Every finding on record at Legacy Nursing and Rehabilitation of Franklin

Based on observations, interviews, and record reviews, the facility failed to protect a resident's right to privacy for 1 (Resident #49) of 4 residents investigated for resident's rights. Findings:Review of the facility's undated Resident Right's and Quality of Life Policy and Procedure revealed, in part, all residents had the right to a dignified existence. Further review revealed residents were to be treated with consideration of his/her dignity, including privacy in treatment and care for his/her personal needs. Review of Resident #49's Minimum Data Set with an Assessment Reference Date of 11/13/2025 revealed Resident #49 had a Brief Interview Mental Status score of 15, which indicated Resident #49 was cognitively intact. Further review revealed Resident #49 required assistance for showering and bathing. Observation on 01/07/2026 at 9:35AM revealed Resident #16, Resident #29, Resident #49, Resident #106, Resident #108, and Resident #113 were all in Shower Room c at the same time. Observation further revealed Resident #49 was in the shower unclothed and being assisted by S7Certified Nursing Assistant. Observation on 01/07/2026 at 9:36AM revealed the door to the shower room opened and S6Certified Nursing Assistant brought Resident #22 intoShower Room c. In an interview on 01/07/2026 at 9:40AM, Resident #49 indicated she was not comfortable showering in Shower Room c with the other residents present. In an interview on 01/07/2026 at 1:20PM, S6Certified Nursing Assistant indicated the number of residents they had in Shower Room c did not allow for privacy of the residents. In an interview on 01/07/2026 at 1:24PM, S3Assistant Director of Nursing confirmed the number of residents that were in Shower Room c did not allow for privacy. In an interview on 01/07/206 at 1:54PM, S1Director of Nursing indicated Resident #49 was out of her comfort zone with the number of residents in Shower Room c as she was showering. S1Director of Nursing further indicated Resident #49 should have been in the shower room with only S7Certified Nursing Assistant to ensure resident privacy and dignity.

Based on observations, interviews, and record reviews, the facility failed to maintain a resident's right to a safe, clean, comfortable, homelike environment for 2 (Resident #22, Resident #128) of 2 sampled residents investigated for resident rights. Findings:Review of the facility's undated Bed Making, Occupied policy and procedure revealed, in part, the facility was to provide a clean and comfortable environment for residents. Review of the facility's undated Certified Nursing Assistant Job Description revealed, in part, Certified Nursing Assistants were to promote residents' rights, assist residents in making informed decisions, and to treat residents with dignity. Further review revealed Certified Nursing Assistants were to help residents with activities of daily living and to promote a safe and clean environment. Resident #22Review of Resident #22's electronic medical record revealed, in part, a diagnosis of a Stage 3 and Stage 4 pressure ulcer of the sacral region and a Stage 2 pressure ulcer of the buttocks. Review of Resident #22's Quarterly Minimum Data Set with an Assessment Reference Date of 12/12/2025 revealed, in part, Resident #22 was always incontinent of bowel and bladder and had a pressure reduction device for her bed. Review of Resident #22's Physician Order dated 05/12/2023 revealed, in part, Resident #22 had an order for a pressure reduction mattress. Review of the manufacturer's guidelines for the Drive DeVilbiss Healthcare Med-Aire Alternating Pressure and Low Air Loss Mattress System (a mattress used to alleviate pressure and prevent pressure ulcers) revealed, in part, a thin cotton sheet could be placed over the mattress' top cover. Observation on 01/05/2026 at 10:29AM revealed Resident #22 did not have a sheet on the pressure reduction mattress of her bed, and Resident #22's skin was in direct contact with the mattress' surface. In an interview on 01/05/2026 at 10:30AM, Resident #22 indicated she informed the facility's staff that she wanted a cover sheet on the pressure reduction mattress on her bed. Observation on 01/06/2026 at 8:39AM revealed Resident #22 did not have a cover sheet on the pressure reduction mattress on her bed, and Resident #22's skin was in direct contact with the mattress' surface. In an interview on 01/06/2026 at 11:00AM, S5Certified Nursing Assistant Supervisor indicated it was the facility's practice not use a cover sheet with a pressure reduction mattress; however, if requested by a resident, as part of resident rights, a cover sheet would be placed over a resident's pressure reduction mattress. In an interview on 01/06/2026 at 11:22AM, Resident #22 indicated she did ask the facility's staff to put a cover sheet on her pressure reduction mattress, and her request was not honored. Observation on 01/06/2026 at 4:00PM revealed Resident #22 did not have a cover sheet on the pressure reduction mattress on her bed, and Resident #22' skin was in direct contact with the mattress surface. In an interview on 01/06/2026 at 3:40PM, S1Director of Nursing indicated it was the facility's practice not use a cover sheet on a pressure reduction mattress. S1Director of Nursing further indicated residents were not given a choice for a cover sheet to be placed over their pressure reduction mattress, but residents should have been given a choice. Resident #128Review of Resident #128's Quarterly Minimum Data Set with an Assessment Reference Date of 12/05/2025 revealed, in part, Resident #128 was always incontinent of bowel and bladder. In an interview on 01/05/2026 at 10:56AM, Resident #128 indicated her bed linens were wet and soiled. Observation on 01/05/2026 at 10:57AM revealed Resident #128's bed linens were wet and soiled. In an interview on 01/06/2026 at 8:35AM, Resident #128 indicated her bed linens were still soiled and had not been changed. In an interview on 01/06/2026 at 11:00AM, S5Certified Nursing Assistant Supervisor indicated the facility's certified nursing assistant staff should check resident rooms every 2 hours for needs or assistance. In an interview on 01/06/2026 at 12:39PM, Resident #128 indicated she requested the certified nursing assistant to change her bed linens yesterday, but her bed linens were still soiled and had not been changed. Observation on 01/06/2026 at 12:39PM revealed Resident #128's bed linens had two circular dried brown stains approximately 2 inches in diameter and a semi-circular dried yellow stain approximately 6 inches long. In an interview on 01/06/2026 at 12:42PM, S9Certified Nursing Assistant indicated a resident's bed linens would be changed if the resident requested linen changes and/or if the bed linens were wet or soiled. In an interview on 01/06/2026 at 1:40PM, S1Director of Nursing indicated Resident #128's bed linens should not have been soiled and should have been changed. In an interview on 01/06/2026 at 1:50PM, S5Certified Nursing Assistant Supervisor indicated it was the responsibility of the certified nursing assistant staff to check a resident's bed linens and to change resident bed linens when the linens were soiled. S5Certified Nursing Assistant Supervisor indicated Resident #128's bed linens should not have been soiled and should have been changed timely.

Based on interviews and record reviews, the facility failed to ensure a Minimum Data Set assessment was transmitted to the Centers for Medicare and Medicaid Services within 14 days of completion for 2 (Resident #14, Resident #62) of 3 sampled residents reviewed for resident assessments. Findings:Resident #14Review of Resident #14's Quarterly Minimum Data Set with an Assessment Reference Date of 12/03/2025 revealed, in part, the Quarterly Minimum Data Set was completed on 12/17/2025. Review of the facility's Validation Report dated 01/02/2026 revealed, in part, Resident #14's Quarterly Minimum Data Set with an Assessment Reference Date of 12/03/2025 was transmitted to the Centers for Medicare and Medicaid Services on 01/02/2026, which was greater than 14 days after the completion date of Resident #14's assessment. Resident #62Review of Resident #62's Annual Minimum Data Set with an Assessment Reference Date of 11/25/2025 revealed, in part, the Annual Minimum Data Set was completed on 12/09/2025. Review of the facility's Validation Report dated 12/31/2025 revealed, in part, Resident #62's Annual Minimum Data Set with an Assessment Reference Date of 11/25/2025 was transmitted to the Centers for Medicare and Medicaid Services on 12/31/2025, which was greater than 14 days after the completion date of Resident #62's assessment. In an interview on 01/07/2026 at 9:30AM, S4Licensed Practical Nurse/Care Plan Coordinator indicated Resident #14's Quarterly Minimum Data Set with an Assessment Reference Date of 12/03/2025 and Resident #62's Annual Minimum Data Set with an Assessment Reference Date of 11/25/2025 were not transmitted within 14 days as required after the completion date, and should have. In an interview on 01/07/2026 at 10:03AM, S1Director of Nursing indicated Resident #14's Quarterly Minimum Data Set with an Assessment Reference Date of 12/03/2025 and Resident #62's Annual Minimum Data Set with an Assessment Reference Date of 11/25/2025 were not transmitted within 14 days as required after the completion, and should have.

Based on interview and record review, the facility failed to ensure discharge planning was reflected on the assessment for 1 (Resident #8) of 1 sampled residents investigated for discharge. Findings:Review of Resident #8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2025 revealed, in part, active discharge planning was not in progress for Resident #8. Further review of Resident #8's MDS revealed Resident #8's family did not want to talk to someone about the possibility of leaving the facility to return home to live and receive services in the community.In an interview on 01/07/2026 at 11:18AM, S2Social Services Director (SSD) indicated Resident #8's family had voiced a desire for Resident #8 to return home. S2SSD further indicated Resident #8 had been placed on the waiver registry on 08/26/2025. S2SSD further indicated Resident #8's MDS with an ARD of 11/15/2025 was miscoded. S2SSD indicated Section Q was not coded for active discharge planning and should have been.In an interview on 01/07/2026 at 1:10PM, S1Director of Nursing (DON) indicated Resident #8's MDS with an ARD of 11/15/2025 did not reflect active discharge planning and should have.

Based on observation, interview, and record review, the facility failed to ensure staff maintained proper infection control while performing wound care for 1 (Resident #24) of 2 residents observed for wound care. Findings:Review of Resident #24's wound assessment record revealed, in part, Resident #24 had a stage 4 right hip pressure ulcer, a stage 4 sacral pressure ulcer, and a stage 3 left gluteal (buttocks) pressure ulcer. Observation on 01/06/2026 at 10:00AM, revealed S10Licensed Practical Nurse/Wound Care Nurse (LPN/Wound Care Nurse) cleaned the left gluteal wound with a 4x4 gauze and normal saline. Further observation revealed S10LPN/Wound Care nurse used the same 4x4 with normal saline to clean Resident 24's sacral wound.In an interview on 01/06/2026 at 10:30AM, S10LPN/Wound Care Nurse stated she should not have used the same 4x4 gauze to clean Resident #24's left gluteal wound and Resident #24's sacral wound. In an interview on 01/06/2025 at 2:30PM, S1Director of Nursing stated S10LPN/Wound Care Nurse should not have cleaned Resident #24's left gluteal wound and Resident #24's sacral wound with the same 4x4 gauze to prevent cross contamination of wounds.

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) registry verification was obtained prior to hire for 1 (S7Certified Nursing Assistant [CNA]) of 5 (S4CNA, S5CNA, S6CNA, S7CNA, 8CNA) personnel records reviewed for registry verification. Findings: Review of S7CNA's personnel record revealed, in part, S7CNA had a hire date of 07/10/2024. Further review revealed a CNA registry verification with a date of 03/20/2025. There was no documented evidence, and the facility did not present any documented evidence, a CNA registry verification was obtained prior to hire for S7CNA. In an interview on 03/20/2025 at 2:06PM, S3Human Resource designee indicated a CNA registry check was not obtained prior to hire for S7CNA as required. In an interview on 03/20/2025 at 2:26PM, S1Adminitrataor indicated the facility did not have documented evidence a CNA registry verification was obtained prior to hire for S7CNA as required.

Based on interviews and record reviews, the facility failed to complete a Physical Therapy, Occupational Therapy, and Speech Therapy evaluation as ordered for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents review for falls, who were at risk for falls and had a history of falls. Findings: Review of the facility's incident/accident log from 01/17/2025 to 03/15/2025 revealed, in part, Resident #1 had falls on 01/17/2025, 02/08/2025, 02/09/2025, 02/10/2025, 02/24/2025, 02/28/2025, 03/02/2025, 03/03/2025, 03/05/2025, 03/07/2025, 03/08/2025, 03/09/2025, 03/11/2025, and 03/15/2025. Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of, in part, impulse disorder, psychosis, schizoaffective disorder, schizoaffective disorder/bipolar type, major depressive disorder, pseudobulbar affect and extrapyramidal movement disorder. Review of Resident #1's most recent Minimum Data Set with an Assessment Reference Date of 01/08/2025 revealed, in part, Resident #1 had short and long term memory loss, had some difficulty in making decisions in new situations, was inattentive, had disorganized thinking at times, had two or more falls since the previous assessment, and did not receive therapy services during the observation period. Review of Resident #1's medical records revealed a request for therapy services form, with a physician approval date and signature date of 01/07/2025. Review of Resident #1 physician's orders revealed, in part, an order dated 01/07/2025 for physical therapy, occupational therapy, and speech therapy to evaluate and treat. Review of Resident #1's therapy records revealed, in part, Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were not completed until 01/27/2025. There was no documented evidence, and the facility did not present any documented evidence Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were completed prior to 01/27/2025. In an interview on 03/20/2025 at 9:16AM, S4Therapy Director indicated staffing issues were one of the reasons therapy evaluations were delayed. S4Therapy Director confirmed Resident #1 physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were not completed until 01/27/2025. In an interview on 03/20/2025 at 10:46AM, S2Director of Nursing (DON) confirmed Resident #1's therapy evaluations ordered on 01/07/2025 were completed on 01/27/2025. S2DON indicated Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations should have been completed as per physician orders. In an interview on 03/20/2025, S1Administrator indicated the facility did not have any documented evidence Resident #1's physical therapy evaluation, occupational therapy evaluation, and speech therapy evaluations ordered on 01/07/2025 were completed before 01/27/2025.

Based on observations, interviews, and record reviews, the facility failed to provide assistance with showering/bathing, shampooing, and shaving for dependent residents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for activities of daily living (ADLs). Findings: Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 revealed, in part, Resident #1 required moderate assistance with showering/bathing, and personal hygiene. Review of Resident #1's Care Plan revealed, in part, Resident #1 require assistance with all ADLs. Further review revealed Resident #1 needed to be assisted with bathing/showering, and personal hygiene. Review of Resident #1's tasks list for bathing revealed, in part, in the last 30 days Resident #1 received a bed bath on 01/24/2025, 02/14/2025 and 02/17/2024. Further review revealed he received a shower on 01/20/2025, 01/31/2025, and 02/07/2025. Further review revealed there was no documented evidence, and the facility did not present any documented evidence Resident #1's hair had been washed. Review of Resident #1's tasks list for AM/PM care revealed, in part, in the last 30 days, Resident #1 was shaved on 01/29/2025 and 02/16/2025. Observation on 02/17/2025 at 10:55AM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. In an interview on 02/17/2025 at 10:56AM, Resident #1 indicated the staff gave him bed baths and he preferred bed baths. Resident #1 further indicated he would like to have his hair washed and his facial hair shaved, but staff had not completed it for him. Observation on 02/17/2025 at 2:10PM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. Observation on 02/18/2025 at 9:30AM revealed Resident #1 had white flakes in his hair and on his shirt. Observation further revealed Resident #1 had facial hair on his cheeks approximately one-fourth of an inch long and the hair above his lip was approximately one-half an inch long. In an interview on 02/18/2025 at 9:30AM, Resident #1 indicated S3Certified Nursing Assistant (CNA) gave him a bed bath this morning. Resident #1 further indicated he did not get shaved nor his hair washed. Observation on 02/19/2025 at 9:28AM revealed Resident #1 sitting in his wheelchair in the common area. Observation further revealed Resident #1 had white flakes in his hair and on his shirt. In an interview on 02/19/2025 at 10:52 AM, S3CNA indicated Resident #1 received bed baths. S3CNA further indicated she had not attempted to wash Resident #1's hair while he was in bed and she also had not shaved Resident #1. In an interview on 02/19/2025 at 11:05 AM, S2Infection Preventionist confirmed Resident #1 had flakes in his hair and on his shirt and he should not. In an interview on 02/19/2025 at 11:06 AM, S1Director of Nursing confirmed Resident #1 had white flakes in his hair and on his shirt and he should not. S1DON further indicated Resident #1 should also have dandruff shampoo. S1DON further indicated Resident #1 should have been given assistance with shaving.

Based on record reviews, observations, and interviews, the facility failed to ensure residents identified as safe smokers maintained their rights to keep their smoking supplies and smoke at their leisure for 4 (Resident #40, Resident #51, Resident #90, and Resident #105) of 4 (Resident #40, Resident #51, Resident #90, and Resident #105) sampled residents reviewed for resident rights. Findings: Review of the facility's undated, Resident Smoking policy revealed, in part, residents who had independent smoking privileges are were permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. Review of the facility's smoking policy revealed, in part, that the purpose was to establish guidelines for the facility's residents' safe smoking. Further review revealed residents who were identified as safe smokers were permitted to keep cigarettes and other smoking articles in their possession. Review of the facility's smoking hours revealed, in part, smoking times were at 8:30 a.m., 10:30 a.m., 1:00 p.m., 3:30 p.m., 6:30 p.m., and 8:30 p.m. Review of the facility's resident council meeting minutes dated 10/04/2024 at 2:00 p.m. revealed, in part, residents requested a meeting with S1Administrator regarding the change in the facility's smoking procedure. There was no documented evidence, and the facility was unable to present any documented evidence the facility responded to the residents' request. Review of the facility's safe smokers list revealed, in part, Resident #40, Resident #51, Resident #90, and Resident #105, were listed as a safe smokers. Observation on 01/6/2025 at 3:15 p.m., revealed a group of residents, which included Resident #40, Resident #51, Resident #90, and Resident #105, waiting for a staff member to give them their smoking material, and go outside with them to smoke at 3:30 p.m. Resident #40 Review of Resident #40's Smoking Safety Screen dated 10/04/2024 revealed, in part, Resident #40 was assessed as being a safe smoker. In an interview on 01/6/2025 at 10:07 a.m., Resident #40 indicated the facility does not allow him to keep his cigarette and lighter, and does not allow him to smoke when he would like to smoke. Resident #40 further indicated he was not a child and the facility should allow him to keep his own smoking materials and should be allowed to smoke when he desires. Resident #51 Review of Resident #51's Smoking Safety Screen dated 12/05/2024 revealed, in part, Resident #51 was assessed as being a safe smoker. In an interview on 01/06/2025 at 3:10 p.m., Resident #51 indicated he was a [AGE] year old veteran and was responsible enough to keep his own smoking materials. Resident #51 further indicated he did not appreciate being treated like a child. Resident #90 Review of Resident #90's Smoking Safety Screen dated 01/03/2025 revealed, in part, Resident #90 was assessed as being a safe smoker. In an interview on 01/06/2025 at 10:10 a.m., Resident #90 indicated she was not happy about not being allowed to keep her smoking materials. Resident #90 further indicated she was grown and should be allowed to smoke when she wishes. Resident #105 Review of Resident #105's Smoking Safety Screening dated 11/18/2024, revealed, in part, Resident #105 was assessed as being a safe smoker. Review of Resident #105's current Care Plan revealed, in part, Resident #105 was identified as a safe smoker with no restrictions. Further review revealed Resident #105 had a diagnosis of Major Depressive Disorder and Generalized Anxiety with an intervention which included to allow Resident #105 to make choices regarding her schedule. In an interview on 01/06/2025 at 10:05 a.m., Resident #105 indicated the smoking times were implemented a couple of months ago, and staff removed the resident's smoking supplies from their possession, locked them in a tackle box behind the nurse's station, and only passed them out to the residents at certain times. Resident #105 further indicated the smoking residents did not have a choice or proper notification of the new procedure. Resident #105 indicated this made her more anxious and was afraid to miss the smoking session so she came out early to ensure she did not miss the smoking session. Resident #105 indicated staff only allowed the smoking residents about 20 minutes to smoke. Resident #105 further indicated that she would prefer to have her smoking supplies in her possession. Resident #105 indicated staff issued two cigarettes per resident during the smoking session, and residents were not allowed to smoke more than two during this time. Resident #105 indicated she should be allowed to have as many of her cigarettes as she wanted to smoke because it was her personal property. Resident #105 indicated she should be able to smoke in the smoking area at her leisure. Observation on 01/06/2025 at 10:25 a.m. revealed staff and 12 residents were in the smoking area when the staff brought a rolling, locked tackle box and started to pass out the resident's smoking supplies. Resident #105 was provided two of her cigarettes and demonstrated safe smoking practices. Resident #105 finished her second cigarette at 10:40 a.m. and then entered the facility with staff and the other smoking residents. In an interview on 01/06/2025 at 12:45 p.m., S3Liscense Practical Nurse (LPN), indicated Resident #105 enjoyed smoking and would wake up ready to go outside to smoke and would spend most of her time outside by the smoking area. In an interview on 01/06/2025 at 3:35 p.m. S1Administrator verified the facility removed the residents smoking material, and the safe smokers were not allowed to keep their smoking material and smoke at their leisure. 51373

Based on record review and interviews, the facility failed to respond and maintain documented responses to the complaints voiced during the facility's resident council meetings for 3 of 3 resident council meeting minutes reviewed. Findings: Review of the facility's undated Grievance Policy and Procedure revealed, in part, the purpose of the policy was to ensure a resident's grievance would be followed up by prompt efforts to resolve the grievance of the resident. Further review of the policy revealed the resident council minute meetings were to be given to administration after completion of the meeting and the findings were to be documented and given to the administrator or designee for review. In interviews on 01/06/2025 at 10:00 a.m., during a meeting conducted with members of the resident council, Resident #40 indicated the facility does not respond to the resident council's concerns discussed in the monthly meetings. Resident # 71, Resident #90, and Resident #101 all agreed the facility did not follow-up with a responds to the concerns discussed during the resident council meetings. Review of the resident council's meeting minutes for the months of October, November, and December 2024 revealed, in part, there were no documented responses to the concerns discussed in the resident council meetings. Review of the facility's October 2024 resident council meeting minutes revealed, in part, the facility's residents requested to meet with S1Administrator regarding the smoking times. Review of the facility's November and December 2024 resident council meeting minutes revealed there was no documented response to the resident council above mentioned October 2024 request. In an interview on 01/6/2025 at 11:00 a.m., S10Assistant Activity Director indicated there was no documented responses to the residents' concerns discussed in the resident council meetings. In an interview on 01/6/2025 at 11:40 a.m., S9SocialWorker indicated she did not have any documented responses to the residents' concerns discussed in the resident council meetings. In an interview on 01/06/2025 at 3:35 p.m., S1Administrator indicated the facility did not have any documented evidence of the facility's response to the resident council concerns as required. S1Adminsitrator further indicated he was not notified the resident council requested to meet with him in October 2024, and he had not met with the resident council regarding their concerns.

Based on record reviews, observation, and interviews, the facility failed to: 1. ensure medications were available for use for 1 (Resident #16) of 3 (Resident #16, Resident #51, and Resident #80) sampled residents reviewed for pharmacy services; and, 2. maintain an accurate count of the disposition of controlled medications for 5 (Resident #51, Resident #54, Resident #72, Resident #73, and Resident #115) of 5 (Resident #51, Resident #54, Resident #72, Resident #73, and Resident #115) sampled residents who received controlled medications from Medication Cart a. Findings: 1. Resident #16 Review of Resident #16's January 2025 physician's orders revealed, in part, Resident #16 had an order for Systane Balance Ophthalmic Solution (a medication used for dry eye) 1 drop in both eyes 4 times a day. Observation on 01/07/2025 at 9:05 a.m. revealed S8Agency Licensed Practical Nurse (LPN) did not administer Resident #16 her Systane Balance Ophthalmic Solution. In an interview on 01/06/2025 at 11:54 a.m., S8Agency LPN confirmed she did not administer Resident #16 her Systane Balance Ophthalmic solution. S8Agency LPN, further indicated Resident #16's Systane Balance Ophthalmic Solution was unavailable because it was on back order. In an interview on 01/06/2025 at 12:30 p.m., S3Assistant Director of Nursing indicated Resident #16's doctor should have been notified about her eye drops being on backorder so that a similar eye drop could have been ordered. 2. Review of the facility's undated policy titled Narcotics Policy and Procedure revealed, in part, the total of each drug found in the controlled substance drawer shall be listed on the narcotic count sheet. On 01/07/2025 at 1:40 p.m. a reconciliation was completed of the controlled substances on Medication Cart a and the controlled substance binder for Medication Cart a and revealed, in part, the following: Resident#51 Review of Resident #51's medication card for Alprazolam (a medication used to treat anxiety) 0.5 milligram (mg) revealed 36 pills remained on the medication card. Review of Resident #51's controlled medication administration record for Alprazolam 0.5mg revealed 37 pills remained on the medication card. Resident #54 Review of Resident #54's medication card for Tramadol (a medication used to treat pain) 50mg revealed 46 pills remained on the medication card. Review of Resident #54's controlled medication administration record for Tramadol 50mg revealed 47 pills remained on the medication card. Resident #72 Review of Resident #72's medication card for Clonazepam (a medication used to treat anxiety) 0.5mg revealed 17 pills remained on the medication card. Review of Resident #72's controlled medication administration record for Clonazepam 0.5mg revealed 18 pills remained on the medication card. Further review revealed Resident #72's medication card for Oxycodone/APAP Tablet (a medication used for pain) 7.5-325 revealed 30 pills remained on the medication card. Review of Resident #72's controlled medication administration record for Oxycodone/APAP Tablet 7.5-325 revealed 31 pills remained on the medication card. Resident #73 Review of Resident #73's medication card for Tramadol (a medication used to treat pain) 50mg revealed 54 pills remained on the medication card. Review of Resident #73's controlled medication administration record for Tramadol 50mg revealed 53 pills remained on the medication card. Resident #115 Review of Resident #115's medication card for Lorazepam (a medication used to treat anxiety) 0.5mg revealed 36 pills remained on the medication card. Review of Resident #115's controlled medication administration record for Lorazepam 0.5mg revealed 37 pills remained on the medication card. In an interview on 01/07/2025 at 1:40 p.m., S8Agency Licensed Practical Nurse (LPN) confirmed the above documented medications available on the medication cards did not match the count documented on the controlled medication administration record. In an interview on 01/07/2025 at 1:45 p.m., S1Director of Nursing (DON) indicated the number of pills available on the medication card and the number of pills documented on the controlled medication administration record should be the same. 45877

Based on record reviews, observations, and interviews, the facility failed to ensure the medication error rate was not greater than 5% by having a medication 12.9% for 1 (Resident #16) of 3 (Resident #16, Resident #51, and Resident #80) sampled residents observed during medication administration. Findings: Review of the facility's undated Medication Pass Administration Policy and Procedure revealed, in part, medications shall be administered as ordered by the physician. Review of Resident #16's January 2025 physician's orders revealed, in part, Resident #16 had the following orders: Tolterodine Tartrate ER (a medication used for blood pressure) 2 milligrams (mg) give 1 capsule by mouth daily; Fetzima Capsule Extended Release 24 hour (a medication used for depression) 20 mg give 1 capsule by mouth with 40 mg capsule to equal 60 mg daily; Fetzima Capsule Extended Release 24 hour 40 mg give 1 capsule by mouth with 20 mg capsule to equal 60 mg daily; Systane Balance Ophthalmic Solution (a medication used for dry eye) 1 drop in both eyes 4 times a day; and, May crush medications except for enteric coated/time released medications Observation on 01/07/2025 at 8:59 a.m. revealed S8Agency Licensed Practical Nurse (LPN) opened 2 Fetzima Capsules and 1 Tolterodine Capsule and placed the medication inside of the capsules on top of pudding. S8Agency LPN then administered the medication with the pudding to Resident #16. Observation on 01/07/2025 at 9:05 a.m. revealed Resident #16 did not have her Systane Balance Ophthalmic Solution administered to her. In an interview on 01/06/2025 at 11:54 a.m., S8Agency LPN confirmed she opened Resident #16's Tolterodine Capsules and Fetzima Capsules and placed the medication that was inside the capsules on top of the pudding, and administered it to Resident #16. S8Agency LPN further indicated she did not know if the medications Tolterodine Capsule and Fetzima Capsule could be opened or not. S8Agency LPN, further indicated Resident #16's Systane Balance Opthalmic Solution was on back order; therefore, she unable to administer the eye drops to Resident #16. In an interview on 01/06/2025 at 12:14 p.m., a Pharmacist, working at the pharmacy that fills Resident #16's medications, indicated Tolterodine and Fetzima capsules should not be opened, and should be taken whole. There were 31 medication administration opportunities for error, with 4 observed errors for a medication administration error rate of 12.9%. In an interview on 01/07/2025 at 11:03 a.m., S2Director of Nursing confirmed the medication error rate should not have been over 5%. In an interview on 01/06/2025 at 12:30 p.m., S3Assistant Director of Nursing indicated Resident #16's doctor should have been notified about her eye drops being on backorder.

Based on interviews and record reviews, the facility failed to ensure a resident's physician was immediately notified of a resident's ear pain and drainage for 1 (Resident #43) of 3 (Resident #29, Resident #43, and Resident #79) residents investigated for pain. Findings: Review of Resident #43's record revealed, in part, Resident #43 was admitted to the facility on [DATE] with a diagnosis of otitis media (ear infection) of the right ear. Review of Resident #43's Minimum Data Set with an Assessment Reference Date of 10/07/2024 revealed Resident #43 had a Brief Interview Mental Status Score of 15 which indicated he was cognitively intact. In an interview on 01/06/2025 at 2:46 p.m., Resident #43 indicated he reported right ear pain and drainage to the nurse last week, but nothing has been done. In an interview on 01/07/2025 at 10:05 a.m., Resident #43 indicated he had not been seen by a physician, and had not received any information about his right ear complaints. In a telephone interview 01/07/2025 at 2:02 p.m., S16Licensed Practical Nurse (LPN) indicated Resident #43 complained to her of right ear pain and drainage over the weekend. S16LPN further confirmed that she did note minimal drainage to Resident #43's right ear. S16LPN further indicated she should have notified the doctor about Resident #43's ear, and should have. In an interview on 01/07/2025 at 2:05 p.m., S2Director of Nursing indicated if S16LPN felt like she should have notified the doctor, then she should have notified the doctor.

Based on record reviews, and interviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 1 (Resident #112) of 1 (Resident #112) sampled residents investigated for abuse. Findings: Review of the facility's undated policy titled Abuse Prevention and Prohibition revealed, in part, each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse is defined as the willful infliction of injury with resulting physical harm, pain, or mental anguish. Resident abuse may include resident to resident abuse. Physical abuse may include an aggressive act, including inappropriate physical contact that is harmful or likely to cause injury or harm to a resident. Examples include hitting, slapping, pinching, biting, shoving, and kicking. Review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 revealed, in part, a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. Review of Resident #112's nurse's notes dated 11/28/2024 at 8:33 a.m. revealed, in part, Resident #112 walked to the dining room doorway. Resident #24 was standing at the dining room doorway and hit Resident #112 in the back of the head. Staff asked Resident #24 why he hit Resident #112 in the head, and he stated he could hit whoever he wanted. Review of Resident #112's nurse's notes dated 01/04/2025 at 8:45 a.m. revealed, in part, Resident #112 was involved in a physical altercation with Resident #174. Resident #112 was in the hallway when Resident #174 started the physical altercation. Resident #112 was in the corner and screamed for help. S7Certified Nursing Assistant (CNA) separated Resident #112 and Resident #174. Resident #112's lip was swollen and bleeding. In a telephone interview on 01/06/2025 at 11:32 a.m., S7CNA indicated she heard Resident #112 scream for help. S7CNA further indicated she observed Resident #112 and Resident #174 in the hallway and Resident #174 had pushed Resident #112 against the wall. S7CNA indicated Resident #112 was observed with blood on her lips. In a telephone interview on 01/06/2025 at 11:53 a.m., S6LPN indicated on 01/04/2025 she heard Resident #112 scream for help. S6LPN indicated Resident #112 and Resident #174 had to be separated. S6LPN further indicated Resident #112 had blood on her lips. In an interview on 01/06/2025 at 12:15 p.m., S2Director of Nursing (DON) confirmed she was aware of the above documented incidents. In an interview on 01/06/2025 at 12:25 p.m., S1Administrator indicated the above documented incidents were resident to resident abuse.

Based on interviews and record reviews, the facility failed to ensure allegations of physical abuse were reported to the Statewide Incident Management System (SIMS) for resident to resident physical abuse for 1 (Resident #112) of 1 (Resident #112) sampled residents investigated for abuse. Findings: Review of the facility's undated policy titled Abuse Prevention and Prohibition revealed, in part, an alleged violation of abuse will be reported immediately, but not later then, 2 hours if the alleged violation involved abuse or resulted in serious bodily injury or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility administrator or designee shall report or cause a report to be made to the mandated stated agency per reporting criteria within guidelines of notification of an alleged abuse. Administrator or designee will have 5 working days from the initial report of abuse to complete SIMS reporting according to DHH guidelines. Review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2024 revealed, in part, a Brief Interview for Mental Status score of 11, which indicated moderate cognitive impairment. Review of Resident #112's nurse's notes dated 11/28/2024 at 8:33 a.m. revealed, in part, Resident #112 walked to the dining room doorway. Resident #24 was standing at the dining room doorway and hit Resident #112 in the back of the head. Staff asked Resident #24 why he hit Resident #112 in the head, and he stated he could hit whoever he wanted. Review of Resident #112's nurse's notes dated 01/04/2025 at 8:45 a.m. revealed, in part, Resident #112 was involved in a physical altercation with Resident #174. Resident #112 was in the hallway when Resident #174 started the physical altercation. Resident #112 was in the corner and screamed for help. S7Certified Nursing Assistant (CNA) separated Resident #112 and Resident #174. Resident #112's lip was swollen and bleeding. In a telephone interview on 01/06/2025 at 11:32 a.m., S7CNA indicated she heard Resident #112 scream for help. S7CNA further indicated she observed Resident #112 and Resident #174 in the hallway and Resident #174 had pushed Resident #112 against the wall. S7CNA indicated Resident #112 was observed with blood on her lips. In a telephone interview on 01/06/2025 at 11:53 a.m., S6LPN indicated on 01/04/2025 she heard Resident #112 scream for help. S6LPN indicated Resident #112 and Resident #174 had to be separated. S6LPN further indicated Resident #112 had blood on her lips. In an interview on 01/06/2025 at 12:25 p.m., S1Administrator indicated the above documented incidents were resident to resident abuse. S1Administrator further indicated the incidents were not reported to the SIMS system, and should have been.

Based on record reviews, observations, and interviews, the facility failed to administer a resident's oxygen per physician's orders for 1 (Resident #69) of 1 (Resident #69) sampled residents investigated for respiratory care. Findings: Review of the facility's undated policy titled oxygen administration policy and procedure revealed, in part, check physician's order for liter flow and method of administration. Review of Resident #69's January 2025 Physician's Orders revealed, in part, an order for oxygen 2 liters per minute (lpm) per nasal cannula (nc). Review of Resident #69's care plan revealed, in part, oxygen to be administered per physician orders. Observation on 01/05/2025 at 11:05 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. Observation on 01/06/2025 at 10:00 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. Observation on 01/07/2025 at 9:10 a.m. revealed Resident #69 received oxygen at 3lpm per nc via an oxygen concentrator. In an interview on 01/07/2025 at 10:38 a.m., S4Licensed Practical Nurse (LPN) confirmed Resident #69's physician order was for oxygen to be administered at 2lpm per nc via an oxygen concentrator, but it was delivered at 3lpm per nc via an oxygen concentrator. In an interview on 01/07/2025 at 10:43 a.m., S2Director of Nursing (DON) indicated Resident #69's oxygen should have been administered at 2lpm per nc via an oxygen concentrator as ordered by the physician.

Based on interview and record review, the facility failed to fully assess a resident's pain for 1 (Resident #43) of 3 (Resident #29, Resident #42, and Resident #79) sampled residents investigated for pain. Findings: Review of the facility's undated Pain Management Policy and Procedure revealed in part, the nurse was to document in the clinical record the reason for pain, characteristics of pain, and pain management effectiveness. Review of Resident #43's record revealed he was admitted to the facility on [DATE] with a diagnosis of otitis media (ear infection) of the right ear. Review of Resident #43's Minimum Data Set with an Assessment Reference Date of 10/07/2024 revealed Resident #43 had a Brief Interview Mental Status Score of 15 which indicated he was cognitively intact. Review of Resident #43's Comprehensive Care Plan revealed he had a history of pain with a goal to verbalize decrease frequency/intensity of pain. Further review revealed an intervention to watch Resident #43 for worsening of pain and report symptoms to the physician. Review of Resident #43's January 2025, Physician's orders revealed, in part, an order for Tylenol (a medication used for pain) Oral Tablet 325 milligrams (Acetaminophen) Give 2 tablets by mouth every 4 hours as needed for sinus headache or general discomfort. Review of Resident #43's Electronic Medical Record revealed, in part, Tylenol was given at the following times: 01/01/2025 at 9:19 a.m. for a pain rating of 6 with no documented evidence and the facility did not present any documented evidence for the reason for pain or characteristic of pain; 01/02/2025 at 8:13 a.m. for a pain rating of 8 with no documented evidence and the facility did not present any documented evidence of the reason for pain or characteristic of pain; 01/05/2025 at 7:35 p.m. for a pain rating of 8 for right side pain/earache; and, 01/06/2025 at 7:58 a.m. for a pain rating of 8 with no documented evidence and the facility did not present any documented evidence of the reason for pain or characteristic of pain. In an interview on 01/06/2025 at 2:46 p.m., Resident #43 indicated he reported right ear pain and drainage to the nurse last week but nothing had been done. In an interview on 01/07/2025 at 10:05 a.m., Resident #43 indicated he still has not had a doctor come assess him or hear about any treatments for his complaints of right ear pain with drainage. In a telephone interview 01/07/2025 at 02:02 p.m., S16Licensed Practical Nurse (LPN) indicated Resident #43 complained of right ear pain and drainage to her over the weekend. S16LPN further confirmed that she did note minimal drainage to Resident #43's right ear. In an interview on 01/07/2025 at 2:05 p.m., S2Director of Nursing could offer no explanation as to why staff had not assessed resident's ear pain and ear drainage, and why staff had not followed the facility's pain management policy and procedures as required.

Based on observations and interview, the facility failed to ensure posted staffing information was accurate and/or current for 4 of 4 days of posted staffing information reviewed. Findings: Observation on 01/05/2025 at 8:50 a.m. revealed Staffing Disclosure Logs dated 01/04/2025, 01/05/2025, and 01/06/2025. Further observation revealed the Staffing Disclosure Logs did not have the facility name and/or the facility census. Observation on 01/07/2025 at 9:05 a.m. revealed the Staffing Disclosure Log dated 01/07/2025 did not include the facility name and/or the facility census. In an interview on 01/07/2025 at 12:13 p.m., S2Director of Nursing (DON) indicated the facility's name and daily census should have been documented on the posted Daily Staffing Disclosure Logs for 01/04/2025, 01/05/2025, 01/06/2025, and 01/07/2025.

Based on record reviews and interviews, the facility failed to implement an effective discharge planning process for a resident who left the facility against medical advice for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for discharge planning. Findings: Review of the facility's form entitled, Leaving Skilled Nursing Facility Against Medical Advice dated 09/13/2024 revealed, in part, the following: I (Resident #1) am voluntarily leaving the nursing home against the advice of S5physican and a representative of the nursing home administration. I have been told by the physician of the risks and consequences involved with leaving the nursing home at this time, the benefits of continued treatment and care, and the alternatives, if any, to continued treatment and care, and the alternatives, if any, to continued treatment and nursing home placement. Resident #1 was his own responsible party. Further review revealed Resident #1 was discharged from the facility on 09/13/2024. Review of Resident #1's diagnoses revealed, in part, Resident #1 had chronic kidney disease, paralysis, had weakness on one side of his body following a stroke, and was receiving dialysis. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed, in part, revealed his cognition was moderately impaired, had renal insufficiency, renal failure, or end-stage renal disease, and had limited range of motion with an impairment to both sides of his upper extremities and impairment to one side of his lower extremity. Further review revealed Resident #1used a manual wheel chair, required partial to moderate staff assistance with toileting, showering, bathing, upper body dressing, and personal hygiene. Resident #1 also required substantial to maximal staff assistance with lower body dressing, putting on and taking off footwear. Review of Resident #1's progress notes, revealed in part, the following: - On 09/13/2024 at 5:04 p.m. Resident #1 was discharged from the facility today on 09/13/2024 at 3:42 p.m. per S3SocialServices; and, - On 09/13/2024 at 3:42 p.m. Resident #1 signed out AMA (Against Medical Advice) with medication in stable condition. There was no documented evidence and the faciity did not present any documented evidence Resident #1 was informed of the implications and/or risks of being discharged to a location that was not equipped to meet Resident #1's needs, attempted to ascertain why Resident #1 was chose that location, documented that other, more suitable, options of locations were equipped to meet the needs of Resident #1 were presented and/or discussed, and that despite being offered other options that could meet Resident #1's needs, Resident #1 refused those other more appropriate settings. In an interview on 10/14/2024 at 12:10 p.m. S3Social Services (SS) indicated Resident #1 was discharged to an apartment on 09/13/2024 since he went AMA. S3SS indicated S1Administrator, S6Assistant Director, and herself were involved in the discharge of Resident #1. S3SS indicated Resident #1 had urgent medical needs due to being on dialysis, and needed assistance with walking and activities of daily living such as using the bathroom. S3SS further indicated she could not set up outside transportation services for Resident #1 to be picked up at his apartment to be transported to dialysis because of it being too early in the morning for the transportation company. In an interview on 10/14/2024 at 2:45 p.m., S7Licensed Practical Nurse (LPN) indicated Resident #1 had weakness on one side of his body, needed help to transfer from a wheelchair to bedside commode, was unable to walk, and required assistance with all activities of daily living and could not walk. S7LPN further indicated the place that he was discharged to was not equipped to tend to his needs In an interview on 10/16/2024 at 10:35 a.m., S6Assistant Director of Nursing indicated she had no documentation to present to dispute the above findings. There was no documented evidence, and the facility did not present any documented evidence, that the facility documented Resident #1 was being discharged to a location that was not equipped to meet his needs, and attempts were being made to ascertain why Resident #1 chose that location. There was no documented evidence, and the facility did not present any documented evidence, that other, more suitable, options of locations equipped to meet Resident #1's needs were presented and discussed, and that despite being offered other options that could meet the resident's needs, Resident #1 refused those other more appropriate settings. In an interview on 10/16/2024 at 10:39 a.m., S2Director of Nursing (DON) indicated she had nothing to present to dispute the above findings other than the documentation to show that Resident #1 left the facility against medical advice (AMA) and had signed the AMA form. In an interview on 10/16/2024 at 12:30pm, S1Administrator indicated the facility did not implement and/or complete the required documentation related to Resident #1 leaving the facility AMA.

Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in condition to the resident's physician and responsible party in a timely manner for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation on 07/12/2024 at 6:08 p.m. for Resident #1, when Resident #1 was unable to adequately eat or drink and Resident #1's physician and responsible party were not notified. This deficient practice continued on 07/13/2024 when Resident #1 was unable to adequately eat or drink and Resident #1's responsible party was not notified. On 07/14/2024, Resident #1 was observed to be lethargic with what was described as involuntary jerky movements and was sent to the emergency room for treatment. Resident #1 was hospitalized in critical condition and diagnosed with severe dehydration, severe hypernatremia [Sodium (Na) 168], moderate acute renal failure [Blood Urea Nitrogen (BUN) 104 and Creatinine 3.2), and metabolic encephalopathy. S1Administrator was notified of the Immediate Jeopardy on 08/08/2024 at 3:10 p.m. The Immediate Jeopardy was removed on 08/09/2024 at 3:04 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to any of the residents residing in the facility who could have a significant change in condition. Findings: Review of the facility's undated Change in Condition Policy and Procedure revealed, in part, the purpose of the policy was to ensure that people involved in the resident's care were made aware of any changes to the resident. Further review revealed the staff were to ensure the people involved in the resident's care, including the physician, responsible family members or legal representatives, were made aware of any changes to the resident. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 07/05/2024 revealed, in part, Resident #1 was admitted to the facility on [DATE]; and had a diagnosis of Alzheimer's Disease, malnutrition, and muscle wasting and atrophy to the right arm. Further review revealed Resident #1 was rarely or never understood and dependent on staff for eating. Review of Resident #1's Weight Note dated 04/10/2024 revealed, in part, Resident #1 had a weight loss of 10.7% over 3 months. Further review revealed the Registered Dietitian recommended Twocal (nutritional supplement) 2 ounces twice a day for 60 days. Review of Resident #1's record revealed, in part, no documented evidence and the facility did not present any documented evidence Resident #1's physician was notified of the Registered Dietitian's recommendation on 04/14/2024 for Twocal 2 ounces twice daily for 60 days. In an interview on 08/07/2024 at 2:00 p.m., S4Quality Improvement (QI) Nurse confirmed she did not notify Resident #1's physician of the above mentioned recommendation and should have. Review of Resident #1's Nurse's Note dated 07/12/2024 revealed, in part, Resident #1 had possible dental issues and would not chew his food for lunch and dinner. In an interview on 08/07/2024 at 3:55 p.m., S5LPN indicated she was responsible for Resident #1 on the day shift on 07/12/2024. S5LPN indicated the nursing staff had difficulty getting Resident #1 to eat lunch and dinner. S5LPN indicated Resident #1 was nonverbal and unable to communicate his wants and needs to staff. S5LPN indicated she did not feel it was necessary to notify Resident #1's physician or responsible party that he had not eaten well on 07/12/2024. Review of Resident #1's Nurse's Note dated 07/13/2024 revealed, in part, Resident #1 was found holding food in his mouth and the food and fluids dripped out of the sides of his mouth. Further review revealed no documented evidence and the facility did not present any documented evidence Resident #1's responsible party was notified of Resident #1's decline in oral intake. In an interview on 08/07/2024 at 12:49 p.m., S8LPN indicated on the morning of 07/13/2024 she received report from S9LPN who indicated Resident #1 had not been eating well. S8LPN confirmed on 07/13/2024 Resident #1 continued with poor oral intake and was letting food and fluids drip out of the sides his mouth. S8LPN indicated she could not recall notifying Resident #1's responsible party of his change in condition. Review of Resident #1's Nurse's Note dated 07/14/2024 revealed, in part, Resident #1 was found lethargic with involuntary jerking movements. Resident #1's physician was notified and he was sent to the hospital for evaluation. Review of the Resident #1's hospital records dated 07/14/2024 through 07/21/2024 revealed, in part, Resident #1 was treated for severe dehydration, hypernatremia, moderate acute renal failure, and metabolic encephalopathy. Further review revealed Resident #1 had laboratory testing completed on 07/14/2024 which indicated Resident #1's sodium level (used to monitor conditions that affect fluid and electrolyte balance) was 168 mEq (normal range 136 - 145 milliequivalents), blood urea nitrogen (BUN) [a test used to determine kidney function] level of 104 mg/dL (normal range 7 - 18 milligrams per deciliter), and Creatinine 3.2 mg/dL (normal 0.7 - 1.3 milligrams per deciliter). Further review revealed Resident #1's weight was 144.6 pounds, which was a difference of 41 pounds compared to Resident #1's last documented weight by the facility on 07/02/2024. In an interview on 08/06/2024 at 4:41 p.m., Resident #1's daughter/responsible party indicated she had not been notified by the facility of Resident #1's decline in oral intake on 07/12/2024 or 07/13/2024. Resident #1's daughter/responsible party indicated had she been made aware on 07/12/2024 and 07/13/2024 she would have gone to the facility to check on her father and she could have ensured that his needs were addressed. In an interview on 08/08/2024 at 2:03 p.m., Resident #1's physician indicated he had not been notified by the facility on 07/12/2024 of Resident #1's decline in oral intake. In an interview on 08/08/2024 at 4:39 p.m., S3Prior Director of Nursing (DON) indicated Resident #1 had a very good appetite and required double portions due to a history of taking food from other people's plates. S3Prior DON indicated if Resident #1 was not able or willing to eat this would be a significant change Resident #1 and the nursing staff should have immediately notified the physician and the responsible party. In an interview on 08/09/2024 at 12:19 p.m., S2DON confirmed the nursing staff did not notify Resident #1's physician and responsible party timely on 07/12/2024 and/or 07/13/2024 of Resident #1's decline in oral intake and confirmed this resulted in an immediate jeopardy situation. In an interview on 08/09/2024 at 12:19 p.m., S1Administrator confirmed the nursing staff did not notify Resident #1's physician and responsible party timely on 07/12/2024 and/or 7/13/2024 of Resident #1's decline in oral intake and confirmed this resulted in an immediate jeopardy situation.

Based on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status/electrolyte balance for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) reviewed for nutritional status as evidence by: 1. Failing to ensure staff followed-up on and/or implemented a dietitian's recommendation (Resident #1); and, 2. Failing to ensure staff assisted a resident with maintaining their food and/or fluid intake to suit their dietary needs (Resident #1). This deficient practice resulted in an Immediate Jeopardy situation on 07/12/2024 at 6:08 p.m. for Resident #1 when Resident #1 was unable to adequately eat or drink and no adjustments were made to suit Resident #1's dietary needs. On 07/14/2024 Resident #1 was observed to be lethargic with involuntary jerky movements and was sent to the emergency room for treatment. Resident #1 was hospitalized in critical condition and diagnosed with severe dehydration, severe hypernatremia [Sodium (Na) 168), moderate acute renal failure [Blood Urea Nitrogen (BUN) 104 and Creatinine 3.2], and metabolic encephalopathy. Resident #1 was noted to have a 41.4 pound weight loss from 07/02/2024, which was the last documented weight in the facility, compared to the weight collected in the emergency roiagnom on [DATE]. S1Administrator was notified of the Immediate Jeopardy on 08/08/2024 at 3:10 p.m. The Immediate Jeopardy was removed on 08/09/2024 at 3:04 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to any of the residents residing in the facility who can have unintended weight loss or poor food and/or fluid intake. Findings: Review of the facility's undated policy titled, Weight Evaluation Policy and Procedure revealed, in part, the Director of Nursing (DON)/designee would review the resident's weights weekly, monthly, and as needed. Further review revealed residents who have had a 5% loss in less than 31 days, 7.5% weight loss in less than 91 days, and/or 10% loss in less than 181 days would be weighed weekly for 4 weeks until stable, unless prescribed by the physician. Further review revealed DON/designee will address weight loss with recommendations in residents chart. Review of Resident #1's Minimum Data Set with an Assessment Reference Date of 07/05/2024 revealed, in part, Resident #1 was admitted to the facility on [DATE]; and had a diagnosis of Alzheimer's Disease, Type 2 Diabetes, malnutrition, and muscle wasting and atrophy to the right upper arm. Further review revealed Resident #1 was rarely or never understood and dependent on staff for eating. Review of Resident #1's Physician Orders dated July 2024 revealed, in part, Resident #1 had an order for a regular diet with double portions for all meals with a start date of 01/25/2024. Review of Resident #1's Care Plan revealed, in part, Resident #1 required staff assistance with feeding related to dementia. Review of Resident #1's Weights and Vitals Summary from 01/16/2024 through 07/02/2024 revealed, in part, Resident #1 had the following weights: On 01/16/2024 196.0 pounds; On 04/09/2024 175.0 pounds; and, On 07/02/2024 186.0 pounds. Further review revealed no documented evidence and the facility did not present any documented evidence of any weights being obtained on Resident #1 after 07/02/2024. Review of the facility's Weights and Vitals Exceptions documentation for Resident #1 for the time period of 01/01/2024 through 08/01/2024 revealed, in part, on 04/09/2024 Resident #1 had a 10.7% weight loss (comparison weight 01/16/2024). Review of Resident #1's Weight Note dated 04/10/2024 revealed, in part, Resident #1 had a weight loss of 10.7% over 3 months. Further review revealed the Registered Dietitian recommended Twocal (nutritional supplement) 2 ounces twice a day for 60 days. Review of Resident #1's record revealed, in part, no documented evidence and the facility did not present any documented evidence Resident #1's physician was notified of the Registered Dietitian's recommendation for Twocal 2 ounces twice daily for 60 days. In an interview on 08/07/2024 at 2:00 p.m., S4Quality Improvement (QI) Nurse indicated she was responsible for notifying the physician of any significant weight changes and recommendations made by the Registered Dietitian. S4QI Nurse further indicated she was not aware of the Registered Dietitian's recommendation for Resident #1 to receive Twocal 2 ounces twice daily for 60 days by staff. S4QI Nurse confirmed she did not notify Resident #1's physician of the above mentioned recommendation and should have. Review of Resident #1's Activities of Daily Living (ADL) documentation for eating for July 2024 revealed, in part, on 07/12/2024 Resident #1 was dependent on staff for assistance with all meals and fluid intake. Further review revealed staff documented at 8:00 a.m. Resident #1 ate 76%-100% of his meal, at 12:00 p.m. Resident #1 ate 51%-75% of his meal, and at 5:00 p.m. Resident ate 0-25% of his meal. Further review revealed on 07/13/2024 staff documented at 8:00 a.m. Resident #1 ate 26 %- 50% of his meal, at 12:00 p.m. Resident #1 ate 0-25% of his meal, and at 5:00 p.m. Resident #1 refused his meal. Review of Resident #1's Nurse's Note dated 07/12/2024 revealed, in part, Resident #1 would not chew his food for lunch and dinner. In an interview on 08/07/2024 at 3:55 p.m., S5LPN indicated she was responsible for Resident #1 on the day shift on 07/12/2024. S5LPN indicated the nursing staff had difficulty getting Resident #1 to eat lunch and dinner. S5LPN indicated Resident #1 was nonverbal and unable to communicate his wants and needs to staff. S5LPN indicated she did not feel it was necessary to notify Resident #1's physician or responsible party that he had not eaten well on 07/12/2024. Review of Resident #1's Nurse's Note dated 07/13/2024 revealed, in part, Resident #1 was found holding food in his mouth and the food and fluids dripped out of the sides of his mouth. Review of Resident #1's nurse note dated 07/14/2024 revealed, in part, Resident #1 was found lethargic with involuntary jerking movements. Review of Resident #1's hospital records dated 07/14/2024 through 07/21/2024 revealed, in part, Resident #1 was treated for severe dehydration, hypernatremia, moderate acute renal failure, and metabolic encephalopathy. Further review revealed Resident #1 had laboratory testing completed on 07/14/2024 which indicated Resident #1's sodium level (used to monitor conditions that affects fluid and electrolyte balance) was 168 mEq (normal range 136 - 145 milliequivalents), BUN (a test used to determine kidney function) level of 104 mg/dL (normal range 7 - 18 milligrams per deciliter), and Creatinine 3.2 mg/dL (normal range 0.7 - 1.3). Further review revealed Resident #1's weight was 144.6 pounds. In an interview on 08/08/2024 at 2:03 p.m., Resident #1's physician confirmed he was not notified of the Registered Dietitians 04/14/2024 recommendation of Twocal 2 ounces twice daily for 60 days. Resident #1's physician further indicated Resident #1 was severely dehydrated when he was hospitalized on [DATE]. Resident #1's physician further indicated Resident #1's level of dehydration was so severe Resident #1 had to have very poor oral intake for a minimum of a week, and the level of Resident #1's dehydration did not happen in 3 days. In an interview on 08/08/2024 at 4:39 p.m., S3Prior Director of Nursing (DON) indicated Resident #1 had a very good appetite and required double portions due to a history of taking food from other people's plates. S3Prior DON indicated if Resident #1 became unable or unwilling to eat, then this would have been a significant change for him, and the nursing staff should have immediately notified the physician.

Based on interviews and record reviews the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure staff communicated a resident's change in condition in a timely manner to the physician and responsible party for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for notification of change; 2. Ensure staff followed-up on and/or implemented a dietician's recommendation for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for nutritional status; and, 3. Ensure staff assisted a resident with maintaining their food and/or fluid intake to suit their dietary needs for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for nutritional status. This deficient practice resulted in an Immediate Jeopardy situation on 07/12/2024 at 6:08 p.m. for Resident #1, when Resident #1 was unable to adequately eat and/or drink. Resident #1's physician and responsible party were not notified of Resident #1's decline in oral intake in a timely manner as required, a dietitian's recommendation, and/or assisted Resident #1 with his food and/or fluid intake to suit their dietary needs. On 07/14/2024, Resident #1 was observed to be lethargic with involuntary jerky movements and was sent to the emergency room for treatment. Resident #1 was hospitalized in critical condition and diagnosed with severe dehydration, severe hypernatremia [Sodium (Na) 168 moderate acute renal failure [Blood Urea Nitrogen (BUN) 104 and Creatinine 3.2], and metabolic encephalopathy. Resident #1 was noted to have a 41.4 pound weight loss from 07/02/2024, which was the last documented weight in the facility, compared to the weight collected in the emergency roiagnom on [DATE]. S1Administrator was notified of the Immediate Jeopardy on 08/08/2024 at 3:10 p.m. The Immediate Jeopardy was removed on 08/09/2024 at 3:04 p.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to any of the residents residing in the facility who could have unintended weight loss, poor food/fluid intake, required dietician recommendations, and/or a significant change in condition. Findings: Cross Reference F580 and F692. In an interview on 08/07/2024 at 3:55 p.m., S5LPN indicated she was responsible for Resident #1 on the day shift on 07/12/2024. S5LPN indicated the nursing staff had difficulty getting Resident #1 to eat lunch and dinner. S5LPN indicated Resident #1 was nonverbal and unable to communicate his wants and needs to staff. S5LPN indicated she did not feel it was necessary to notify Resident #1's physician or responsible party that he had not eaten well on 07/12/2024. In an interview on 08/06/2024 at 4:41 p.m., Resident #1's daughter/responsible party indicated she had not been notified by the facility of Resident #1's decline in oral intake on 07/12/2024 or 07/13/2024. Resident #1's daughter/responsible party indicated had she been made aware on 07/12/2024 and 07/13/2024 she would have gone to the facility to check on her father and she could have ensured that his needs were addressed. In an interview on 08/07/2024 at 2:00 p.m., S4Quality Improvement (QI) Nurse indicated she was responsible for notifying the physician of any significant weight changes and recommendations made by the Registered Dietitian. S4QI Nurse further indicated she was not aware of the Registered Dietitian's recommendation for Resident #1 to receive Twocal 2 ounces twice daily for 60 days by staff. S4QI Nurse confirmed she did not notify Resident #1's physician of the above mentioned recommendation and should have. In an interview on 08/08/2024 at 2:03 p.m., Resident #1's physician confirmed he was not notified of the Registered Dietitian's recommendation on 04/14/2024 of Twocal 2 ounces twice daily for 60 days. Resident #1's physician further indicated Resident #1 was severely dehydrated when he was hospitalized on [DATE]. Resident #1's physician further indicated Resident #1's level of dehydration was so severe Resident #1 had to have very poor oral intake for a minimum of a week, and the level of Resident #1's dehydration did not happen in 3 days. In an interview on 08/08/2024 at 4:39 p.m., S3Prior Director of Nursing (DON) stated Resident #1 had a very good appetite and required double portions due to a history of taking food from other peoples plates. S3Prior DON indicated if Resident #1 became unable or unwilling to eat, then this would have been a significant change for him, and the nursing staff should have immediately notified the physician. In an interview on 08/09/2024 at 12:19 p.m., S2DON confirmed the nursing staff did not notify Resident #1's physician and responsible party timely on 07/12/2024 and/or 07/13/2024 of Resident #1's decline in oral intake, and confirmed this resulted in an immediate jeopardy situation. In an interview on 08/09/2024 at 12:19 p.m., S1Administrator confirmed the nursing staff did not notify #1's physician and responsible party timely on 07/12/2024 and/or 7/13/2024 of Resident #1's decline in oral intake and confirmed this resulted in an immediate jeopardy situation.

Based on interviews and record reviews, the facility failed to ensure 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents reviewed for falls were free from accident hazards by staff failing to implement safe transfer techniques to reduce the risk of a fall. This deficient practice resulted in an actual harm for Resident #1 on 10/09/2021, when Resident #1 fell on the floor while being transferred from the wheelchair to the resident's bed by the Certified Nursing Assistant (CNA) staff. After the CNA staff picked Resident #1 up off the floor and placed the resident in bed, the CNA staff heard the resident saying Ouch. On 10/10/2021, the CNA staff observed Resident #1's right leg to be swollen and flinching in pain while care was being provided. On 10/11/2021, Resident #1 was crying, pointing to her right leg. Resident #1 was transferred to a local hospital on 10/11/2021 where she was diagnosed with a right femur fracture. Findings: Review of the facility's Policy and Procedure titled Incident and Accident revealed, in part, the following: 1.) Reporting of Incidents and Accidents- the incident and accident must be reported to the designated departmental supervisor; 2.) Assisting Incident and Accident victims- provide immediate assistance, do not move the victim until they have been assessed for injuries, and if assistance is needed, call for help; 3.) Medical Attention: assess all incident and accident victims, notify physician, and notify family/responsible party. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/09/2021 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. Resident #1 required extensive assistance with bed mobility, required total staff dependence (two person assist) with transfers, and had impaired mobility on one side to her upper and lower extremities bilaterally. Review of Resident #1's Care Plan, with an onset date of 05/12/2021, identified Resident #1 had an Activities of Daily Living (ADL) self-care deficit, and one approach included a two-person assistance with transfers. Resident #1 was further identified at risk for falls related to [CONDITION(S)], impaired vision, and incontinence with approaches to include wheelchair for mobility, and anticipate and meet needs. Review of Resident #1's emergency department's physician's report revealed, in part, on 10/11/2021, Resident #1 arrived to the hospital's emergency department from the facility by ambulance at 4:17pm and was seen by the physician at 4:29pm. Further review revealed Resident #1 had an injury to right leg with swelling, and the cause of injury was unknown which occurred at the facility. Further review revealed Resident #1 was experiencing moderate pain, and Resident #1 was diagnosed with a fracture to the right femur. Review of Resident #1's Radiologist report dated 10/11/2021 revealed Resident #1 found to have an acute fracture of the right distal femur. Review of Resident #1's nurse's notes revealed, in part, the following: 10/11/2021 at 9:05am-summoned to resident #1's room per CNA. The nurse arrived in the room and Resident #1 complained of right leg pain, and was crying. Upon assessment, resident #1's leg was noted to be swollen, and nurse unable to move Resident #1's right leg without her moaning. Physician was notified; 10/11/2021 at 9:45am-Phyisican ordered a portable x-ray of Resident #1's right leg, hip and knee; 10/11/2021 at 11:45am-portable x-ray to Resident #1's right leg completed; 10/11/2021 at 1:05pm-Results of Resident #1's portable x-ray to right leg revealed positive for acute [MEDICATION(S)] fracture of distal right femur; 10/11/2021 at 3:14pm-Resident #1 was sent to the hospital per physician's order for evaluation of right leg; 10/11/2021 at 3:39pm-Resident #1's Responsible Party (RP) was notified of Resident #1's complaint of pain to her right leg, and informed her that an x-ray was completed. Review of Resident #1's nurse's notes revealed nurse informed Resident #1's RP that Resident #1 was sent to the hospital for further evaluation, and; Further review of Resident #1's nurse's notes revealed there was no documented evidence regarding Resident #1's complaints of pain to staff, or pain assessment for Resident #1 on 10/10/2021. Review of S5Certfied Nursing Assistant's (CNA) Personnel Form dated 10/13/2021 revealed S5CNA was involved in an accident where a resident was injured, and S5CNA failed to report incident to appropriate staff thus causing a delay in reporting per regulations. In an interview on 12/06/2021 at 3:55pm, Resident #1 acknowledged she fell when facility's staff were assisting with transferring her on 10/09/2021, and she acknowledged she had pain to her right leg at the time of the fall. In interview on 12/06/2021 at 4:00pm, S4CNA stated Resident #1 required two-person assistance with transfers prior to the incident on 10/09/2021. In an interview on 12/06/2021 at 4:20pm, S13CNA stated Resident #1 required total assistance with transfers. In an interview on 12/07/2021 at 2:00pm, S1Administrator and S2Director of Nursing (DON) stated they could not determine how Resident #1's fall occurred on 10/09/2021 from the facility's investigation of the incident. In an interview on 12/07/2021 at 2:15pm, S2DON stated S5CNA never reported the incident to anyone on 10/09/2021, and S2DON stated the incident should have been reported to nursing staff immediately. In a telephone interview on 12/08/2021 at 12:18pm, S5CNA stated, in part, on 10/09/2021 around 6:00pm to 7:00pm she and S6Agency CNA, who S5CNA could not recall the name, went into Resident #1's room to perform peri-care. S5CNA asked S6Agency CNA for assistance to transfer Resident #1 to the bed because Resident #1 was sitting in her wheelchair. S5CNA and S6Agency CNA lifted Resident #1 from under Resident #1's arms toward the edge of the bed, and in the process of doing so Resident #1 missed the edge of the bed and fell on the floor. S5CNA stated she picked Resident #1 up from the floor and placed her back in her bed. S5CNA stated she gently moved and turned Resident #1 while in the bed in order to change Resident #1's diaper. S5CNA stated she heard Resident #1 say ouch and Resident #1 shook head in the direction of her left leg. S5CNA further stated she did not report Resident #1's fall to anyone on 10/09/2021. In a telephone interview on 12/08/2021 at 12:43pm, S6Agency CNA stated she did not provide assistance for Resident #1 on 10/09/2021. In an interview on 12/08/2021 at 10:08am, S11CNA Supervisor stated on 10/11/2021 she noticed Resident #1's right leg was turned inward when she pulled down her bed sheet cover, and Resident #1 communicated to her by pointing to her right this leg. S11CNA Supervisor stated when staff observes a resident fall then they should press the call light to call for help, ask the resident if they are okay, stay with the resident, and staff should not pick up or move the resident without notifying the nurse. S11CNA Supervisor stated Resident #1 grimaced when she touched the right leg. S11CNA Supervisor stated she reported this finding to S8Licensed Practical Nurse (LPN). In an interview on 12/08/2021 at 11:24am, S12CNA stated Resident #1 required two-person assistance with transfers, and Resident #1 could not stand on her own due to paralysis to her right side. In an interview on 12/08/2021 at 1:34pm, S7Treatment Nurse/LPN stated she was assigned to the floor providing care to residents on the evening of 10/10/2021, and S7Treatment Nurse/LPN did not recall anyone reporting that Resident #1 right leg was swollen. S7Treatment Nurse stated she would not assess the resident unless she was notified by a nurse or by any staff if there was a concern with a resident. S7Treatment Nurse/LPN stated she found out about incident involving Resident #1 on 10/11/2021. In an interview on 12/08/2021 at 1:50pm, S8LPN stated on 10/11/2021 at 9:00am she was notified by S11CNA Supervisor of Resident #1 crying and pointing to her right leg. S8LPN stated she assessed Resident #1 on 10/11/2021, and observed Resident #1's right leg to be edematous, and painful to touch. In an interview on 12/08/2021 at 2:44pm, S9Agency CNA stated she assisted S10CNA with peri-care for Resident #1 on 10/10/2021. S9Agency CNA stated Resident #1 would not open her legs for them to provide care. S9Agency CNA further stated Resident #1 flinched in pain when they touched her legs. S9Agency CNA further stated Resident #1 nodded her head up and down which indicated yes when asked if in pain. S9Agency CNA neither confirmed nor denied reporting that Resident #1 displayed signs of pain to anyone. In an interview on 12/08/2021 at 2:50pm, S10CNA stated Resident #1 was groaning and Resident #1's right leg was swollen. S10CNA stated she notified S7Treatment Nurse/LPN of this information. S10CNA stated she observed S7Treatment Nurse/LPN enter Resident #1's room to assess Resident #1's right leg for signs of [CONDITION(S)] on 10/10/2021. In an interview on 12/08/2021 at 3:15pm, S7 Treatment 10Nurse/LPN stated she assessed Resident #1's right leg was swollen with 3+ [CONDITION(S)] on 10/10/2021. S7Treatment Nurse/LPN further stated she did not notify the physician or any staff of Resident #1's condition on 10/10/2021. In an interview on 12/08/2021 at 3:36pm, S1Administrator and S2DON stated S5CNA never reported the incident to anyone on 10/09/2021, and S2DON stated the incident should have been reported to nursing staff immediately.

Based on interviews and record reviews, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the goals and preferences for 1 (Resident #2) of 5 sampled residents by: 1.) Failing to ensure a resident's pain was adequately controlled; 2.) Failing to notify the physician that pain was unrelieved by measures already prescribed; and 3.) Failing to ensure a resident did not have a decline in Activities of Daily Living (ADLs) due to pain. This deficient practice resulted in an actual harm for Resident #2 on 01/13/19, when the resident experienced continuous excruciating breakthrough pain to the lower back pain as stated in an interview with S3LPN. S3LPN did not notify the resident's doctor that the resident was having continuous breakthrough pain after her PRN (as needed) ordered medications were given. S4CNA stated the resident had an increased need for assistance with all ADLs. On 01/14/19 at 7:30 a.m., the resident's family member asked that the resident be transported via ambulance to the hospital where the resident was diagnosed with [REDACTED]. Findings: Review of the facility's policy of Interact Change in Condition regarding when to report to the Medical Doctor/Nurse Practitioner/Physician's Assistant (MD/NP/PA) revealed, in part, Immediate Notification of the Physician was required with: Any symptom, sign or apparent discomfort that is: 1.) Acute or Sudden in onset, and: a.) A marked change (ie more severe) in relation to usual symptoms and signs, or b.) Unrelieved by measures already prescribed. Review of the record revealed Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], and discharged again on 01/14/19, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 01/14/19 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. Further review revealed Resident #2 required supervision with eating; limited assistance with toilet use, personal hygiene, and locomotion off the unit; and extensive assistance with bed mobility, transfers, and dressing. Review of Resident #2's record revealed, in part, a care plan was developed, which identified Resident #2 as at risk for discomfort. Some approaches included report unrelieved or unacceptable levels of pain to the physician as needed. Further review revealed a care plan was developed which identified Resident #2 as at risk for injury related to falls. One approach included to notify the physician and family of falls or injuries as needed. Review of the nurse's notes entry dated 01/09/19 at 01:28am revealed, in part, Resident #2 was being assisted by a Certified Nursing Aide (CNA) with transfer to a wheelchair, when she slid from the bed to the floor. Resident #2 was then assisted by a nurse and a CNA to a standing position, and then to the bathroom via wheelchair. When in the bathroom, and upon standing, Resident #2's knees buckled. Resident #2 was lowered to the floor by the nurse and CNA. Resident was assessed and noted with redness to her back, and complained of pain to her back which she rated 7 of 10 on a pain scale. Resident #2 was sent, and admitted , to a local hospital for evaluation for complaint of fever and chills, and complaint of back pain. Review of the clinical record revealed Resident #2 was readmitted to the facility from the hospital with orders to monitor for pain every shift. Further review revealed a verbal order was given on 01/11/19 for [MEDICATION NAME] (a narcotic medication used to treat moderate to severe pain) 7.5mg-325mg by mouth every 4 hours as needed for pain. When Resident #2 was readmitted to the facility on [DATE] at 12:10pm, she had complaints of being in a great deal of pain, which she rated 10 of 10 on a pain scale. Upon four (4) person transfer from the stretcher to the bed, Resident #2 screamed in pain. On 01/11/19, Resident #2 refused to eat lunch, and refused to be weighed because it would hurt too much. Further review revealed Resident #2's last pain medication was at the hospital at 07:15am, and she was not provided pain medication from facility staff on 01/11/19 until 04:12pm. Review of Resident #2's (MONTH) 2019 Medication Administration Record [REDACTED] [MEDICATION NAME] 7.5-325mg give one by mouth every four (4) hours as needed for pain, start date of 01/11/19. [MEDICATION NAME] (a narcotic medication used to treat moderate to severe pain) 50mg (milligrams) one tablet every six (6) hours as needed for pain, start date of 01/12/19. Further review revealed Resident #2 received the following medications for pain: 01/11/19 - [MEDICATION NAME] 7.5-325mg at 04:12pm 01/12/19 - [MEDICATION NAME] 50mg at 03:14pm and 09:44pm [MEDICATION NAME] 7.5mg-325mg at 07:35am 01/13/19 - [MEDICATION NAME] 50mg at 07:41am and 01:48pm [MEDICATION NAME] 7.5mg-325mg at 07:34pm 01/14/19 - [MEDICATION NAME] 7.5mg-325mg at 06:52am Review of Resident #2's nurses' notes revealed, in part, the following: Entry dated 01/12/19 at 04:00pm revealed, in part, at 07:35am, Resident #2 complained of lower back pain, and PRN [MEDICATION NAME] was administered. Entry dated 01/12/19 at 06:34pm revealed Resident #2's family was concerned with her pain medications affecting her ability to urinate, and requested something else for pain. The physician ordered [MEDICATION NAME] 50mg one tablet every six (6) hours as needed for pain. The physician stated the resident could have several options to choose for pain. Entry dated 01/13/19 at 12:17am revealed, in part, medicated at 09:45pm with [MEDICATION NAME] for 7 of 10 pain scale. Entry dated 01/13/19 at 03:51pm revealed, in part, Resident #2 complained of back pain and [MEDICATION NAME] was administered. Review of Resident #2's (MONTH) 2019 MAR indicated [REDACTED]. Entry dated 01/13/19 at 11:55pm revealed, in part, Resident #2 required total care with ADLs since her return from the hospital. She was medicated with her [MEDICATION NAME] at 07:30pm. Her family member reported she hasn't had an appetite since all this started a week ago. Resident #2 voiced to me (S3LPN) I can't go on like this, I need to find me a new doctor. I reminded her that I was unable to make that happen now, due to it being midnight. Resident #2 said I will let my kids know this tomorrow. Entry dated 01/14/19 at 02:52pm revealed, in part, Resident stated I cannot take being this weak and in pain and want to go to a local hospital. At 07:30am, Resident #2's family member informed this nurse (S3LPN) that the resident wanted to go to a local hospital, and asked if I could call the doctor. The doctor was called and stated that the family could do what they wanted to do, but he would not give an order to send the resident to the hospital. Resident #2's family member was informed of the doctor's decision. Resident #2 was weak and could not sit in her wheelchair. Resident #2's family member asked this nurse to call a local ambulance service for transport. Resident #2 was transported to a local hospital for evaluation. Review of Resident #2's Health and Physical (H&P) hospital record dated 01/14/19 at 03:44pm revealed, in part, patient had complaints mostly of back pain. Family reported the patient had progressive weakness since returning to the nursing home, as well as episodes of disorientation. Her lower back pain had been worsening. She had some weakness and difficulty with coordination of her arms noted by them as well. Mood was depressed. Review of Resident #2's hospital records with an admission date of [DATE], and a discharge date of [DATE] revealed, in part, Resident #2's primary [DIAGNOSES REDACTED]. Family reported the patient had progressive weakness since returning to the nursing home as well as episodes of disorientation. Her lower back pain had been worsening. She had some weakness and difficulty with coordination of her arms noted by them as well. She was admitted to the hospitalist medicine service for evaluation of anterior Lumbar 1 fracture. She was seen in consultation by neurosurgery who felt there was no surgical intervention appropriate, and recommended a brace for a minimum of 3 months when out of bed. She had a very prolonged hospitalization due to overall generalized debility. She was very resistant to mobilizing due to discomfort. Patient was quite debilitated. She was elderly, morbidly obese, had severe [MEDICAL CONDITION] with inability to bear weight on left lower extremity due to plantar wound and Charcot deformity, now with Lumbar 1 fracture, pain. Stressed importance to patient and daughters that with continued immobility, she was at risk for being bed bound. She was high risk for continued ongoing issues and overall decline. In an interview on 05/08/19 at 3:53pm, S4Certified Nursing Aide (CNA) stated she worked the 02:00pm to 10:00pm shift with Resident #2, and prior to going to the hospital, Resident #2 was able to move around real good, was continent and able to go to the bathroom on her own, but liked staff to supervise her so she wouldn't fall. S4CNA stated Resident #2 was able to get out of the bed and into her wheelchair with supervision, and liked to go to the dining room to eat. S4CNA stated when Resident #2 came back from the hospital, she was in a lot of pain in her shoulder and back, and didn't want us (CNA staff) to fool with her because it would hurt her. Resident #2 stayed in the bed and would have accidents on herself because she couldn't get to the bathroom anymore and it would hurt her to get personal care. S4CNA stated Resident #2 could no longer transfer herself. Her family started to bring her food and she wouldn't go to the dining room. In a telephone interview on 05/08/19 at 02:08pm, S3Licensed Practical Nurse (LPN) stated when Resident #2 returned to the facility on [DATE], she had tremendous pain in her lower back. S3LPN stated while caring for Resident #2 on her 07:00pm to 07:00am shift on 01/13/19, Resident #2 informed her that she wanted a new doctor because she couldn't take the pain anymore. S3LPN confirmed Resident #2 was in excruciating pain every 2 hours when she was turned and repositioned. S3LPN first stated she wouldn't call a doctor at midnight if a resident already had orders for pain medications. S3LPN then stated that if a resident's pain medications were ineffective, she would notify the physician. S3LPN confirmed Resident #2 was in pain, but was unable to confirm if medications were given, if medications were effective, or if the physician was notified, because she had no access to the medical record from home. In a telephone interview on 05/08/19 at 03:25pm, S2Physician confirmed that he should have been notified when a resident was still complaining of excruciating pain after pain medications were administered. This would indicate that the medications were ineffective. S2Physician further confirmed that a [MEDICAL CONDITION] Vertebra would cause a significant amount of pain. In a telephone interview on 05/08/19 at 03:32pm, Resident #2's family member stated when Resident #2 returned to the facility after falling twice, which resulted in a brief hospitalization , she was in an extraordinary amount of pain, was weak, disoriented, couldn't get out of bed. Prior to the fall, Resident #2 could do most things for herself with little assistance. Resident #2's family member stated her pain medications were ineffective, and reported this to the nurse. Resident #2's family member stated she reported to staff that she wanted to move Resident #2 to another local hospital for evaluation, because of her complaint of pain and change in condition. When she told this to the nurse, the nurse reported it to S2Physician, who refused to write an order for [REDACTED].#2's family member stated Resident #2 was transported via ambulance to a local hospital, where she admitted with a fracture to her Lumbar Vertebra, and hospitalized for [REDACTED]. In an interview on 05/08/19 at 04:45pm, S1Director of Nursing (DON) reviewed the above findings with this surveyor and confirmed that the nurses should have assessed Resident #2 more frequently, knowing she was experiencing severe pain. S1DON confirmed Resident #2 could have gotten more doses of the prn pain medications, or get an order to change to scheduled pain medications, which may have kept her pain under control. S1DON confirmed Resident #2 required more assistance with ADLs after her return to the facility on [DATE], due to pain. S1DON confirmed the nurses should have informed the physician of Resident #2's unrelieved pain. S1DON stated S3LPN should have gone a step further in assessing the resident's needs, and should not have told the resident nothing could be done because it was midnight.