: Jentadueto Oral Tablet 2.5-1000 mg, give 1 tablet by mouth two times a day for diabetes type 2, ordered 1/7/23. According to the nursing progress notes on 1/10/23 at 2:35 a.m. the facility staff responded to the resident's room. The resident was noted to be in bed with a dazed look while yelling for help. Nursing staff called emergency services. Staff obtained vital signs and found her blood sugar to be 60 mg/dl. The resident was given orange juice. Staff called on-call provider who recommended the resident be evaluated by paramedics. Paramedics determined that Resident #1 was stable and resident declined to go to the hospital since she started to feel better. The on-call physician was called and informed of resident's decision, also that there were no current blood sugar orders in electronic medical record. New order was received to check blood sugar every hour for the next four hours and to do vital signs every four hours for 24 hours. At 9:39 a.m. the resident's blood sugar dropped to 61 mg/dl. -There was no evidence that the provider was notified and resident's below normal blood sugar was treated. At 11:24 a.m. (two hours later) the resident's blood sugar was recorded as 68 mg/dl. -There was no evidence that the provider was notified and resident's below normal blood sugar was treated. -The blood sugar checks were discontinued at that time and the resident's blood sugar was not checked again until the resident experienced a change in her condition and became unable to think and react properly. According to nursing progress notes at 7:25 p.m. the facility staff responded to the resident's room. The resident was noted to be sitting on her bed with a dazed look while yelling for help. The staff noted that the resident appeared to be sweating. The resident's blood sugar was 53 mg/dl. The resident was given orange juice. The resident's daughter informed the staff to call 911. -The resident's blood sugar was not rechecked by staff. According to the paramedic's notes on 1/10/23, upon arrival the resident was found in bed. The facility staff stated that at 6:45 p.m. the resident started having slurred speech and having right sided arm weakness and right leg weakness. The paramedics transferred the resident to the hospital for possible stroke rule out and low blood sugar. The paramedics took the resident's blood sugar which was 52 mg/dl. The resident was given dextrose solution intravenously enroute to the hospital which improved her blood sugar to 137 mg/dl. IV. Staff interviews The registered nurse (RN) was interviewed on 4/19/23 at 10:55 a.m. She said the facility's standard precautions for diabetic residents were any blood sugars recorded below 70 mg/dl, the staff were required to notify the provider, give the resident juice and recheck blood sugar every 15 minutes. She said that the facility carried a glucagon emergency kit in the event of an emergency. These kits were kept in the medication room and in the medication carts. The facility medical director was interviewed on 4/19/23 at 11:16 a.m. She said she was a treating physician for Resident #1. She reviewed Resident #1's records and stated she was not notified on 1/10/23 when the resident's blood sugar dropped below 70 mg/dl. She said the only notifications she received were the first episode and second time when a resident was sent to the hospital. She said if the nursing staff had communicated the resident's low blood sugar results, she would have continued the order to monitor blood sugars every two hours and the emergency would be avoided. She said the resident could have been treated in the facility without going to the hospital. She said she discussed the above concerns with the DON and the facility would start to put in place standing orders for diabetic residents to include twice daily blood sugar checks. The DON was interviewed on 4/19/23 at 2:00 p.m. She said all diabetic residents should have their blood sugars checked at least twice a day. She said any change of condition should be documented by nursing staff and the DON and provider should be notified. She said that if the provider had been aware of the low blood sugars, the facility could have treated the resident without sending her out to the hospital. She said she planned to educate the staff on the facility's diabetic policies and procedures in the near future.

Based on record review and interviews, the facility failed to ensure the right to be treated with respect and dignity for one (#4) of five sample residents. The facility failed to ensure Resident #4 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by an incident that occured on 5/10/2021 were Resident #4 was treated in an undignified manner by registered nurse (RN) #4. Because of this treatment, Resident #4 said she felt, belittled, worthless, and crazy which triggered her [CONDITION(S)]. Findings include: I. Facility policy and procedure The Resident Rights policy, revised 3/1/18, was provided electronically by the nursing home administrator on 5/19/21. It read, in pertinent part: Patients have the fundamental right to considerate care that safeguards their personal dignity along with respecting cultural, social, and spiritual values. The purpose was To treat each patient with respect and dignity and care for each patient in a manner and in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. To incorporate the patient's goals, preferences, and choices into care. To recognize each patient's individuality as well as honor and value hi/her input. To protect and promote the rights of the patient. II. Resident #4 A. Resident status Resident #4, age 65, was admitted on [DATE]. According to the May 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/16/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required limited assistance of one staff member with her mobility and activities of daily living (ADLs). B. Incident 5/10/21 On 5/11/21 an investigation was started at the facility related to possible verbal abuse. According to the facility investigation, Resident #4 reported a nurse was rude and unprofessional towards her and she was uncomfortable with this nurse providing her care. The investigation revealed the resident recorded the incident with her cell phone for proof of the nurse's behavior. A transcript of the nurse's comments were included in the investigation and included: I do not control your medications; I'm not a doctor I can't do that right now. I'm telling you it will be changed. Your TPN (total [MEDICATION(S)] nutrition) is first I don t care about your wounds right now. That's not important right now Your CNA can bring you a gown. Put your light on. I'm doing the TPN I can't do two things at one time The investigation revealed the resident was tearful during the interviews regarding the incident and reported this was her baseline due to her mental health issues and her [CONDITION(S)]. She accepted the offer for psychosocial services. The nurse involved in the incident was interviewed during the investigation and revealed she did make the comments to the resident and did not feel she was rude or unprofessional. During the interview, she described the resident as crazy and delusional. The nurse resigned immediately when she was informed the incident was being investigated by the facility and the police had been contacted. The investigation concluded the incident was not verbal abuse, though the nurse did not treat the resident with respect and dignity and did not follow the standards of practice expected at the facility. The nurse resigned and the facility reported the behavior to the state board of nursing. C. Resident interview Resident #4 was interviewed on 5/18/21 at 2:00 p.m. She stated she was tired of talking about the incident but the nurse was very rude and it was unnecessary. She stated the nurse would not listen to her or provide the care in the order or the way she wanted it done. She stated she had asked the nurse to care for her [CONDITION(S)] first, which was leaking and smelled bad and was getting on her gown and bed. She stated the nurse refused her request and insisted on doing the TPN first. She stated the nurse responded very rudely to her requests and told her to put on her call light and ask the CNA to for a new gown and bedding, rather than helping her with her first priority. She stated the nurse's behavior really upset her and made her feel belittled, worthless, and sad and triggered her [CONDITION(S)] feelings from her past. She stated the nurse involved was the only staff she had encountered at the facility who had treated her badly and the rest of the staff was kind and patient. She stated she was satisfied with the way the facility responded to the incident and was glad the nurse was no longer working at the facility. D. Progress note A progress note written by the nurse from the incident was written on 5/11/21 at 5:22 a.m. The note read: Patient is delusional, keeps asking for anxiety injection. Pt has no injection anxiety meds (medications). Pt is receiving PRN (as needed) [MEDICATION(S)] and PRN [MEDICATION(S)]. In addition pt is taking 400 mg of trazedone (sic). Pt is more concerned about anxiety meds versus pain med. Pt takes her meds by mouth with (sic) sip of water. Pt is not an NPO (nothing by mouth). Pt was admitted with abdominal fistula leaking. TPN infusing and started at 9:00 p.m. pain medication was given at 9:00 p.m. pt was so anxious about her wound versus TPN. (sic) III. Staff interviews The NHA was interviewed on 5/18/21 at 3:30 p.m. She stated the nurse had failed to treat Resident #4 with respect and dignity. She stated the investigation revealed the nurse had acted unprofessionally and after watching the video and hearing how the nurse treated the resident, she would have been terminated if she had not resigned. She stated following the investigation, the resident received psychiatric services and all staff received additional education regarding respect and dignity. IV. Follow up Written record of this education was not provided by the facility.

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance to prevent accidents for one (#2) of five sample residents. Specifically, the facility failed to ensure the resident was transferred by two staff members appropriately to prevent a humerus fracture which caused the resident pain and changed her transfer status from a two person assist to a full mechanical lift. Findings include: I. Facility policy and procedure The Accidents/Incidents policy, revised 11/28/16, was provided electronically by the nursing home administrator (NHA) on 5/19/21. It read, in pertinent part: An accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice. An incident is defined as any occurrence not consistent with the routine operation of the center or normal care of the patient. An incident can involve a visitor or staff member, malfunctioning equipment, or observation of a situation that poses a threat to safety or security. The Gait Belt Transfer policy, revised 6/1/21, was provided electronically by the NHA on 6/2/21. It read, in pertinent part: Explain procedure to patient and provide privacy. Plan transfer to patient's strong side. Bend your knees and maintain normal curves in back and neck. Place both hands on gait belt, reaching around to back of patient. Lean patient slightly forward, ensure patient's feet are just under them, not in front or behind. Instruct the patient to assist by reaching back to the chair arms or bed and pushing off. Do not allow patient to grasp you around the neck during transfer. Brace patient's leg just below the knee with your leg. On count of three, rock patient forward and up, instructing patient to push off chair arms or bed to assist. Stand and pivot to transfer. To reposition back in chair or bed, slide patient completely to the back of the chair or bed in small increments. If necessary, repeat the above steps. Maintain hands on back and side of gait belt at all times. II. Resident #2 A. Resident status Resident #2, age 78, was admitted on [DATE]. According to the May 2021 computerized physician orders (CPO), the diagnoses included displaced fracture of the upper end of the right humerus (added 4/12/21), type II diabetes mellitus with diabetic [CONDITION(S)], muscle weakness, unsteadiness on feet, and difficulty walking. The 4/27/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She required extensive assistance of two staff members with her mobility and activities of daily living (ADLs). B. Incident 4/12/21 On 4/12/21 Resident #2 reported feeling a pop in her right arm during a transfer back to bed after a shower she reported pain in her right arm and shoulder area. An x-ray revealed a right humerus fracture and she was sent to the emergency department for evaluation and treatment. She returned from the hospital the same day with a sling. The facility investigated the incident and could not substantiate any neglect or wrong doing. C. Resident interview Resident #2 was interviewed on 5/18/21 at 1:30 p.m. She stated she would never forget the sound her arm made when it broke. She stated the staff transferred her from her bed to the shower chair by holding her arms, she stated the staff placed a gait belt around her waist but mostly used her arms to lift her. She stated she was uncomfortable with the way she was transferred and told them it was not the right way. She stated after her shower, when they brought her back to bed, the two staff members transferred her back to bed in the same manner by her arms and that was when she heard and felt her arm pop and it was very painful. She said she told the two staff members right away. She stated the two staff members convinced her that was the way they should transfer her, even though she felt it was not right. D. Record review An ADL care plan was initiated on 2/4/21 and revised on 4/12/21. It read, in pertinent part: Resident/Patient requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Limited mobility, RUE NWB (right upper extremity non weight bearing), RUE no shoulder ROM (range of motion). The goals for the care plan included: Resident will maintain highest capable level of ADL ability throughout the next review period and Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: hoyer only - ensure arms are at midline w/i (within) the hoyer sling prior to transfer initiated 4/12/21; Pt (patient) prefers to feed self, even with decreased mobility to BUE (bilateral upper extremities). Provide pt finger foods as much as possible to assist in pt's preference to feed self initiated 4/28/21; Provide resident/patient with extensive assist of 1-2 for bed mobility initiated 2/4/21; and Provide resident/patient with extensive assist of 2 for transfers using a hoyer lift and wheelchair initiated 2/4/21 and revised 4/12/21 to include the hoyer lift. On 4/13/21 a physician assistant note read the resident was seen to follow-up after the fracture and hospitalization . The note read: Patient was sent to (name of hospital) yesterday for Ortho evaluation after confirmed fracture to right humeral head on x-ray. Repeat x-rays at (name of hospital) did confirm this fracture, CT head was negative for acute findings. Patient was placed in a sling and sent back to (name of facility). Hopeful that patient can be placed on skilled services due to fragility and new fracture. The cause of the fracture was discussed with patient today, she states staff got her out of the bed and into the shower chair via a 2 person assist transfer. She did report to this provider that she discussed using the Hoyer lift at that time with staff who proceeded with a 2 person transfer. She showered without any complications. Patient reports that on the transfer back into the bed, that she again expressed using the Hoyer lift but staff proceeded with a two-person transfer. She heard a pop to her right shoulder and immediately felt pain to RUE. X-ray confirmed fracture and patient was sent to ED. Report was given to EMS by RN. (sic) Review of the resident's record revealed the resident was to be transferred by a stand and pivot with two assist and a gait belt. Following the fracture and hospitalization the resident's transfer status was changed to a full mechanical lift due to her injuries. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/18/21 at 2:40 p.m. She stated she had worked in the facility for three months and had been a CNA for [AGE] years. She stated the resident was a two person assist for transfers with a gait belt. She stated the incident with Resident #2 occurred on her first day in the facility. She stated she and the other CNA, who was providing her orientation, were giving resident showers. She stated they placed the gait belt on the resident and transferred her from her bed to the shower chair, gave her a shower, then did the same transfer back to bed after the shower. She stated she did not remember the resident protesting the transfer and she stated she did not know the resident as it had been her first day working in the facility. She stated she did not use the resident's arms to transfer her and she was on the resident's left side. She stated as soon as the resident complained of pain, they went to get the nurse. CNA #2 was interviewed on 5/18/21 at 2:55 p.m. She stated she had been working in the facility for eight years. She stated she was familiar with the resident. She stated she and the other CNA involved used a gait belt for the transfers and remembered the resident complaining about the gait belt being tight, but not about the way they transferred her. She stated she did not remember hearing or feeling a pop during the transfer, but she stated she was holding onto the resident's right arm to steady her during the transfer. She stated when the resident complained of pain, they went to get the nurse immediately. CNA #3 was interviewed on 5/27/21 at 9:40 a.m. He stated when a resident was a two person transfer, the staff should always have two people, and always use a gait belt. He stated the staff on either side of the resident should hold the resident steady by the gait belt and should not push or pull or lift by the resident's arms. The director of nursing (DON) was interviewed on 5/27/21 at 10:30 a.m. She stated two person transfers should use a gait belt to assist the resident to steady and turn. She stated the staff should not really have to use the resident's arms at all. She stated if a resident was uncomfortable with a transfer, the staff should stop and ask the nurse or other staff for assistance with the transfer or give the resident time rather than try to convince them to do something they are uncomfortable with.

Based on observations, record review and interviews, the facility failed to ensure one (#8) of three residents reviewed for pressure ulcers of ten sample residents received the care and services necessary to prevent the development and worsening of pressure ulcers. Specifically, the facility failed to thoroughly and accurately assess and document the resident's skin condition, and implement measures to prevent the development and promote healing of pressure ulcers. The failures contributed to the resident acquiring two advanced stage pressure ulcers, one to the heel and one to the mid-spine. The findings included: 1. Professional Reference According to the National Pressure Ulcer Advisory Panel, NPUAP Pressure Injury Stages, 2016, <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages> (accessed on 5/19/16): NPUAP Pressure Injury Stages: The National Pressure Ulcer Advisory Panel redefined the definition of a pressure injuries during the NPUAP 2016 Staging Consensus Conference that was held April 8-9, 2016 in Rosemont (Chicago) .The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressures or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on an ischemic limb or the heel(s) should not be removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions). 2. Resident Status Resident #8, age 89, was admitted on [DATE] and re-admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 4/22/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance for bed mobility, transfers, ambulation, locomotion, dressing and toilet use. She needed limited assistance with personal hygiene and supervision with meals. The care plan, initiated on 3/16/16 and revised on 5/3/16, identified risk for skin breakdown as evidenced by recent hip surgery. The goal was to prevent the risk for skin breakdown over 90 days. Interventions included monitoring skin for signs/symptoms of skin breakdown, such as redness and decreased sensation; and implementing pressure redistribution surfaces on the bed per protocol, for example, utilizing a specialty mattress. Weekly skin assessments were to be done by a licensed nurse. 3. Record Review A. Heel Wound The resident's care plan, initiated 3/30/16, and revised 5/3/16, further identified actual skin breakdown related to deep tissue injury to the resident's left heel. The goal for this wound was that it would remain free from signs/symptoms of infection for 90 days. Interventions included: -instruct/assist the resident in methods of reducing friction and shear -monitor skin for signs/symptoms of skin breakdown -pressure redistribution surfaces to bed as per protocol -pressure redistribution surfaces to chair as per protocol -utilize positioning devices as appropriate to prevent pressure over boney prominences -a weekly skin assessment completed by a licensed nurse. According to the skin integrity report and nurse's note, the resident's heel wound was first discovered on 3/30/16. It was described as a pressure ulcer to the left heel, staged as a deep tissue injury (DTI), measuring 3.5 x 3.5cm, surrounding tissue & wound edges healthy, care plan updated. A skin integrity report dated 4/22/16 described the resident's heel wound as a deep tissue injury. A telephone order, dated 4/15/16, revealed skin checks were to be completed weekly on Fridays. The 4/16 treatment record revealed there was no documentation of the 4/29/16 skin check. The skin check on 4/22/16 noted the resident had a DTI but no size or description was recorded. Review of physician orders, nurses' notes, medication administration records (MARs) and treatment administration records (TARs) revealed: - Physician orders [REDACTED]. -There was no evidence these treatments were done, and the orders were discontinued on 4/7/16. - The resident was hospitalized ,[DATE]-[DATE] and again 4/9-4/15/16. - Readmission orders [REDACTED]. This was transferred to the TAR. However, there was no evidence of a dressing order for the resident's heel (see above, the [MEDICATION NAME] order had been discontinued but was not resumed and there was no evidence new orders were requested. There was no evidence of a 4/29/16 skin check. There was no evidence wound treatment orders were resumed or requested (although the dressing was applied - see observations below), or that heel wound assessments were conducted after the resident's hospitalization . There was no evidence of a turning and repositioning schedule, or care planning for how often staff were to turn and reposition the resident. B. Back Wound As of 5/4/16, no care plan had been developed for the resident's newly identified back wound. A skilled nursing note, dated 4/17/16, revealed a registered nurse (RN) encouraged the resident to position side to side, off of her back, related to redness on the mid-back area present upon readmission. Review of nurses' notes and physician orders [REDACTED].>-On 5/3/16, a general notation in the nurse's note section of the resident's record revealed resident #8 had a new skin wound, with redness measuring 4x3 cm with a resolving dry, scabbed wound bed noted on the skin over mid-spine. Blanchable redness measuring 4x3cm with resolving dry scabbed wound bed X2 w/ negligible depth noted to skin over mid spine. Treatment dressing applied, denies discomfort to site unless palpated. -On 5/3/16, a physician telephone order (TO) directed, Xray to lower spine, Xray to [MEDICATION NAME] spine, Xray to mid spine. -An event summary report prepared on 5/3/16 documenting resident #8 had a pressure ulcer on her back. The injury was described as an open area with surrounding redness. According to this report, the risk factors for skin breakdown were not correctly identified. The resident's kyphosis (an exaggerated rounding of the back), and sitting in the upright position were not identified as problems. The report also documented the interventions were not successful for the intended goal, and the preventative measures for her back were not in place for her wheelchair. The conclusion, according to documentation on this report, revealed the nurse documented the wound was avoidable. -On 5/4/16, a nurses' change of condition skin note revealed, New onset pressure ulcer mid-spine, on-call MD notified, new orders obtained, treatment and Xray orders obtained. Treatment order 5/4/16 [MEDICATION NAME] dressing to site of impaired skin integrity at mid spine, apply Santyl to wound daily, change daily and PRN every evening. -The 5/4/16 skin integrity report documented: the Pressure Ulcer heading was marked out, there was no presence of pain and no pain medication. The wound appearance was noted as S for slough. Measurements were: length 2cm, width 0.8cm, depth zero, no undermining, no drainage, surrounding tissue inflamed, measurement 5.5x5. Wound stage was blank. Wound edges were noted as healthy, no odor, care plan updated. -Another general nurse's note, dated 5/4/16, clarified the measurements. The open area to the [MEDICATION NAME] spine was 2 cm wide by 0.8 cm in length with surrounding redness measuring 5.5 cm by 5 cm. According to the note the RN spoke with the resident regarding wound care and the treatment plan to address the [MEDICATION NAME] pressure area. An air mattress was ordered for her bed, and therapy was contacted to assess for a new wheelchair with a keyhole back or offloading foam while the resident was sitting in the wheelchair. 4. Resident Interview and Observation The resident was first observed on 5/3/16 at 3:30 p.m., seated in a regular wheelchair with both legs elevated with pedals in an upward position. Her left was propped and floated with a pillow. Her left heel was bandaged. An interview was conducted with resident #8 on 5/4/16 at 11:00 a.m. She said she was aware she had a new wound on her back, and said the nurse put a bandage on it. -During the interview, the resident was observed sitting up in a regular wheelchair that did not have a keyhole back. Both her legs were elevated with the pedals in an upward position. Her left heel was bandaged and floated with a pillow. Further observations revealed the resident had a regular mattress on her bed. In a follow up interview with resident #8 on 5/4/16 at 3:05 p.m., the resident said she received her new alternating pressure air mattress, though she was not sure what the difference was. She stated she could not feel any air moving. (The new specialty mattress was in place and on the nurse said the representative had adjusted it to her weight.) chair order had been placed but not received. On 5/4/16 at 3:05 p.m., the evening floor nurse was observed to change the resident's dressing to her left heel. The nurse said the resident's wound had stayed the same. However it was observed that although the wound appeared the same size as when first assessed (see above 3.5 x 3.5), the wound had opened and there was blood on the dressing. -The wound on the resident's back was not observed because the night nurse had changed the dressing early that morning, just prior to the day nurse taking over; and the next dressing change was not due until later on the evening shift (see RN #3 interview below). 5. Staff Interviews An interview was conducted with registered nurse (RN) #3 on 5/4/16 at 11:15 a.m. The RN said the resident's dressing change was scheduled on the evening shift. Any skin changes observed were reported to the unit manager, and also reported to the on-coming shift. According to RN #3, the evening nurse discovered the wound on the night of 5/3/16. She described it as a small skin abrasion, on a bony prominence visible upon examination of the area. The night shift nurse provided RN #3 report on the wounds with the new orders for treatment. The nurse stated staff tried to encourage resident #8 to reposition. However, staff had to prompt her to reposition. The resident denied she had pain. The interventions in place before the pressure ulcer developed were to get her up so she would not lie in bed all day. Her skin was checked every day including the pressure points. Her back would be one of the pressure points as noted above. What I've observed from her is she stays in one position and is afraid to change. We do check her. We have to prompt her to reposition. She said the new wound was discovered yesterday. She said the resident had TED hose ordered for lower extremities. She said, We get her up so she doesn't lay in bed all day; we check her skin every day including the pressure points; yes, her back is one of the areas we check. It's a little red around it with a little area of abrasion, scabbed. The unit manager (UM) was interviewed on 5/4/16 at 11:35 a.m. The UM stated resident #8's back wound was discovered yesterday afternoon. A certified nurse aide (CNA) was assisting the resident to the bathroom and saw the wound. The CNA told the nurse, and the nurse called the doctor. She stated weekly skin checks were done and the resident was added to the list to be followed for pressure ulcers. A change of condition assessment was started and the wound would be monitored each shift for 72 hours. The facility obtained physician's orders [REDACTED]. The result revealed it was negative and the resident was started on an antibiotic for infection prevention because of the redness at the wound site. An order was obtained for therapy to assess the resident for a new wheelchair. The facility also obtained an order for [REDACTED]. In an interview with the director of nursing (DON) on 5/4/16 at 5:30 p.m., the DON stated she was aware of the wound and knew the unit manager obtained orders for treatment. She added the resident had been in and out of the building several times including hospitalization . During her previous stay in the facility (3/7/16, see above) she had an air mattress on her bed. The DON produced the report dated 5/4/16 completed for the new wound on the resident's back. She stated the wound was related to the resident's kyphosis. The DON was interviewed a second time on 5/5/16 at 1:30 p.m. She stated the wound on the resident's spine was avoidable.

Based on record review and resident representative and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care for one (#1) of four sample residents reviewed for care and services of four sample residents. Specifically, resident #1's medications were not provided timely per physician's orders [REDACTED]. Cross-reference F323 Falls/Accidents: the resident experienced a fall which increased her pain and contributed to bleeding to her fractured leg. The findings include: Resident #1, [AGE] years of age, was admitted to the facility for acute rehabilitation on 8/18/15 and discharged on [DATE]. According to the admitting computerized physician's orders [REDACTED]. The resident, newly admitted , did not have a completed 5-day minimum data set (MDS). Record review: Review of a report sheet dated 8/18/15 revealed in part the resident was scheduled to be picked up from the acute care hospital to transfer to the facility at 3:00 p.m. The report further revealed the resident was on an anti-coagulant ([MEDICATION NAME]) and narcotic pain medication ([MEDICATION NAME] every 4 hours). The sheet showed the last dose of [MEDICATION NAME] pain medication was administered at 12:00 p.m. (at the hospital), and [MEDICATION NAME] (no milligram listed) was given at 2:30 p.m. (prior to discharge from the hospital). Written to the side of this entry was the following: Pain level of 5 is comfort. The admission CPO revealed the following medication orders in pertinent part: [MEDICATION NAME] Tablet (a narcotic) 5/325mg, give 1 tablet by mouth every 4 hours as needed for pain 1-5; -[MEDICATION NAME] Tablet 5/325mg, give 2 tablet by mouth every 4 hours as needed for pain 6-10; -Oyxcontin tablet ER 12 hour 10mg, give 1 tablet by mouth every 12 hours as needed for severe pain; -[MEDICATION NAME] sodium solution, inject 30mg subcutaneously every morning and at bedtime for prevent blood clots for 14 days. Review of a content list of emergency medications provided in the Omnicell unit (an electronically sealed emergency kit system) with the last date updated of 3/9/15, revealed in part the e-kit contained [MEDICATION NAME] 10mg tablets and [MEDICATION NAME] 100mg/ml 1milliliter syringe. The list did not show that [MEDICATION NAME] (above) was available in the sealed system. Review of an electronic nurse note entry dated 8/18/15 at 3:24 p.m. and, documented as a late entry, revealed in part the resident was admitted with a fractured left tibia and the physician was notified and orders verified. Review of a new admission cover sheet dated 8/18/15 revealed the resident's medication list was faxed to the pharmacy at 4:44 p.m. (over an hour after her admission above) to include all of the resident's ordered medications. The cover sheet was marked to send the new order STAT (immediately). Review of the 8/15 Medication Administration Record [REDACTED]. The first dose of [MEDICATION NAME] two tablets was administered on 8/18/15 at 7:21 p.m. (7 hours and 21 minutes from the last dose at the hospital) and [MEDICATION NAME] 10 mg was administered on 8/18/15 at 11:00 p.m. (eight and one-half hours from the last dose at 2:30 p.m.). Review of a copy of an electronically documented pain level summary revealed on 8/18/15 at 7:21 p.m. the resident's numeric pain level was a ten (see resident's comfort level of five above). Review of an electronic nurse note entry dated 8/18/15 at 7:21 p.m. revealed in part the pharmacy was faxed an order at 4:30 p.m. for the resident's [MEDICATION NAME] (above) pain medication, however; the facility did not send authorization for the e-kit until 7:20 p.m. Review of a nurse note entry dated 8/19/15 at 12:23 a.m. revealed in part the [MEDICATION NAME] ([MEDICATION NAME]) was not available and the pharmacy was aware. Review of a care plan for alteration in comfort related to acute pain initiated 8/20/15 with a target date of 11/17/15 revealed in part the resident was at risk for pain and she would achieve acceptable level of pain control through the next review date. Some of the approaches included to medicate resident as ordered for pain and monitor for effectiveness, monitor frequency of episodes of breakthrough pain to determine the need for pain med adjustment. Review of an anti-coagulant care plan initiated 8/20/15 with a target date of 11/17/15 revealed in part the resident was at risk for injury or complications related to the use of anticoagulant therapy medication ([MEDICATION NAME]). The intervention listed was the anticoagulant to be given as ordered, monitor for active bleeding, obtain vital signs as ordered. Review of a form entitled Request for Removal of Schedule II-V (two through five) medication from Contingency supply, and with the supplying pharmacy's name and phone number revealed the pharmacy was sent a fax for the resident for [MEDICATION NAME] 5mg tab = (equal) dose 10mg BID (twice a day) PRN (as needed) and per the time stamp of the fax revealed the fax was sent at 4:37 p.m. A copy of a return fax from the pharmacy at 4:53 p.m. showed the order was circled and a written message at the top of the paper read the order was for [MEDICATION NAME] and to please re-write. Review of a second form written for the correct [MEDICATION NAME] order (above) revealed the request was sent at 7:20 p.m. At the bottom of the form was a section to be filled out showing the pharmacy authorized release of the ordered medication from the Omnicell e-kit along with an authorization number (code) in order to access the locked system to remove the ordered medication. In conclusion, the documentation above revealed the resident did not receive her first dose of pain medication ([MEDICATION NAME]) until 7:21 p.m. and the [MEDICATION NAME] (for severe pain) until 11:00 p.m. A delay of 7 hours and 21 minutes. The resident's pain level at that time was 10 out of 10. Additionally, the [MEDICATION NAME] was a medication available in the e-kit (see above e-kit contents). Interviews: On 9/15/15 at approximately 3:00 p.m. the resident's representative was interviewed by phone. The resident representative stated the resident was in a lot of pain to begin with from her broken leg and then after her admission (on 8/18/15) she fell being transferred to the toilet and was in additional pain from that. The resident representative stated the resident could not get any pain medication because it was not available. The resident representative stated it was approximately four hours before the resident received any pain medication. On 9/29/15 at approximately 9:30 a.m. RN #2 was interviewed. RN #2 stated that when a resident was newly admitted their medications are ordered right away and it takes the pharmacy three to four hours to deliver the medications. On 9/29/15 at approximately 4:20 p.m. RN #2 was interviewed a second time. RN #2 stated the primary care physician for this resident required that their residents are physically in the building before calling to verify the resident's medications and then faxing the orders to the physician and the pharmacy. RN #2 stated if the resident was on narcotics they had to send a copy of the e-kit authorization form in order to access the electronic e-kit. He stated that there were some medications that are not available in the e-kit but the facility was currently in the process of adding more of a selection. On 9/30/15 at 12:00 p.m. a physical therapist (PT #1) familiar with resident #1 was interviewed. PT #1 stated she remembered completing the resident's initial evaluation the following day after her admission. The PT recalled the resident was non weight bearing (NWB) and had a huge immobilizer on her left leg due to a fracture. PT #1 remembered the resident had declined to attempt to transfer out of the bed due to having pain. The PT remembered the resident was complaining because she did not get her scheduled pain medication in the morning prior to the evaluation and did not get her pain medication timely when admitted the night before (8/18/15). On 9/30/15 at approximately 3:30 p.m. the director of nursing (DON) was interviewed. The DON stated the facility had two electronic e-kits (Omnicell) which did contain some narcotics but not all class two controlled narcotics were available. She stated that when a resident was newly admitted the health unit coordinator (HUC) could fax the admission orders [REDACTED]. After the physician was contacted to verify medications, the physician would then have to speak directly to the pharmacy in order for the pharmacy to authorize the removal of the medication from the e-kit. The DON stated the electronic e-kit system required a specific authorization code which was inputted allowing the unit to unlock. The DON stated the removal of a narcotic from the e-kit required two nurses. The DON stated there were currently six routine pharmacy deliveries per day and the delivery time was four hours once the orders were faxed. The DON stated if there was a delay in receiving the authorization to remove the pain medication from the e-kit she would have expected the nurse to place a follow up call to the pharmacy to check the status. On 9/30/15 at approximately 12:30 p.m. the nursing home administrator (NHA) and with the DON present, was interviewed. The NHA stated that they became aware of the issue of timely access to the electronic e-kit back in 5/15 and discussed it in quality assurance. He also stated he started initial meetings with the pharmacy on 5/20/15 and the facility goal was to have authorizations for pain medications within four hours of a resident's admission. The NHA stated that on 7/1/15 they noted there was an issue that all nurses did not have access to the electronic e-kit. The DON was asked if the agency nurses had access to the e-kits and she stated that either one of the regular staff or the house supervisor could assist the agency nurses to gain access. The NHA confirmed that in 8/15 they were still seeing delays in receiving of pain medications upon admission as reflected through grievances being filed. As of 9/5/15 delays in receiving pain medications timely was still occurring and the NHA stated they were addressing it ongoing. On 10/2/15 at 12:00 p.m. LPN #1 was interviewed by phone. LPN #1 stated he was working the evening the resident was admitted to the facility. The LPN stated that receiving medications on time from the pharmacy had been an ongoing problem over the past year. LPN #1 stated for example if a resident arrived around 6:00 p.m. their medications may not arrive until 1:00 a.m. the next morning. The LPN stated when a resident was admitted the nurse gets report and the person at the nurse's desk was supposed to take the orders and fax them to the pharmacy. The LPN stated he had not been trained on how to take orders off and put them on the computer. Additionally, new orders have to be called to the physician to get approved. LPN #1 stated he did not have authorization to access the e-kit because he was an agency nurse and would have to try and find a facility nurse to access the e-kit for him. LPN #1 stated it was very difficult to ensure a resident was settled in, assessed on time and received their medications on time because it just gets too busy.

Based on observations, record review and staff, resident and family interviews, the facility failed to ensure residents were as free of accident hazards as possible for two (#1 and #4) of two residents reviewed for falls of four sampled residents. Specifically: -Resident #1 sustained an assisted fall with injury and it was not reported as a fall. Additionally, there was no investigation of the incident, no evidence of assessment of the resident's injury, and no consistent monitoring of noted bleeding. These failures contributed to the resident experiencing bleeding at her surgical site, increased pain and return to the hospital. -Resident # 4 sustained an unwitnessed fall and stated she hit her head, but no evidence of follow-up neurological assessments was found and fall provisions were not fully in place. The findings include: A. Facility Policy: Review of the facility fall policy effective 9/15/01 and last revised 5/15/14 revealed in part, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Patients experiencing a fall will receive appropriate care and investigation of the cause. -Practice Standards: If patient falls: . perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. -Document accident/injury: .As a new event in the risk management system (RMS), on a change of condition note, on the 24-hour report, investigation using the fall investigation/QA and other appropriate tools in RMS . B. Resident #1 Resident #1, [AGE] years of age, was admitted to the facility for acute rehabilitation on 8/18/15 and discharged on [DATE]. According to the admitting computerized physician's orders [REDACTED]. The resident, newly admitted , did not have a completed 5-day minimum data set (MDS). Record review: Review of an initial nursing assessment dated [DATE] revealed under the section for fall history on admission the resident was marked as not having a fall any time in the last month prior to admission. The report sheet from the hospital revealed in part the resident had a fall and sustained a left tibial fracture. Review of an electronic nurse note entry dated 8/18/15 and listed as a late entry, revealed the resident was at low risk for falls with a score of 5. However, the resident was admitted with a fractured left leg in an immobilizer, pinned in place. Review of an electronic skilled nurse note entry dated 8/19/15 at 9:11 p.m. revealed in part the resident required two person extensive assistance for transfers and toileting. The note documented the resident had an assisted fall the day before during a transfer from the bed to the commode and the nurse aide had assisted the resident by lowering the left lower extremity gently to the floor. The resident stated after the incident there was blood noted on the ace wrap around the lower pin site and underneath the calf of the left leg. The note further documented the area was marked with a sharpie pen (permanent marker) earlier in the morning and three hours later a quarter size of blood was noted outside the mapped area. The note revealed the on-call surgeon was notified and a paramedic at the emergency room answered the call and advised the facility to continue to monitor the bleeding and to call if it got worse. Review of a skilled nurse note dated 8/20/15 at 1:06 p.m. revealed the resident continued to have bleeding from the calf and anterior shin at fixator site. The resident's pillow case was saturated with blood last night, but appears to be decreasing. The note further indicated the surgeon's office was called and a message was left with the medical assistant. The resident was reporting severe pain to the LLE. There was no further documentation found after this entry of any return call from the physician's office. Review of a general nurse note entry on 8/20/15 at 6:47 p.m. and noted as a late entry revealed in part at the end of the shift on this date there was no bleeding noted from the left tibial fracture site and that the chucks (absorbent) pad under the leg remained dry throughout the day. The resident reported some tingling to her toes. There was no further documentation the tingling was reported to the physician. Further review of the resident's electronic record revealed a final nurse note entry on 8/20/15 at 11:38 p.m. revealing in part the resident was stating she was having numbness to her left leg and the next thing the resident called 911 and left the facility for an acute care hospital. The note revealed the resident was discharged to the hospital via ambulance. Review of a fall care plan initiated 8/20/15 and with a target date of 11/17/15 revealed in part the resident was at risk for falls related to impaired mobility. The goal was the resident will have no falls with serious injury through the next review date. The interventions included provide verbal cues for safety and sequencing when needed, provide resident/caregiver education for safe techniques, monitor for and assist toileting needs. A second care plan, initiated 8/20/15 with a target date of 11/17/15 was in place for the use of an [DEVICE] to the left lower leg surgically placed. The goal was the resident's wound would remain free from signs and symptoms of infection. The interventions included evaluating wound area daily including surrounding tissue and presence or absence of drainage/infection and/or new wound pain and report to the MD as indicated, monitor for verbal and non-verbal signs of pain related to wound or wound treatment, skin check per policy. There was no documentation found prior to the nurse note above on 8/19/15 of any incident of a fall/assisted fall occurring. There was no documentation of any assessment completed. There was no documentation found for the overnight shift (8/19 to 8/20) addressing monitoring of the resident for a post-fall or regarding any bleeding to the left leg. There was no evidence provided that an investigation of the incident was completed Interviews: On 9/30/15 at 12:00 p.m. a physical therapist (PT #1) familiar with resident #1 was interviewed. PT #1 stated she remembered completing the resident's initial evaluation the following day after her admission. The PT recalled the resident was non weight bearing (NWB) and had a huge immobilizer on her left leg due to a fracture. PT #1 remembered the resident had declined to attempt to transfer out of the bed due to having pain. The PT remembered the resident was complaining because she did not get her scheduled pain medication in the morning prior to the evaluation and did not get her pain medication timely the night before (8/18/15; evening of admission). -The PT stated she educated the resident and caregivers (staff) about the therapy plan and scheduling pain medication prior to therapies. -PT #1 stated the resident's evaluation revealed she was a high fall risk due to a history of a previous fall. The PT stated the resident would be a minimum assist for transfers but someone would have to hold on to the leg immobilizer because it needed to be kept straight. -PT #1 stated she had not heard anything about the resident falling the night before. On 9/30/15 at 3:40 p.m. the director of nursing (DON) was interviewed regarding the resident's fall. The DON stated the resident had an assisted fall and not an actual fall therefore there would not have been a fall investigation completed. The DON stated she followed up on it the following day and knew there were three people involved and that one certified nursing assistant (CNA) had a hold of the resident's left leg brace and it never touched the ground. In the process that CNA injured her back. -The DON stated she only looked into and investigated the CNA report of injury. She stated she was under the impression that a staff member got injured and not the resident. The DON stated there was not a change of condition in the resident at the time and the nurses reported to her that the resident did not have any further bleeding from the incident. The DON was informed there was no evidence of any charting related to the incident and no evidence of a formal assessment of the resident until the following day. -The DON stated the nurse responsible for the entry on 8/19/15 got that the resident had a fall. The DON stated she would have expected that the nurse on duty at that time would go and check on the resident to evaluate any concerns. The DON had no further comments about the incident. On 9/30/15 at 5:12 p.m. CNA #1 was interviewed by phone. CNA #1 stated she remembered assisting with resident #1's transfer but she was not the assigned aide. The CNA stated the incident occurred sometime around 9:00 p.m. She stated the resident's husband was present, herself and another CNA. The resident needed to go to the bathroom so they prepared to transfer her out of the wheelchair and onto the bed side commode. She remembered the resident was asking for pain medication. CNA #1 stated when the resident went to stand from the bed side commode she panicked and lost her balance and fell into CNA #1. The CNA stated she was holding the resident's leg the whole time the resident was going down and the resident fell on top of CNA #1. The CNA stated the resident's leg did not hit anything that she recalled and after assisting the resident back up the nurse was called to come and check the resident. CNA #1 stated she stayed with the resident while the nurse came in to check on her and the resident was still expressing pain. On 10/1/15 at 12:00 p.m. LPN #1 was interviewed by phone. The LPN stated he remembered the resident's situation somewhat but none of the details. The LPN stated he had so many residents with problems revolving around pain and other issues it was hard to remember them all. The LPN stated he barely remembered going in to check on her after it was reported to him that she had fallen. LPN #1 stated when he went into the room the husband was present and the resident was intact. The LPN stated the resident said she was ok. The LPN stated he did not remember writing anything down about the incident. -The LPN stated the resident was expressing pain and that was the priority. LPN #1 stated that one of the facility staff nurses should have done the fall assessment and according to the procedures the supervisor was supposed to do that. The LPN confirmed he was so far behind in his assignment of trying to medicate residents that he did not get to resident #1's admission assessment until 2:00 a.m. (into the following shift). On 10/1/15 at 6:00 p.m. a telephone interview was conducted with the resident. The resident said that she had fallen even with assistance while trying to go to her walker and after she fell two of the pins surgically attached to her left leg bone started to bleed. She stated that no one came in to check on her after her fall that night. The resident stated by the second and third day her overall condition began to go bad with the bleeding and pain control. C. Resident #4 Resident #4 was admitted to the facility on [DATE]. According to the most recent face sheet the resident had [DIAGNOSES REDACTED]. The resident did not have a completed, comprehensive 14-day MDS as her stay was less than 14 days. Record review: Review of the initial nursing assessment dated [DATE] did not reveal any history of fall risk. Review of an admission note dated 9/18/15 at 3:33 p.m. revealed in part the resident's fall risk score was 9, indicating low fall risk. Review of a fall care plan initiated 9/21/15 with a target date of 12/18/15 revealed in part the resident was at risk for falls related to weakness. The goal was the resident would have no falls with injury through the next review date. The interventions included to assess for changes in medical status, pain status, mental status and report to MD as indicated, provide resident/caregiver education for safe techniques, bed alarm to alert staff members of resident's need to ambulate Review of an activity of daily living (ADL) care plan initiated 9/21/15 with a target date of 12/18/15 revealed in part the resident required assistance with transfers and ambulation. Review of an electronic skilled nurse note entry dated 9/22/15 at 12:10 p.m. revealed in part the resident continued to be confused with no safety awareness and had a fall in the morning trying to ambulate on her own with no apparent injury. The family and doctor were notified. There was no specific documentation regarding in what state the resident was found or the type of assessment provided. Review of a general note dated 9/22/15 at 12:56 p.m. revealed the resident was found on the floor after trying to get into bed. The resident stated hitting her head on side of chair and no apparent injury noted. The note concluded that neuro checks were unchanged and the doctor was notified. Review of a fall investigation follow up dated 9/22/15 at 8:15 a.m. revealed in part a question that read if the fall was unwitnessed or resident hit their head was a neurological evaluation completed? The section was marked yes. The interventions immediately implemented were fall alarm put into place. Summary of the investigation revealed the root cause was the resident was cognitively impaired and impulsive. There was no evidence of any neurological checks found in the electronic record or in the resident purged paper record. Observations: On 9/29/15 at 2:00 p.m. the resident was observed in her room with a family member visiting her. The resident was attempting to get out of her bed and subsequently setting off an alarm. The family member assisted her back to bed and the alarm ceased alarming. The family member then went to sit on the resident's arm chair and, not realizing what was on the seat, set off another alarm. On 9/29/15 at 4:20 p.m. the resident was observed ambulating in the hallway at a slow pace with her forward wheeled walker (FWW). There was a staff member walking beside her and occasionally placing a hand on her right arm to straighten her direction. The resident identified to be a fall risk and having had a recent fall, did not have a gait belt observed around her waist. Interviews: On 9/29/15 at 2:00 p.m. the resident's daughter-in-law who was visiting the resident was interviewed. She stated the resident was a fall risk but felt she was capable of getting up and going on her own. She stated the facility did let her husband know the resident had fallen about a week ago then next thing they knew the resident had these alarms on. The daughter in law confirmed that the resident was unsteady on her feet even with her walker and needed assistance to get in and out of bed and when walking. On 9/30/15 at 11:40 a.m. PT #1 was interviewed. The PT stated the resident was currently on therapy services for strengthening and ambulation. The PT confirmed the resident was currently a high fall risk requiring supervision with ambulation due to her dementia. PT #1 confirmed that a gait belt should always be used with a resident even if they are only stand-by supervision. On 9/30/15 at approximately 4:00 p.m. the DON was interviewed regarding resident #4's neuro checks. The DON confirmed she checked everywhere and there were not to be found. The DON confirmed that neuro checks should be initiated with a fall in order to detect any changes.

Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four of 41 sample residents to maintain their highest practicable well-being according to their plan of care (#480, #525, #564, and #517). Specifically, 1. Resident #480 had an acute respiratory change of condition without a thorough medical assessment or timely notification to the physician for treatment options. The resident's medical condition declined and the resident expired in the facility three hours later. The resident's advance directives requested full medical treatment interventions. 2. For sample resident #525, the facility failed to adequately and consistently assess, monitor and manage pain; and 3. The facility failed to assure a timely and thorough assessment of newly developed pain and failure to assure adequate pain control for resident #564; and 4. The facility failed to complete nursing assessments prior to [MEDICAL TREATMENT] for resident #517. The findings include: 1. Acute change of condition, lack of nursing assessments and timely notification with physician to discuss treatment options. The resident's condition declined and vital signs ceased requiring the initiation of CPR. The resident expired in the facility. Review of the facility policy (in pertinent part), "The acute condition of changes - clinical protocol was reviewed in pertinent part ...5. Before contacting a physician about someone with an acute change of condition, the nursing staff will make pertinent observations and collect appropriate information to report to the physician... The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within a half-hour or less). The staff will notify the Medical Director for additional guidance and consultation if a timely response is not received. 2. As needed, the Physician will discuss with the resident and/or family the benefits and risks of diagnosing and managing the situation in the facility or via hospitalization ...This discussion should consider the resident's overall condition, prognosis and wishes... The physician will help identify and authorize appropriate treatments...The staff will monitor and document the resident's progress and responses to treatment. 2. The physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized." A. Resident #480, [AGE] years old, was admitted to the facility [DATE] following a hospital stay for a perforated colon, peritonitis, status [REDACTED]. The past medical history also included hypertension, diabetes mellitus and [MEDICAL CONDITION] with mets to lungs. The resident was admitted for rehabilitation and therapy services. The [DATE] care conference indicated the resident's goal was to return home. The resident expired in the facility on [DATE] (see below for facility failures). Review of the advance directive form noted the resident's wishes were for Yes COR and full treatment for [REDACTED]. On the hospital discharge instructions, it directed staff to call the physician for sudden shortness of breath. [DATE] Care plans: The resident had a new history of pacemaker related to [MEDICAL CONDITION]. Staff was directed to monitor vital signs as ordered/per facility protocol, record and notify physician of significant abnormalities. The resident had an alteration in gastrointestinal status related to perforated bowel. Staff was directed to monitor vital signs as ordered/per protocol, record and notify physician of significant abnormalities (rapid pulse, shallow, rapid or labored respirations, low blood pressure). The resident was on antibiotic therapy related to [MEDICATION NAME], recent [MEDICAL CONDITION] placement and resected bowel. Staff was directed to observe for possible side effects every shift. The resident had potential for fluid deficits related to poor intake and monitor for vital signs as ordered/per protocol, record and notify the physician of significant abnormalities. [DATE] On [DATE] at 7:21 p.m., the physician documented the Physician's Assistant assessed resident and noted he had an apneic episode (without breaths), had productive cough and chest congestion. Chest x-rays ordered to rule out pneumonia and labs reviewed. Respirations were 18, oxygen 93% and pulse 70. Preview of the respirations from [DATE] through [DATE] am (morning) - revealed a range of 19 per minute. No oxygen was required. [DATE] The other recorded vital signs for blood pressures and pulse showed one outlier on [DATE] at 10:45 a.m. a pulse of 20 was recorded (could be user entry error into the system). On [DATE] at 1:30 p.m., the nursing assessment by the Licensed Practical Nurse (LPN) included vital sign entries (10:45 a.m. and 1:22 p.m.). The pulse of 20 was recorded at 10:45 a.m. Respirations of 20 were recorded at 10:45 a.m. The nurse noted no oxygen was in use and the oxygen rate was 96% on room air. There were no complaints of chest pain or dyspnea. The nurse noted shortness of breath was present and he had a productive cough. There were thin secretions without odor and the guest was given an [MEDICATION NAME] nebulizer treatment to help with cough and wheezing. The guest had complaints of cough and congestion. The Physician was notified. A chest x-ray and blood work was requested. On [DATE], lab work and x-rays were reviewed by the Physician's Assistant on [DATE] and [DATE]. On [DATE], staff documented the resident ate breakfast, lunch and refused dinner. Acute change of condition: There was no documentation regarding the onset of an acute resident change of condition in the nursing notes near change of shift (Respirations noted at 44 and not found in nursing notes). There was no corresponding assessment or indication the physician was notified at this time (approximately 5:50 p.m.). -On [DATE] at 6:40 p.m., an LPN documented oxygen therapy was applied with positive results. (Review of oxygen vital records from [DATE] - [DATE] indicated the resident was normally on room air). Vital signs were recorded and taken by a CNA. On [DATE] at 6:40 p.m., the resident's pulse ox rate was recorded as 82%. There was no clinical assessment of the resident's medical condition/respiratory status by the nurse at the onset of the resident's change of condition. There was no further clinical assessment of monitoring the resident's status by nursing. The change of condition started around 5:50 p.m. Review of the April Medication Administration Record (MAR) showed the nurse signed that oxygen was applied on ,[DATE]. The prn (as needed) nebulizer [MEDICATION NAME] treatment was blank for [DATE] (ordered for [MEDICAL CONDITION] as needed). According to the investigation, a nebulizer treatment was given to the resident but there was no documentation or corresponding assessment. The next entry was made on [DATE] at 10:16 p.m. by the Director of Nursing (DON), "Guest noted to have change of condition at approximately 1800 (6pm) by nursing staff. Vitals noted to be BP - ,[DATE], p-80, R-44, T - 98.3, Pox - 82%. Oxygen placed on guest and pox (pulse ox) improved to 93%. R-38. Guest continued to be monitored. Call placed to MD at 1950 (7:50 p.m.), with no immediate return. DON called at 2014 (8:14 p.m.), DON instructed nursing staff to call 911 and send guest out. At 2015 (8:15 p.m.) guest noted to have faint pulse, sporadic gasps, Guest stopped breathing and no pulse noted. 911 was called, while CPR was initiated. Paramedics arrived on scene at 2026 (8:26 p.m.). Guest was pronounced dead at 2048 by MD at (name of hospital). DON arrived on scene at 2100 (9 pm) to speak with family. Coroner's office was notified by DON and released the body... " Facility response: On [DATE], the facility started retraining nursing staff on 'Emergent Situations' - covering acute change of conditions require immediate assessment from an RN, changes in vital signs require an immediate closer look at what the situation is, and how it relates to their condition. The support system available is other nurses working in the building. If the guest has a change of condition, call the physician as needed. If there are signs of acute and emergent changes, you do not have to wait for doctor approval to call 911. If family requests to have 911 called, then call. Assessment vs. Diagnosis - As nurses we assess only and do not diagnose. Chart appropriately. Chart what you see and hear. In servicing continued through [DATE] to ensure all nursing staff trained. (Provided the day after survey exit on [DATE]) On [DATE], the utilization review committee met to review the events that occurred on the evening of [DATE]. The following comments were made: The first responding LPN #7 did not notify the physician of the change of condition and only passed it on in report. The second LPN #8 should have completed the resident's vital signs versus asking the CNA (CNA #10) to take the vital recordings. The second LPN #8 reassessed the resident 48 minutes later. Summary: Both LPNs noted the change of condition and did not provide emergency interventions. It took 2 hours and 19 minutes for 911 to be called, while the guest was having R of ,[DATE] and labored breathing. Family requested 911 to be called multiple times before the nurse called 911. Through the facility's investigation, the assessment findings indicated the resident was noted to have labored breathing, wet breath sounds, decreased pulse ox, rapid respirations and low BP. Oxygen had been applied and a nebulizer treatment administered (although not documented). After RN #6's assessment, it was reported (not documented in the medical chart) the resident had wet breath sounds, breathing was not normal, labored breathing, and gurgling. LPN #8 had stated the resident had not been like this all day. RN #6 directed the nurse to call the physician. On [DATE], audits were initiated and ongoing to monitor for resident change of conditions (COC), nurse involved, timely catch of COC, proper documentation with family/MD notification, clear description of events, transfer out and comments. On [DATE], (following the surveyor's first visit on [DATE] and resident care questions) further training was started with nursing staff regarding clarification documentation which included the following: Ensuring a transfer in note was written when the resident returned from the hospital, medication documentation to ensure staff document on prn medications, what to do when a medication was not available for administration and charting documentation. With this last component, staff was instructed to be as thorough as possible with interventions, what was done, order changes and an RN assessment is needed when establishing cease of vitals, LPNs asking for an RN assessment and the RN should document their assessment. Always create a progress note on all COC that occur during your shift. Prior to [DATE], staff had been educated on change of condition assessments and documentation on [DATE]. On [DATE], the physician's discharge summary indicated the cause of death was an acute cardiac event probable [MEDICAL CONDITION] infarction with terminal arrhythmia with contributing causes from his co-morbidity health problems. Recent chest x-ray on [DATE] was negative for any acute process. The physician documented, 'shortly before his death, he began to have rapid decline in condition and suffered a [MEDICAL CONDITION]. Full resuscitative efforts were provided by facility staff and paramedics. These were not successful and the patient was pronounced dead at 8:48 p.m.' Interviews: On [DATE] at 3:12 p.m., the Director of Nursing (DON) was interviewed. The DON stated LPN #8 felt interventions were provided such as oxygen and the vitals had improved (44 to 38) and was not as concerned to call the physician right away. The DON stated she did not think nursing staff went along with the facility's policies and procedures or used good nursing judgment when addressing the change of condition or notifying the physician. Both nurses were suspended and education was started. Nursing documentation should include resident changes, assessments, notifications, follow up and interventions. It was in the LPN's scope of practice to determine that an RN was needed. Nursing staff should sign out when prn medications are administered and the effectiveness. On [DATE] at 2:10 p.m., the DON stated with respirations of 44, the physician should have been called right away as this was an acute change of condition. 2. The facility failed to assure a timely and thorough assessment of pain and failure to assure adequate pain control for resident #525 FACILITY PAIN MANAGEMENT POLICY The facility Pain Assessment and Management policy dated 2010 stated in pertinent part: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident ' s goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: -Assessing the potential for pain -Effectively recognizing the presence of pain -Identifying the characteristics of pain -Addressing the underlying causes of pain -Developing and implementing approaches to pain management -Identifying and using specific strategies for different levels and sources of pain -Monitoring for the effectiveness of interventions and -Modifying approaches as necessary Assess the resident ' s pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Assessing Pain: During the comprehensive pain assessment gather the following information: -History of pain -Characteristics of pain -Impact of pain on quality of life -Factors that precipitate or exacerbate pain -Factors and strategies that reduce pain -Symptoms that accompany pain Assess pain using a consistent approach and a standardized pain assessment instrument Discuss with the resident goals for pain management and satisfaction with the current level of pain control. Documentation: Document the resident ' s reported level of pain with adequate detail as necessary and in accordance with the pain management program. Upon completion of the pain assessment, record the information obtained from the assessment in the resident ' s medical record. A. Resident #525 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] after a brief hospital stay. [DIAGNOSES REDACTED]. There was no completed minimum data set (MDS) for the resident. The resident's admission assessment for pain on [DATE] on readmission indicated that the resident had pain to the lower back and that the pain was chronic. The assessment revealed that the resident had pain frequently in the past five days and pain had affected sleep and day to day activities. The assessment indicated that the resident rated the pain at a seven/10 and that it was moderate. B. Resident observations and interview On [DATE], at 10:45 a.m. the resident was observed to be participating in therapy. The resident had a very pained facial expression, was breathing heavily and was sweating. On [DATE], at 11:01 a.m. resident #525 was interviewed in his room. The resident was lying in bed on his back during the interview. The resident stated that he did not think that the pain medications help enough as he was always in pain. He stated that the doctors and nurses had changed his medications and that the [MEDICATION NAME] was more effective than other medications but if the [MEDICATION NAME] did not " knock him out " he was in pain when awake. He stated that he was in pain with any movement including therapy, repositioning and using the bathroom. He stated that the pain would be tolerable at a five if he could just lie in bed and not move, but it was usually at an eight. The resident went on to state that the nursing staff do not always give him pain medication prior to therapy and that he could not participate as well when he was in pain. He also stated that the nurses do not always ask him to rate his pain; they just came in and give him medications. On [DATE] during the resident interview, at 11:16 a.m., LPN #6 came into the room to disconnect and flush the resident ' s intravenous IV line. She asked the resident if he was ready for more pain medication. The resident asked if he was due for more and she stated that he could have more because it was ordered for every three hours. LPN #6 did not ask the resident to rate his pain prior to leaving the room. Resident #525 confirmed that LPN #6 did not ask him to rate his pain. C. Record review Computerized Physician Orders The resident ' s [DATE] computerized physician orders (CPO) in pertinent part read: -[MEDICATION NAME] Patch 72 hour- Apply 25 mcg [MEDICATION NAME] in the morning every three days for pain/discomfort. Remove old patch and document site. This order was written on [DATE]. -[MEDICATION NAME] tablet 400 mg- give one tablet by mouth every six hours as needed for pain. This order was written on [DATE]. -[MEDICATION NAME] Solution-give 10 mg by mouth every three hours as needed for moderate pain. This order was written on [DATE]. -[MEDICATION NAME] Solution-give five mg by mouth every three hours as needed for mild pain. This order was written on [DATE]. -Tylenol- give 325 mg by mouth every six hours as needed for pain and discomfort. Not to exceed three gm/3000 mg in 24 hours mild to moderate pain. This order was written on [DATE]. -Tylenol- give 650 mg by mouth every six hours as needed for pain and discomfort. Not to exceed three gm/3000 mg in 24 hours moderate to severe pain. This order was written on [DATE]. Further review of the resident's CPO indicated that the resident had past orders for pain medication which included: -[MEDICATION NAME] HCL tablet 5 mg- give 10 mg by mouth every three hours as needed for pain scale five to 10. This order was written on [DATE] but discontinued. -[MEDICATION NAME] HCL tablet 5 mg- give five mg by mouth every three hours as needed for pain scale one to four. This order was written on [DATE] but discontinued. -[MEDICATION NAME] Concentrate 20 mg/ml- give five mg by mouth every three hours as needed for pain. This order was written on [DATE] but was discontinued. Care Plan The resident's pain care plan dated [DATE] stated, " Resident had chronic pain related to postoperative discomfort, disease process osteo[DIAGNOSES REDACTED], Parkinson ' s. " The goal for this care plan was, " resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. " Interventions included: 1) Administer [MEDICATION NAME] five mg by mouth every three hours as needed. Give half an hour before treatments or care; 2) Resident is able to call for assistance when in pain, reposition self, ask for medication, tell how much pain was experienced, tell what increases or alleviates pain; 3) Monitor, record, report to nurse resident complaints of pain or requests for treatment. Medication Administration Record (MAR) The resident ' s MAR for [MEDICATION NAME] revealed that the resident received the five mg dose on [DATE] at 4:45 p.m., on [DATE] at 12:07 p.m., and on [DATE] at 3:40 p.m. The resident received the [MEDICATION NAME] 10 mg dose on [DATE] at 1:48 p.m. The MAR showed blank spaces for [DATE]-[DATE] which indicated that the resident did not receive the [MEDICATION NAME] at all on those days, though the order was written on [DATE]. According to the MAR, the above medications were effective on the dates given. Nurses Notes On [DATE], at 1:48 p.m. an electronic MAR note stated that the resident received 10 mg of [MEDICATION NAME] sulfate, -resident reported pain seven/10 to right shoulder and upper back. " There was no note to indicate whether the medication was effective. On [DATE], at 4:46 p.m. an electronic MAR note was written indicating that the resident received five mg of [MEDICATION NAME] sulfate- resident reported pain eight/10 and the resident did not want to get out of bed for dinner. A second note was attached to the above with no time stamp which read, PRN (as needed) administration was effective: resident stated pain six/10, but resident still able to remain comfortable in bed. On [DATE], at 12:07 p.m. an electronic MAR note was written indicating that the resident received five mg [MEDICATION NAME] sulfate - resident complained of eight/10 pain post physical therapy. There was no note regarding the effectiveness of the medication. On [DATE], at 3:40 p.m. an electronic MAR note was written indicating that the resident received five mg [MEDICATION NAME] sulfate - resident complained of eight/10 pain on his right shoulder and that five mg was given at that time. An effectiveness note was written at 4:12 p.m. indicating that the PRN administration was effective and reduced the resident ' s pain to two/10. Assessments The resident ' s daily skilled assessment on -[DATE] conducted by nursing staff indicated that the resident ' s pain hurt a little bit, was severe, and rated a six/10 in the resident ' s bilateral shoulders and lower back. The assessment also stated that PRN pain medications, ice, and repositioning were effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -[DATE] indicated that the resident ' s pain hurt a little bit, was mild, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. -Review of the nurses ' notes showed no evidence that the resident ' s pain was ever treated with ice in the facility. D. Interviews On [DATE], at 3:25 p.m. a certified nurse assistant (CNA #5) was interviewed. CNA #5 stated that the resident did not normally use the call light, so staff checked on him every hour and encouraged him to use the call light. CNA #5 stated that the resident did not complain of pain to the CNAs that she knew of. On [DATE], at 3:40 p.m. a licensed practical nurse (LPN #3) was interviewed. LPN #3 stated that she rounded with every patient when her shift started, to ask if they were in pain or needed anything. She stated that resident #525 was checked on every hour because the resident did not use his call light or ask for pain medication. She stated that resident #525 had orders for pain medication every four hours as needed and that she knew when he needed pain medication depending on how the resident was acting. She stated that if he said he was in pain, staff asked him to rate the pain on the one to ten scale and that the resident would always state five, six or ten. She stated that she documented the resident ' s pain scale rating on the progress notes every time she asked. She went on to state that the resident had [MEDICATION NAME] sulfate orders for mild pain and that mild pain was between one and three on the scale. She stated that the resident also had an order for [REDACTED]. She stated that she knew how much [MEDICATION NAME] to give the resident by how he rated his pain as well as using her own judgment as some residents took advantage of pain medications. On [DATE], at 3:58 p.m. the director of nursing (DON) was interviewed. The DON stated that the assessment of pain was documented once a day in the daily skilled charting but she would expect nursing staff to ask about pain anytime they were giving medications or in the resident room providing care. She stated that there was no set time or frequency for pain assessment in the facility. After reviewing the resident ' s order for [MEDICATION NAME], she stated that she would consider mild pain to be one to five and moderate pain would be six to ten. Upon review of the resident ' s MAR for the [MEDICATION NAME] where the resident received the lower dose (5 mg) for a rating of eight/10 and the higher dose (10 mg) for a seven/10, she stated that the orders would be much clearer and less open to interpretation if there were parameters for mild, moderate pain. She then stated that the nurse should use their judgment and talk to the resident to see what dosage the resident wanted, but she would expect to see this conversation in the nurses ' notes. On [DATE], at 10:15 a.m. the DON provided a copy of the pain policy for the facility. She stated that since the interview yesterday, orders for the resident's [MEDICATION NAME] were clarified and given parameters. Upon review of the copies of the MAR and orders, the resident ' s new order read: [MEDICATION NAME] Solution- give five mg by mouth every three hours as needed for pain management (one to five or per patient request). [MEDICATION NAME] Solution- give ten mg by mouth every three hours as needed for pain management (six to ten or per patient request). E. Continued failure after change in medication order on [DATE] On [DATE] at 11:25 a.m. LPN #6 was interviewed. She stated that she assessed the resident ' s pain every three hours. She stated that she always asked the resident for a pain rating number and that he was very vocal about his pain and he always rated his pain at a ten. She stated that she did not ask the resident for a number when she was in his room because she was not going to be giving him the medication just yet. She stated that she would ask him for a pain scale rating prior to giving him the medication which would determine which dosage she would give. Documentation after the order change ([DATE]-[DATE]) Daily Skilled Assessments [DATE] indicated that the resident ' s pain hurt a little bit, was moderate, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective " when he did not have to move too much. " [DATE] indicated that the resident ' s pain hurt a little bit, was moderate, and rated a six/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective " when he did not have to move too much. " [DATE] indicated that the resident ' s pain hurt a little bit, was severe, and rated an eight/10 in the resident ' s bilateral shoulders and lower back with PRN pain medications, ice and repositioning being effective. Nurses Notes On [DATE], at 10:35 p.m. a nurse ' s note stated that the resident remained in bed the entire shift and stated that his pain was adequately controlled when in bed. On [DATE], at 11:40 p.m. an electronic MAR note stated that resident received five mg of [MEDICATION NAME] sulfate solution- the resident complained of lower back pain and was given medication and positioned for comfort. -There was no documentation of the resident ' s pain scale rating at this administration. On [DATE], at 2:43 a.m. an electronic MAR note stated that the resident received five mg of [MEDICATION NAME] sulfate solution- the resident was resting in bed, restless and moaning and was given [MEDICATION NAME] sulfate as ordered. -There was no documentation of the resident ' s pain scale rating at this administration. -An effectiveness note at 2:43 a.m. stated that the administration was effective; the resident slept for a while but after three hours was restless and moaning. On [DATE], at 9:43 a.m. an electronic MAR note stated that resident received [MEDICATION NAME] 400 mg for back spasms and a pain rating of eight/10. -An effectiveness note at 10:56 a.m. stated that the [MEDICATION NAME] was ineffective and that the resident was still having pain of seven/10. On [DATE] at 6:40 p.m. an electronic MAR note stated that resident received five mg of [MEDICATION NAME] sulfate for pain in his left shoulder seven/10. -An effectiveness note at 10:33 p.m. stated that that the administration was effective with the resident ' s pain lowered from seven to two/10. On [DATE], at 10:47 p.m. an electronic MAR note stated that the resident received [MEDICATION NAME] 400 mg for pain of four/10 to his right shoulder. On [DATE] at 11:46 p.m. an electronic MAR note stated that the resident received 10 mg of [MEDICATION NAME] sulfate for pain of six/10 to lower back. -Two effectiveness notes on [DATE] at 1:10 a.m. stated that the administrations were effective. There was no other narrative. On [DATE] at 9:49 a.m. an electronic MAR note stated that the resident received 650 mg of Tylenol for complaints of back pain rated at five/10. -An effectiveness note on [DATE] at 10:44 a.m. stated the administration was effective- pain ,[DATE]. On [DATE] at 6:17 p.m. an electronic MAR note stated that the resident received 10 mg of [MEDICATION NAME] sulfate for pain seven/10 to his lower back. -An effectiveness note on [DATE] at 10:54 p.m. stated that the administration was effective - the resident's pain went down to one out of 10. 3. The facility failed to assure a timely and thorough assessment of newly developed pain and failure to assure adequate pain control for residents. Resident #564 - Pain Sample resident #564, [AGE] years of age, was admitted to the facility on [DATE]. According to the most current, ,[DATE], computerized physicians order (CPO) the resident had [DIAGNOSES REDACTED]. The resident, newly admitted to the facility, did not have a completed minimum data set (MDS). Resident observation: On [DATE] at 3:30 p.m. during an interview with the resident, she was sitting up in a chair in her room. She had a cold pack to her left shoulder area. From the beginning, and throughout the interview (approximately 15 minutes), the resident was observed to have visible signs of pain including facial grimacing, tearfulness, strained speech and groaning. She continuously changed positions in her chair. Resident interviews: On [DATE] at 3:30 p.m. the resident was asked if she had any discomfort such as pain, heaviness, burning, or hurting with no relief. The resident stated that her left shoulder was "really hurting" and was at a level of ,[DATE] (severe). Due to the resident ' s pained appearance she was asked if she would like to delay or decline being interviewed; however, she stated she would participate in the interview, but did not know how well she would be able to interact. The resident stated she had been in miserable pain for the past four days. She stated the pain came on suddenly and she did not know what might have caused it. The nurses had been giving her pain medication, specifically Tylenol and [MEDICATION NAME]. The resident stated the Tylenol did not seem to relieve her pain as much as the [MEDICATION NAME]. The resident stated she had not seen a doctor since she had been there but the physician assistant had been in to see her. On [DATE], at 8:30 a.m. the resident was interviewed a second time. The resident acknowledged that she was still having frequent pain and it was an ,[DATE] pain level that morning. She state