Every finding on record at Life Care Center of Port Saint Lucie

Based on observations, record review and interviews the facility failed to ensure a proper assessment, obtain physician orders, a consent and assessment was done quarterly for 5 of 6 sampled residents reviewed for bed rails. (Resident #8, Resident #9, Resident #10, Resident #68 and Resident #71). The findings included:A review of the facility policy for Bed Rails issued 11/22/17, revised 12/30/22 and reviewed 09/03/25 documented: The facility must attempt to use appropriate alternatives prior to installing a side rail or bed rail. Review the risks and benefits of bed rails with the resident or representative and obtain consent prior to installation. Procedure: Residents will be assessed upon admission, readmission, or upon initiation utilizing the Evaluation for use of Bed Rails Assessment. If bed rails are determined to be appropriate a reassessment of bed rails use will be assessed at a minimum quarterly and potentially with a change of condition. The facility will document alternatives to the use of the bed rails and how the alternatives did not meet the resident's assessed needs prior to the utilization of the bed rails.1). Observations were made on 01/27/26 at 2:30 PM, 01/28/26 at 8:15 AM, and 01/29/26 at 9:30 AM of Resident #8, with the bed rails in the up position. Review of Resident #8's medical records revealed she was admitted to the facility on [DATE] with a readmission on [DATE]. Her diagnosis includes Seizures, Parkinson's Disease, Diabetes, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. A review of her Bed Rail assessment dated [DATE] readmission documents question 1. Is the resident being considered for bed rails or assistive device for the bed? No. However, this resident was observed with the bed rails on her bed and in the up position. 2). Observations were made on 01/27/26 at 2:45 PM, 01/28/26 at 9:00 AM, and 01/29/26 at 7:30 AM of Resident #9, with the bed rails in the up position. Review of Resident #9 medical records revealed Resident #9 was admitted to the facility on [DATE] with a readmission on [DATE] from the hospital with a diagnosis to include Hospice, Muscle Weakness, Right and Left Knee Pain and Back Pain. A review of the bed rail assessment dated [DATE] documents question 1. Is the resident being considered for bed rails or assistive device for the bed? Yes. Question #2a, were appropriate alternatives attempted prior to considering bed rails? Yes, Question #23 Bed rail is recommended at this time due to conditions identified on evaluation. This question is not answered. There is not a physician's order, but does have a consent signed. The bed rail assessment is not being completed quarterly. Does not document what alternatives were tried and documented. However, this resident was observed with bed rails on the bed and in the up position. 3). Observations were made on 01/27/26 at 2:20 PM, 01/28/26 at 7:10 AM and 01/29/26 at 11:00 AM of Resident #10, with the bed rails in the up position. Review of Resident #10 medical records revealed he was admitted to the facility on [DATE] with a diagnosis to include Rachial Plexus Disorder, Rhabdomyolysis, End Stage Renal Disease, Muscle Weakness and Type II Diabetes. A review of the Bed Rail assessment dated [DATE], a readmission from the hospital documented 1. Is the resident being considered for bed rails or assistive device for the bed. YES. 2a. documented were appropriate alternatives attempted prior to considering bed rails. No. 2b. If no, then bed rails should not be placed on bed. Alternatives must be attempted prior to proceeding with placement of bed rails. If alternatives have been attempted and proven to be unsuccessful then a new evaluation needs to be completed. Further record review revealed there was no consent signed and no physician order. However, this resident was observed with bed rails on the bed and in the up position. 4). Observations were made on 01/27/26 at 2:25 PM, 01/28/26 at 8:25 AM, 01/29/26 at 7:45 AM of Resident #68, with the bed rails in the up position.Review of Resident #68's medical records revealed Resident #68 had been initially admitted to the facility on [DATE] with a readmission on [DATE], His diagnosis included Fracture Right Femur and Lower Back Pain. A review of the resident's bed rail assessment documented the following. 1. Is the resident being considered for bed rails or assistive device for the bed. YES. 2a. documents were appropriate alternatives attempted prior to considering bed rails. No. 2b. If no, then bed rails should not be placed on be. Under Assessment it documents that he has had bed rails since 2022 but the last assessment was in 2025. However, this resident was observed with bed rails on the bed and in the up position. During an interview on 01/29/26 at 6:06 PM Staff N, MDS (Minimum Data Set) Coordinator, she stated that Resident #68 has had the bed rails on since 2022. Though under assessment it shows he did not have any assessment after 2025 until he went to the hospital and came back in 01/2026. 5). Observations were made on 01/27/26 at 2:50 PM, 01/28/26 at 7:40 AM and 01/29/26 at 9:00 AM of Resident #71, with the bed rails in the up position.Review of Resident #71 medical records revealed that she was admitted to the facility on [DATE] with a diagnosis to include History of Falling, Difficulty Walking, Pain to Right Knee, Pain to Back and Muscle Weakness. A review of the resident's bed rail assessment documented her last evaluation was done 11/27/24. and documented the following: 1. Is the resident being considered for bed rails or assistive device for the bed. YES. Further review revealed this resident has an assessment for bed rails completed but no physician order; the last assessment completed in 2024 and not being done quarterly and no consent signed.During an interview on 01/29/26 at 10:15 AM with Staff M Unit Manager she was asked when are the bed rail assessments done. She stated we complete all of them all on admission then they do them quarterly and physical therapy does it as well. She stated that the bed rails are up on admission and we automatically put them up .We don't get consents at that time nor do we get a physician's order.

Based on observation, interview, and record review, the facility failed to ensure comfortable room temperatures for 7 of 7 sampled residents who voiced complaints, as evidenced by uncomfortably cold room temperature readings below 71 degrees F (Fahrenheit) in the rooms of Resident #129, #128, #131, #76, #81, #105, and #83.The findings included:Review of the weather history at https://www.localconditions.com/weather-port-saint-[NAME]-florida/34952/past.php, revealed the following low temperatures during the survey week: On Monday 01/26/26 at 11:00 PM the temperature had dropped to 61 degrees F. On Tuesday 01/27/26 hourly temperature ranged from a low of 46 degrees F. to a high of 60 degrees F. On Wednesday 01/28/26 the low temperature at 6 AM was 39 degrees F. The high temperature reached 67 degrees F. at 3:00 PM, with the temperature dropping to 49 degrees F. at 11:00 PM. On Thursday 01/29/26 the low temperature was 37 degrees F. at 4:00 AM with a high of 65 degrees F. at 2:00 PM. Further review of the 30-day weather history revealed the following: On 01/20/26 the low temperature was 45 degrees F. with a high of 66 degrees F. On 01/19/26 the low temperature was 40 degrees F. with a high of 63 degrees F. On 01/16/26 the low temperature was 41 degrees F. with a high of 62 degrees F. On 01/15/26 the low temperature was 51 degrees F. with a high of 63 degrees F. On 01/02/26 the low temperature was 46 degrees F. with a high of 68 degrees F. On 01/01/26 the low temperature was 38 degrees F. with a high of 69 degrees F. On 12/31/25 the low temperature was 44 degrees F. with a high of 67 degrees F. 1) Review of the record revealed Resident #129 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. During an interview and observation on 01/27/26 at 9:50 AM, when asked how he was doing, Resident #129 stated, I'm freezing. An observation revealed the resident in bed covered up to his neck. When asked if he told anyone, he stated he told the CNA (Certified Nursing Assistant) who stated she would tell the nurse. When asked his preference regarding the room temperature, the resident stated he usually kept his house at 72- or 74-degrees F. On 01/27/26 at 9:59 AM, using the Agency issued thermo-hygrometer, the room temperature read 68.0 degrees F. The thermostat on the wall was set to 78 degrees with a room temperature reading of 67 degrees. Photographic evidence obtained. At that time the resident's family member came into the room, and when asked how he was doing in Spanish, Resident #129 stated in Spanish, Tengo frio (I'm cold). On 01/28/26 at 11:34 AM, when told he was observed earlier that day with the blanket over his head, Resident #129 stated, I'm freezing, further commenting that the last few days have been like being in New York. When told the thermostat in his room was between 67 and 70 degrees, he stated, 70 is still cold. The resident stated he was going to put on a sweatshirt when he got up for therapy. On 01/28/26 at 11:45 AM, using the Agency issued thermos-hygrometer, the room temperature read 70.3 degrees. The thermostat on the wall of the resident's room was set at 78 degrees with the room temperature reading was 68 degrees. Photographic evidence obtained. 2) Review of the record revealed Resident #128 was admitted to the facility on [DATE]. The MDS had not yet been completed but the nursing admission evaluation documented the resident as being alert and oriented. An observation in the room of Resident #128 on 01/28/26 at 10:14 AM revealed a temperature of 69.4 degrees as per the Agency issued thermo-hygrometer. The wall thermostat in the room was set to 85 degrees with a room temperature reading of 68 degrees. During an interview on 01/28/26 at 1:46 PM, when asked if she had been comfortable, Resident #128 stated it had been cold in the building. 3) Review of the record revealed Resident #131 was admitted to the facility on [DATE]. On 01/28/26 at 11:48 AM, when asked if she was warm, the resident stated, yes, with this on, referring to the heavy sweater she was wearing. On 01/28/26 at 11:53 AM the temperature in the room of Resident #131 was at 70.7 degrees using the Agency issued thermo-hygrometer. The room lacked any thermostat. Upon leaving the room, cold air was felt coming from the ceiling vent at the door. The temperature at the door was 67.4 degrees. Photographic evidence obtained. 4) Review of the record revealed Resident #76 was admitted to the facility on [DATE]. During an interview on 01/28/26 at 12:24 PM, the resident stated it was too cold in her room. The resident stated it had been cold the past couple of days and that she had to ask for extra blankets. The resident further stated it was cold in her room a week or so earlier with the last cold snap. An observation on 01/28/26 at 12:29 PM revealed the temperature reading, using an Agency issued thermo-hygrometer, was 69.6 degrees. 5) Review of the record revealed Resident #81 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented a BIMS score of 15. During a medication administration observation on 01/27/26 at 1:50 PM, the resident stated it had been cold in the room last night. On 01/28/26 at 12:34 PM, Resident #81 stated it was still freezing in his room. An observation of the Agency issued thermo-hygrometer read 70.3 degrees. Photographic evidence obtained. The resident explained since he had been at the facility, anytime it had been cold outside it was freezing in his room. On 01/27/26 at 10:18 AM, while in the hallway of the 200 unit, Staff B, Licensed Practical Nurse (LPN) stated, It's cold in here. When asked if she has had resident complaints, the LPN stated she had and had reported it to maintenance. On 01/28/26 at 10:18 AM, three maintenance men and a corporate consultant were observed in the common area of the 400 unit, with one of them on a ladder with the ceiling tile removed. When asked what the issue was with the lack of heat, the corporate consultant stated, Old AC from the 1990s and we can't get parts. We have to go up and adjust it manually. When asked what plan they had in place or what had been done as they should have been aware of the dropping temperatures, the corporate consultant stated, I'll have to find out. On 01/28/26 at 12:00 PM the temperature in the therapy room, as per the thermo-hygrometer read 69.4 degrees. During an interview on 01/28/26 at 2:32 PM, when asked how he kept the building warm and comfortable for the residents, the Maintenance Director explained some of the rooms had individual thermostats that could be adjusted, while the rest of the resident rooms and general areas were controlled by an old computer in the maintenance room. The Maintenance Director explained he had to go onto the computer and manually change the temperatures for each room or area. When asked about this week's cold snap and the cold temperatures in the building, the Maintenance Director explained he arrived at the facility about 7:30 AM on Tuesday, did his outside rounds, and about 8 AM had met with an outside company and was walking the building to get a quote for individual thermostats in the resident rooms. The Maintenance Director explained he adjusted the main computer thermostats when he heard some resident complaints that morning. When asked why the computer temperatures had not been adjusted Monday night with the pending cold temperatures, the Maintenance Director stated, I really didn't know it was going to get cold. 6) During an observation on 01/27/25 at 2:25 PM Resident #83 was noted in her recliner under a blanket shivering. She stated, It's really cold in here. The thermostat on the wall in her room read 68 degrees. The regional nurse then came down the hallway and overheard the resident complaining of it being cold. He went and got the resident more blankets. The regional nurse stated, The maintenance guys are working on the heat now. During an observation on 01/27/26 at 2:56PM, the temperature on hallway of the Bayside (4Unit) was 70.5 degrees, measured with the agency issued thermo-hydrometer. ([NAME]) During an interview on 1/28/26 at 1:32 PM, when asked how did you rest last night, Resident #83 stated, It was still cold. 7) Record review revealed Resident #105 was admitted to the facility on [DATE]. Review of a comprehensive assessment dated [DATE], documented a Brief Interview Mental Status (BIMS) score of 15, on a 0-15 scale indicating no cognitive impairment. During an interview with on 01/28/26 at 9:45 AM, when asked how are you, Resident #105 stated It was very cold last night. The maintenance guys were here last night checking the temperature in my room, and it was 67 or 68 degrees. They said they would come back but I didn't see them. I had to sleep with 3 blankets last night. We had this problem a couple of weeks ago when it was cold. It took them 3 days to get the heat working. During an observation on 01/28/26 at 9:55 AM, the temperature in Resident #105's room that was checked with the agency issued thermo-hydrometer, the temperature was currently 68 degrees in her room. During an interview on 01/29/26 at 10:20 AM, Resident #105 was noted lying in bed underneath several blankets. When asked how the temperature in your room was last night, she stated, Still cold. 8) On 01/28/26 at 7:15 AM this surveyor began completing air temperatures in the hallways and two rooms of the facility with an Agency issued thermo-hygrometer . Resident #81 was observed to have two blankets over him. The room temperature in his room was 67.1 Fahrenheit. Resident #129's room temperature was 66.9 Fahrenheit. The hallway temperatures by room [ROOM NUMBER] was 66.5 Fahrenheit. and by room [ROOM NUMBER] was 66.7 Fahrenheit On 01/29/26 at 7:25 AM the air temperatures were taken again for Resident #81, the room temperature was 67.6 Fahrenheit and in Resident #129's room, the room temperature was 69.8 Fahrenheit. The hallway on the 400 unit by the nurse's station was 70.1 Fahrenheit. The main dining room was 69.4 Fahrenheit. During an interview on 01/28/26 and 01/29/26 at 7:30 AM with Resident #81, he stated it was so cold in his room. He only had two very thin blankets. He was so angry and couldn't wait to leave the facility.

Based on observations, record review and interviews, the facility failed to ensure care and services for respiratory care for 4 of 5 sampled residents as evidenced by failure to ensure Resident #4 and #1 was provided oxygen, failure to ensure Resident #83 received breathing treatments as ordered, and failure to ensure Resident # 131's oxygen tubing was stored properly.The findings included:1) Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-15 scale, indicating moderate cognitive impairment. Review of the medical diagnosis for Resident #4 revealed a history of acute and Chronic Respiratory Failure and Cognitive Communication Deficit. During an observation on 01/26/25 at 2:20 PM, Resident #4 was noted sitting in her wheelchair wearing oxygen via nasal cannula. The nasal cannula was only in one nostril. Review of a physician order dated 12/01/25 revealed instruction for Resident #4 to wear oxygen at 3 liters per minute per nasal cannula as need related to Acute and Chronic Respiratory Failure. Review of the vital signs for Resident #4 revealed the last documented oxygen saturation level was on 1/13/26. Review of the physician order dated 11/26/25, instructed staff to check Resident #4 vital signs, but the order did not include to check the oxygen saturation. Review of the care plan dated 12/15/25 documented a focus the Resident #4 has oxygen therapy related to Chronic Respiratory Failure with a goal that Resident #4's will have no signs or poor oxygen absorption with the intervention for staff to administer oxygen as ordered via nasal cannula, observe for signs and symptoms of respiratory distress and report to the doctor (respirations, pulse, oxygen saturation). During an observation on 01/27/2026 at 9:20 AM, the Assistant Director of Nursing was observed coming out of Resident #4s room. Surveyor entered the room after she walked out. The resident was noted lying in bed sleeping, the oxygen cannula was wrapped around the resident's face but not in her nostrils. During an observation on 01/28/26 at 1:26 PM, Resident #4 was observed sitting in her wheelchair, oxygen cannula on but only in one nostril. The resident's skin appeared pale. Resident #4 was asked Do you feel like you are getting air? She stated, I can't tell. Observation of the oxygen tank that was on the back of the resident's wheelchair, revealed that the tank was closed and displayed red but the tank was full. Photographic Evidence Obtained. An interview was conducted on 01/28/26 at 1:40, with Staff C, LPN in the conference room. She was asked if she had a pulse oximeter and she said yes. Staff C, LPN was asked to bring it with her to Resident #4s room. The resident was noted sitting in the wheelchair with the nasal cannula hanging out of 1 nostril. Staff C, LPN placed the pulse oximeter on the resident's finger, and her oxygen saturation read 79% initially and then went up to 82. She stated, let me check the oxygen tank. Staff C, LPN checked the tank and stated, Oh it's closed and it's a full tank. She opened the tank and the residents' oxygen slowly increased fluctuating between 83 to 84%. Staff C, LPN removed the oxygen nasal cannula from the oxygen tank and attached it to the oxygen flow meter on the wall above the resident's bed. Resident #4's oxygen level increased to 92%. During an interview on 01/28/26 at 1:48 PM when asked how do you know when your resident needs oxygen if there is not an order to check the levels. Staff C, LPN stated, I checked Resident #4 oxygen level this morning. She was asked where did you document it, she had no response. During an interview on 01/28/26 at 1:52 PM, the DON was made aware that the resident's oxygen level was initially 79%, she had not received any oxygen from the tank on the back of her chair because it was closed. She asked who put her in the chair. The LPN stated, I'm not sure, I have to find out. During an interview on 01/28/26 at 2:08 PM, Staff D, Certified Nursing Assistant (CNA) was asked if she knew who transferred Resident #4 to the wheelchair this morning, she stated, I did and Staff E, Certified Nursing Assistant (CNA) helped me, we used the hoyer lift to transfer her. When asked did you attach the oxygen to the resident, she stated, Yes. During an interview on 01/28/26 at 2:15 pm, when asked if she assisted Staff D, CNA with transferring Resident #4 to the wheelchair, Staff E, CNA stated, Yes. 2) Record review revealed Resident #1's was readmitted to the facility on [DATE] after being hospitalized for pneumonia. Review of Resident #1 medical diagnosis revealed she had a history of Chronic Obstructive Pulmonary Disease (COPD) (restrict airway) and Chronic Respiratory Failure. Review of care plan date 1/06/26 documented a focus that Resident has COPD with an intervention that staff will Administer oxygen to the resident as ordered. During an observation on 01/27/2026 at 9:27 AM Resident, #1 was observed sitting in her wheelchair in her room with the oxygen nasal cannula on her face and attached to oxygen tank on her chair. The oxygen tank was noted to be empty. The resident stated it feels like it's empty, as she played with the nasal cannula in her nose. Review of a physician order dated 1/13/26 instructed staff that Resident #1 is to wear oxygen at 2 liter per minute continuously per nasal cannula. 3) Review of the record revealed Resident #83 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15, on a 0-15 scale, indicating no cognitive impairment. Review of the medical diagnosis for Resident #83 revealed a history of Chronic Obstructive Pulmonary Disease (COPD). During an interview on 01/27/2026 at 9:17 AM, when Resident #83 was asked do you receive the breathing treatments, she stated yes usually twice a day, early in the morning and at night. Review of a physician order dated 01/18/26 instructed staff to administer Resident #83, Ipratropium-Albuterol inhalation solution 0.5-2.5 3MG/3ML (breathing treatment) 1 Inhalation four times a day for COPD. During an interview on 01/27/26 at 2:17 PM, Resident #83 was noted to have a moist cough. She was asked if she had received the breathing treatment, she stated I got it early this morning. When asked if she had it that afternoon she stated, No its only twice a day, morning and night. During an interview on 01/28/26 at 1:10 PM, Resident #83's family member was at bedside visiting Resident #83, when the resident was asked had she received a breathing treatment today she stated, No, I've been out of my room all morning, because it was too cold in here. I went to get my hair done, then I was in the dining room. During review of the Medication Administration Record (MAR), documentation revealed that Staff F, Licensed Practical Nurse, (LPN) signed acknowledging she had administered Resident #83 the breathing treatment that was scheduled 01/28/26 at 12:00 PM. Further review of January MAR revealed that staff had signed acknowledging Resident #83 had received the breathing treatment four times a day as ordered. During an interview on 01/28/26 at 2:10 PM, when asked does Resident #83 have an order for breathing treatments, Staff F, LPN stated, Yes, I think they are prn (as needed). She went to review the prn orders in the resident's record and stated, yes, she has a prn order. Staff F, LPN, was asked to go to the resident's scheduled orders. She reviewed the MAR for that day and realized a breathing treatment was scheduled at 12pm, but she had already signed the record. Staff F, LPN was asked if the resident had received the breathing treatment that was scheduled at 12:00 PM, she stated, No, I will give her one now. Review of the Medication Audit revealed that Staff F, LPN, signed the MAR on 01/28/26 at 11:34 AM acknowledging that she had administered the breathing treatment due at 12:00 PM. 4) Review of the record revealed Resident #131 was admitted to the facility on [DATE]. Review of current physician orders documented the resident had orders for oxygen at 2 liters per minute via nasal cannula, as needed for shortness of breath, since admission. Review of the oxygen saturations level documented the resident had used the oxygen on both 01/22/26 and 01/23/26. A progress note dated 01/24/26 also documented the oxygen use for Resident #131. An observation on 01/26/26 at 2:16 PM revealed Resident #131 in bed sleeping. Oxygen tubing dated 01/22/26 was observed with the nasal canula lying directly on the floor. The tubing was connected to the oxygen which was running at 2 liters per minute. Photographic evidence obtained. An observation on 01/27/26 at 10:17 AM revealed the same oxygen tubing dated 01/22/26 that had been on the floor the previous day, was now hanging on the wall over the oxygen regulator. Photographic evidence obtained. When asked if she uses the oxygen, Resident #131 stated she wears it as needed, especially in the evening or at night. An observation on 01/29/26 at 10:45 AM revealed the same oxygen tubing, dated 01/22/26 that had been on the floor, was hooked to the oxygen regulator. During an interview on 01/29/26 at 10:43 AM, when asked what she would do if the oxygen nasal cannula was found on the floor, Staff B, Licensed Practical Nurse (LPN) stated she would throw it away. The LPN was told the tubing was noted on the floor a couple of days ago (01/26/26) and the same tubing was still in use. The LPN stated she would change it.

Based on policy review, observation, interview, and record review, the facility failed to ensure nursing staff clarified intravenous medication volume for 1 of 1 sampled resident, Resident #81, with IV medications. The facility failed to follow their medication administration policy by not preparing medications for one resident at a time and by failing to explain medications to residents during administration. This practice created a potential risk for medication error, including the possibility of medication exchange during the administration process. This deficiency involved 2 of 28 sampled residents. Residents #27 and #100. The findings included:1) Review of the facility policy titled, General Dose Preparation and Medication Administration, revised 11/15/24, documented staff were to compare the medication to the Medication Administration Record (MAR) to the prescription label prior to administration. Review of the policy, Admixing IV (intravenous) Medication, revised 05/01/24, documented staff were to verify prescriber order, inspect medication for integrity, expiration date, and strength, and to notify pharmacy if any questions. During a medication administration observation on 01/27/26 at 1:50 PM, Staff B, Licensed Practical Nurse (LPN) obtained the IV antibiotic cefepime, a 2-gram dose in 50 ml (milliliters) of dextrose to administer to Resident #81. The LPN hooked up the medication to the IV pump and administered it to Resident #81. Review of the physician order documented the cefepime 2 grams was ordered to be administered in 100 ml of dextrose. During a side-by-side review of the actual medication administered compared to the physician order, the LPN stated, but it says here 100 milliliters while pointing to the documented rate of administration which was 100 ml per hour. When told that was the rate of administration and not the concentration, the LPN agreed. When asked if what she administered was the correct concentration, the LPN agreed it was not. During an interview on 01/27/26 at 2:26 PM, when told the IV cefepime for Resident #81 that was administered was a different concentration than what was ordered, the Director of Nursing agreed with the findings and stated the nurse should have clarified the order. Review of the pharmacy Proof of Delivery for Resident #81 revealed the more concentrated cefepime in 50 ml of dextrose was delivered to the facility on [DATE]. Review of the January 2026 MAR revealed twelve different nurses administered the cefepime 2 grams in 50 ml of dextrose without clarifying the order. 2). The facility policy titled General Dose Preparation and Medication Administration, last revised on 11/15/24, required staff to: Prepare medications for only one resident at a time. Use a three-way check by comparing the medication to the medication administration record (MAR) and the prescription label. Facility staff should not leave medications or chemicals unattended. Verify resident identification per facility policy (example picture, armband, name). Observe each resident's privacy and rights in accordance with applicable law (example knocking before entering the room, pulling privacy curtains, informing resident what is to occur before administration, blocking unnecessary access to the MAR.) Provide the resident with any necessary instructions, including explaining the medication use and possible side effects. Observe the resident's consumption of the medications. 2a). Clinical record review revealed Resident #27 was admitted on [DATE] with diagnoses including depression and psychotic disorder. The admission minimum data set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Review of scheduled morning medications included: Apixaban 5 mg, one tablet by mouth twice daily for deep vein thrombosis (scheduled 10:00 AM) Diltiazem 120 mg, one capsule by mouth daily for hypertension and chest pain (scheduled 10:00 AM) Acidophilus, one capsule by mouth twice daily (scheduled 8:00 AM) Multivitamin, one tablet by mouth daily for nutritional risk (scheduled 9:00 AM) 2b). Clinical record review revealed Resident #100 was admitted on [DATE] with diagnoses including cancer, bipolar disorder, and psychotic disorder. The significant change MDS dated [DATE] documented a BIMS score of 12, indicating Resident #100 was cognitively intact. Review of scheduled morning medications included: Apixaban 5 mg, one tablet by mouth every 12 hours for atrial fibrillation (scheduled 9:00 AM) Bupropion 150 mg, one tablet by mouth daily for depression/anxiety (scheduled 8:00 AM) Olanzapine 5 mg, one tablet by mouth twice daily for bipolar disorder (scheduled 8:00 AM) Colace 100 mg, one capsule by mouth daily for constipation (scheduled 9:00 AM) Cyanocobalamin 500 mcg, one tablet by mouth daily for neuropathy (scheduled 9:00 AM) Famotidine 20 mg, one tablet by mouth daily for indigestion (scheduled 9:00 AM) Folic Acid 1 mg, one tablet by mouth daily as a supplement (scheduled 9:00 AM) Lisinopril 20 mg, one tablet by mouth daily (scheduled 9:00 AM) Sunitinib 50 mg, one capsule by mouth daily for cancer treatment (scheduled 9:00 AM) On 01/26/26 at 11:07 AM, while the surveyor was present in the room interviewing Resident #27, Staff A, a licensed practical nurse (LPN), entered the room with medications for both residents occupying the room (Resident #27 in Bed A and Resident #100 in Bed B). Staff A handed a medication cup to Resident #27 while the privacy curtain remained open and immediately proceeded to Resident #100 and handed her a medication cup. Staff A did not explain the medications to either resident and did not provide privacy during the medication administration process. On 01/29/26 at 8:48 AM, during an interview with the Director of Nursing (DON), the surveyor described the medication administration observed involving Resident #27 and #100.

Based on facility policy, observation, record review and interview, the facility failed to ensure safe medication administration for 5 of 8 sampled residents as evidenced by failure to ensure narcotic reconciliation for Resident # 11, # 45, # 96, # 99 and #101. The findings included: Review of the facility policy General Dose Preparation and Medication Administration revised 11/15/25, documented in part 5. During medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 5.5 Document the administration of controlled substances in accordance with applicable law. Medication storage was conducted on 8 residents. Narcotic reconciliation was conducted for 01/28/26 at 1:00 PM with Staff F, Licensed Practical Nurse (LPN), during review of the Controlled Medication Utilization Record for Tramadol 50mg prescribe for Resident #11 documentation revealed on line 4 the time of administration of the Tramadol was not documented. Narcotic reconciliation was conducted on 01/29/2026 at 1:30 PM with Staff B, LPN, review of the Controlled Medication Utilization Record for Oxycodone 10mg IR prescribed for Resident #45 revealed documentation of a count of 7 remaining oxycodone, the pill packet revealed a count of 6 pills.During an interview on 01/29/25 at 1:32 PM, with Staff B, LPN, when asked if she knew why the count was wrong for Resident #45 oxycodone, she stated I gave him a pill this morning and I didn't sign it out. Can I do it now? Narcotic reconciliation was conducted on 01/29/2026 at 1:35 PM with Staff B, LPN, review of the Controlled Medication Utilization Record for Oxycodone 5mg IR prescribed for Resident #96 revealed no documentation on line 3 of the date and time the oxycodone was administered. Photographic evidence obtained Narcotic reconciliation was conducted on 01/29/26 at 3:00 PM with Staff C, LPN, review of the Controlled Medication Utilization Record for Oxycodone 10mg IR prescribed for Resident #99 revealed no documentation on line #2 of the time the oxycodone was administered on 01/25/26. Photographic evidence obtained Narcotic reconciliation was conducted on 01/29/26 at 3:10 PM with Staff C, LPN, review of the Controlled Medication Utilization Record for Oxycodone 5mg IR prescribed to Resident #101 revealed documentation of the medication being received on 01/10/26. Further review revealed documentation of the oxycodone administered on 01/13/26 at 4:00 PM and 01/13/26 at 11:19 PM. Review January Medication Administration Record (MAR) revealed no documentation of this medication being administered on 01/13/26. According to the MAR the medication was last administered on 01/01/26 and then discontinued on 01/09/26. Photographic evidence obtainedReview of the physician orders for Resident #101 revealed documentation of Oxycodone 5mg IR discontinued on 01/09/26. There was not an active order for Oxycodone 5mg IR on 1/13/26. During an interview with the Regional Nurse on 01/29/26 at 3:45P, he was made aware that staff administered Oxycodone 5mg IR to Resident #101 without an active order.

Based on record review and interview, the facility failed to ensure proper monitoring of psychotropic medications as evidence by the AIMS (Abnormal Involuntary Movement Scale) for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #9. The findings included:A review of the facility policy, titled, Tardive Dyskinesia (AIMS) initiated 06/08/20, revised 05/09/22 and reviewed on 08/29/25 documented that residents receiving antipsychotic medications require ongoing assessment for Tardive Dyskinesia. The procedure documents upon initiation of a medication with known extrapyramidal symptoms (EPS) side effects, the facility will complete a baseline Tardive dyskinesia AIMS Assessment and then every 3 months as needed thereafter for as long as the medication is being used.A review of Resident #9's medical records revealed that she was admitted to the facility on [DATE] with a diagnosis to include Unspecified Dementia, Psychotic Disturbance, Major Depressive Disorder, and Anxiety. Her physician orders included Seroquel Oral tablet 25 MG by mouth two times a day for psychosis. A review of the AIMS (Abnormal Involuntary Movement Scale) documented she had this completed on 08/01/25 with a score of 0.0.During an interview on 01/29/26 at 5:05 PM with the Assistant Director of Nursing she acknowledged that the AIMS should be done quarterly and would have been due in November of 2025.

Based on observation, interview and record review, the medication error rate was 9.38% percent. Three medication errors were identified while observing a total of 32 opportunities, affecting 3 of 5 residents observed (Residents #81, #7, and #117).The findings included: 1) A medication administration observation was made for Resident #81 on 01/27/26 at 1:50 PM. Staff B, Licensed Practical Nurse (LPN), obtained the medication cefepime 2 gm (grams) in 50 ml (milliliters) of dextrose to be administered via IV (intravenous) infusion. The LPN entered the room, hooked up the IV, and started the infusion. Photographic evidence obtained. Review of the record revealed the physician ordered IV medication was cefepime 2 gm in 100 ml of dextrose. When shown the photo of the IV medication and asked about the concentration of 2 gm/50 ml, the LPN stated, but it says here 100 ml/hr. When told that was the rate of administration and not the concentration, the LPN agreed. When asked if what she administered was the correct concentration, the LPN agreed it was not. During a side-by-side review of the record on 01/27/26 at 2:26 PM, the Director of Nursing (DON) agreed with the findings. 2) During an observation of medication administration on 01/28/25 at 8: 40 PM, Staff B, Licensed Practical Nurse (LPN) was observed pouring the following medications for Resident # 7: Oxcarbazepine 300mg 1 tablet, Clopidogrel 75mg 1 tablet, Quetiapine 25mg 1 tablet, Docusate Sodium 100mg 1 capsule, Apixaban 5mg 1 tablet, Lexapro 10mg 1 tablet, Aspirin 81mg 1 tablet, Glipizide 2.5 mg 1 tablet, Metoprolol Succinate 25mg ER 1 tablet, Acetaminophen 325 mg 2 tablets, Potassium Chloride 20meq 1 tablet, Senna-Plus 1 tablet. Review of physician orders and reconciliation of the medications administered for Resident #7 revealed the following physician order: Locosapent Ethyl (for cholesterol) 1 gm 2 capsules twice a day (8:00 am and 5PM). This medication was not administered during observation of med pass with Staff B, LPN. Review of January Medication Administration Record revealed that Staff B, LPN documented that she administered the medication to Resident #7 today. Further review of the MAR revealed documentation that staff had signed some days that the medication was administered and other days that it was not available. During an interview on 01/28/26 at 2:28 PM, Staff B, LPN was asked if she administered Locosapent Ethly to Resident #7 during med pass observation and she stated, I administered that medication before you observed me. She was asked to show the medication, she stated I gave the resident the last 2 this morning. She was asked to display on the record the last time the medication was reordered, in which it revealed that the medication was on order. She stated, I reordered the medication this morning. Review of the Medication Admin Audit Record revealed documentation that Staff B, LPN signed that she administered the Locosapent Ethyl scheduled for 8:00 AM at 8:41AM. During an interview on 01/28/26 at 5:42 PM, when asked when the last time Locosapent ethyl 1gm for Resident #7 was reordered, Pharmacist stated, The last time this medication was reordered was in November 2025, 120 capsules, which was a 30-day supply During an interview with the DON she was made aware Staff B, LPN had acknowledged to surveyor that she administered Locosapent Ethyl to Resident #7 prior to med pass observation, but the medication was not available to be given. 3) During an observation of medication administration on 01/28/26 at 9:00 AM, Staff C, Licensed Practical Nurse, LPN was observed pouring the following medications for Resident #117: Aspirin 81 mg 1 tablet, Metolazone 2.5mg 1 tablet, Potassium Chloride ER 20 meq 1 tablet. Review of the physician orders and reconciliation of medications administered to Resident #117 revealed the following physician order: Symbicort Inhalation 160/4.5 MCG/ACT inhale 2 puffs orally twice a day for shortness of breath. Staff C, LPN did not administer this medication during med pass. Review of January MAR revealed documentation that Staff C, LPN signed the record acknowledging that the medication was administered during med pass. During an interview with Staff C, LPN, when asked if Resident #117 received any respiratory medications, she went into her med cart and pulled out a box of nebulizer medication. She was then asked does the resident received anything else, Staff C, LPN looked throughout the cart and found a Symbicort inhaler with the resident's name on it. She was asked if she administered the Symbicort to the resident during her med pass, she stated I gave it to her earlier before she took her other medications. Review of the medication admin audit report for Resident #117 on 01/28/26, revealed documentation that Staff C, LPN signed that she administered the Symbicort at 9:08 AM , when the other medications were administered.

Based on record review and interview, the facility failed to follow physician orders for 1 of 5 sampled residents as evidenced by failure to administer blood pressure medication as ordered for Resident #4. The findings included:Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of the comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 10 on a 0-15 scale, indicating moderate cognitive impairment. Review of the Medical diagnosis for Resident #4 revealed a history of Essential Hypertension (high blood pressure), Cognitive Communication Deficit.Review of the care plan dated 11/26/25 documented a focus that Resident #4 had Hypertension with a goal that the resident will remain free from complications related to Hypertension with interventions that staff will give Resident #4 antihypertensive medication as ordered. Review of a physician order dated 01/14/26, instructed staff to check Resident #4 blood pressure every 8 hours, give clonidine HCL by mouth every 8 hours as needed for systolic blood pressure (top number) over 160. A second order dated 1/14/26 instructed staff to give Clonidine HCL 0.1mg by mouth every 8 hours as needed for systolic blood pressure over 160. Review of the January 2026 Medication Administration Record (MAR) for Resident #4 revealed the following. documentation: B/P 161/90 (1/15/26 at 10:00 PM), B/P 168/88 (1/15/26 at 10:00 PM), B/P 169/84 (01/17/26 at 6:00 AM), B/P 186/93 (01/22/26 at 10:00 PM), B/P 161/75 (1/24/26 at 2:00 PM), B/P 175/84 (01/26/26 at 10:00 PM), B/P 178/98 (01/27/26 at 10:00 PM). Further review of the MAR revealed that staff administered the clonidine only on 1/22/26 at 9:48 PM and 1/26/26 at 11:07 PM.

Based on policy review, observation, interview, and record review, the facility failed to ensure medications were not left unattended at the bedside for 2 of 35 residents reviewed (Residents #36 and #67). Additionally, the facility failed to ensure medication carts and medication rooms were free from expired medications for 1 of 9 medication carts and 1 of 3 medication rooms. The findings Included: The facility policy titled General Dose Preparation and Medication Administration, last revised 11/15/24, indicated that facility staff should not leave medications or chemicals unattended. 1). Clinical record review revealed Resident #36 was admitted on [DATE] with diagnoses including brief psychotic disorder, low vision of the right eye (category 1), blindness of the left eye (category 3), bilateral hearing loss, and dementia. The quarterly Minimum Data Set (MDS) assessment with a reference date of 10/29/25 documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS documented no mood or behavioral concerns. Further review of the clinical record revealed Resident #36 had the following scheduled morning medication orders: Quetiapine 100 mg, one tablet by mouth twice daily for brief psychotic disorder (scheduled at 9:00 AM and 9:00 PM). Namenda 10 mg, one tablet by mouth twice daily for dementia (scheduled at 9:00 AM and 9:00 PM) Review of the care plan, revised 11/03/25, documented that Resident #36 required antipsychotic medication related to brief psychotic disorder, with the intervention to administer antipsychotic medications as ordered by the physician. The care plan also documented impaired visual function related to total vision loss in the left eye and impaired vision in the right eye. Review of the Medication Administration Records (MARs) for January 2026 indicated the scheduled morning doses of Quetiapine 100 mg and Namenda 10 mg were signed as administered by the attending nurse. On 01/29/26 at 10:39 AM, record review revealed no documented self-medication assessment indicating Resident #36 was assessed and determined to be capable of self-administering medications. On 01/26/26 at approximately 11:00 AM, during an interview with Resident #36, the surveyor observed a medicine cup containing two pills (one yellow and one grayish in color) left unattended on the bedside table. No nursing staff were present at the bedside at that time. Resident #36 was observed to be hard of hearing. On 01/29/26 at 8:48 AM, the Director of Nursing (DON) was informed that medications had been observed left unattended at the bedside for Resident #36. On 01/29/26 at 11:06 AM, the surveyor reviewed the medication packets for Resident #36's scheduled morning doses of Namenda and Quetiapine and compared them with the medications observed at the bedside. The medications were consistent in appearance with those found in the unattended medication cup. On 01/29/26 at approximately 12:28 PM, during a subsequent interview, the DON stated she reviewed Resident #36's medication records and confirmed that the medications left unattended at the bedside were Quetiapine and Namenda and stated those medications should have been administered by staff. 2) Record review revealed Resident #67 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 15 on a 0-15 scale, indicating no cognitive impairment. During an observation on 01/26/2026 at 11:32 AM, 2 white bottles of medication with a gray top were noted on Resident #67's nightstand. The larger bottle was labeled Omega Guard. Photographic evidence obtained. Review of the assessments for Resident #67, did not reveal a self-medication administration assessment completed for the resident to self-administer medications. During an observation on 01/27/2026 at 9:20 AM, 2 white bottles of medication with a gray top were noted on Resident #67s nightstand. The larger bottle was labeled Omega Guard and the small bottle with a black label was labeled Lecithin. Photographic evidence obtained. Review of the physician orders for Resident #67 did not reveal an order for Omega Guard or Lecithin. During an interview with Resident #67, she was asked what happened to the 2 bottles of medication that were sitting on her nightstand. She stated They took them and told me they had to be locked up. I will continue taking them when I go home Medication storage was conducted on 01/28/26 at 12:25 PM with the Unit Manager on Bayvista (4U), observation of the med room revealed 2 opened, unlabeled insulin vials were inside a zip lock bag and stored in the refrigerator. Photographic evidence obtained. Medication storage was conducted on 01/29/26 at with Staff B, Licensed Practical Nurse (LPN) on Bayvista, observation of the med cart revealed several bottles of expired medications in the cart. Photographic evidence obtained.

Based on facility policy review, record review and interviews, the facility failed to provide services to avoid skin breakdown for 3 of 3 sampled residents, as evidenced by not performing skin assessments as ordered for Resident #4, #5, and #1. The findings included:Review of facility policy titled Area of Focus: Basic Skin Management revised on 11/21/2024, documented in part, The facility must ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical conditions demonstrate they were unavoidable and a resident with ulcer receives necessary treatment and services consistent with professional standards, to promote healing, prevent infection, and prevent new ulcer from developing. 2. All residents have a head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing. This policy further documented the assessments were documented in their electronic medical record under NRSG: Weekly Skin and the nurse was to review the User-Defined Assessment (UDA) for assignments.1) Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 14 on a 0-15 scale, indicating the resident was cognitively intact. During a phone interview on 10/14/25 at 10:45 AM, the daughter of Resident #4 stated, I just don't know why they were refusing to give me updates on my father's status when I called. He has pressure ulcers on his bottom and heels, the hospital said it is a stage 3 (a wound that has full-thickness skin loss that presents as a shallow open ulcer) wound on his buttocks, and the heels have the beginning of a sore.Review of the care plan dated 09/17/25 revealed a focus that Resident #4 had a break in skin integrity and an intervention for staff to do weekly skin checks.Review of the weekly skin assessments for Resident #4, revealed no skin assessments were done on the week of 09/08/25, 09/22/25, and 09/28/25. During an interview on 10/14/25 at 2:34 PM, when asked if Resident #4 had a pressure ulcer on admission, the Wound Care Nurse (WCN) stated, Yes. When asked if the resident had a wound when he was discharged to the hospital on [DATE], she stated, The wound was resolved on 09/16/25. When asked when skin assessments were done on a resident, she stated, On admission by the admitting nurse, I do a secondary skin check, and then it's done every seven days by the floor nurses assigned to the resident. When asked how the nurse knows when the skin assessment was due to be done, she stated, The UDA populates in the system for the nurse. When asked if there was an order written for the skin assessment, she stated, No, not that I'm aware of. When asked when skin checks done on Resident #4, the WCN stated on 09/16/25 and 09/18/25.2) Record review revealed that Resident #5 was admitted to the facility on [DATE]. Review of the quarterly assessment dated [DATE], documented the BIMS score as not able to be assessed. Review of physician orders revealed staff were currently treating two wounds.Review of the care plan revealed a focus that Resident #5 was at risk for unavoidable recurrent pressure injury development or decline of skin integrity due to weakness, prognosis, fragile skin with a goal the resident's skin injury will be healed. An intervention was for staff to do weekly skin checks.Review of the skin assessments for Resident #5 revealed that skin assessments were not done on the week of 10/05/25, 09/14/25, 09/21/25, 09/28/25, 08/17/25, 08/10/25, and 08/03/25, and no skin assessments were completed in the month of July. 3) Record review revealed Resident #1 was admitted to the facility on [DATE]. Review of the annual assessment documented a BIMS score of 15 on a 0-15 scale, indicating no cognitive impairment.Review of the care plan dated 09/16/25 revealed a focus that Resident #1 had a potential for pressure ulcer development and skin breakdown related to impaired mobility, bladder incontinence, diagnosis of peripheral vascular disease (decreased blood flow) with a goal that the resident will have intact skin free of redness blister discoloration. An intervention documented on this care plan was that staff do weekly skin checks.Review of the physician orders revealed an order dated 08/01/2024 instructed staff to complete weekly skin checks every day (7:00 AM to 3:00PM) shift on Thursday for skin monitoring.Review of the skin assessments for Resident #1, revealed that skin assessments were not done on 07/24/25, 07/31/25, 08/14/25, 08/21/25, 08/28/25, 09/04/25, 09/11/25, 09/18/25, 10/02/25, and 10/09/25.Review of the August and September Treatment Administration Record for Resident #1 revealed staff had signed acknowledging that the skin checks were done. During an interview on 10/15 at 09:18 AM, when asked how do you know when a resident is scheduled for a skin check Staff A, Licensed Practical Nurse (LPN) stated. It will pop up on the UDA in the computer to let me know it is due. When asked where do you document the skin assessment, she stated, I will click on the UDA tab, and it will open up to the skin assessment for documentation. During an interview on 10/15/25 at 09:20 AM, when asked how the nurse knows when the resident is scheduled for a skin check, the Unit Manager (UM) stated, It will pop up on the UDA to let them know that the skin check is due. Also, I print out a list of the skin checks that are due for that day and highlight the names. When asked where the nurse documented the skin assessment, she stated, They document in the record under assessment. During an interview on 10/15/25 at 9:21 AM, when asked how do you know when your resident is due for a skin check, Staff B, LPN stated, It pops up on the UDA. When asked where she documented the skin check, she stated In the assessment, I go to the resident that is due and choose skin assessment.

Based on facility policy review, record review and interview, the facility failed to provide care and services to address the nutritional status for 1 of 3 sampled residents, as evidenced by not weighing according to policy and addressing Resident #4's weight loss, in a timely manner.The finding included:Review of the facility policy titled, Weight monitoring, long term care revised 09/15/25, documented in part Weighing a resident in a long term care facility is an important part of assessing a resident's health. Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, record residents' weight at the time of admission, weekly for 4 weeks, and then monthly. Keep in mind that many residents' have comorbidities that can cause unplanned weight changes and some residents require more frequent weight assessments. Implementation: compare the resident's weight with previous measurements to assess trends in weight gain or loss. If you have a weight change, assess the resident using a facility approved malnutrition screening tool (if in use at your facility). Notify the practitioner if weight changes are beyond the expected range. Record review revealed Resident #4 was admitted to the facility on [DATE]. Review of comprehensive assessment dated [DATE] documented a Brief Interview Mental Status (BIMS) score of 14 on a 0-15 scale, indicating no cognitive impairment.During an interview on 10/14/25 at 10:45 AM, Resident #4's daughter stated, I just don't know why they (the facility) were refusing to give me updates on my father's status when I called. He lost 34 pounds in less than a month of being there. Now he is in the hospital fighting for his life due to failure to thrive.Review of the documented weights for Resident #4, did not reveal a weight taken on 09/05/25, his admission date or within 24 hours of admission. The initial weight was taken on 09/09/25 which was 176.8 pounds. There was no weekly weight documented on 09/16/25. On 09/23/25 the recorded weight was 157.2 pounds, which indicated he had lost 21 pounds in 2 weeks. The resident was reweighed on 09/30/25 and his weight was 142.4 pounds, indicating a weight loss of 34 pounds. Review of the care plan revealed a focus that Resident #4 had a nutritional problem related to status post hospitalization due to fall, anemia, depression with a goal the resident will maintain adequate nutritional status as evidenced by maintaining weight within (95)% of 177# no signs of malnutrition, and consuming at least (75)% of at least (2)meals daily with an intervention of the staff to observe for and report to MD as needed signs of malnutrition: Emaciation(Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week,>5% in 1 month, >7.5% in 3 months, >10% in 6 months. Review of the progress notes did not reveal documentation of Resident #4 weight loss reported to the physician.Review of a progress note dated 09/25/25 revealed documentation of a care plan meeting held with Resident #4 and his daughter and stated that the current plan of care, medications, care preferences, treatments, therapy progress, diet and care plan was reviewed, and the resident remained stable with no changes.During an interview with the Unit Manager (UM) on 10/14/25 at 1:02 PM, when asked, did you notice a change in the resident's appetite, she stated, No change in his appetite, no real concern with him refusing food. When asked what the process is for obtaining weights, the UM stated, Usually there is an order. When asked what if there isn't an order, she stated then its monthly. When asked when the resident is usually weighed when they are admitted , she stated, Upon admission. When asked what she meant, she stated, When they arrive that day or the next day if not done at that time. When asked who is responsible for doing the weights, she stated, the CNA assigned, the day shift (7:00 AM TO 3:00 PM) does the even numbered rooms and the 3:00 PM to 11:00 PM shift does the odd numbered rooms. When asked who enters the weights in the record, she stated, The floor nurse assigned or me. The dietician will review the weights, and we have a weekly meeting to discuss weight changes. When asked what she would do if she noted a significant change in a resident's weight, she stated, I would call the doctor and get and order for a reweigh. I would reweigh the resident to make sure it's accurate. The UM was asked to review Resident #4's weights, after her review, she was asked when did the resident have a significant change in his weight, She stated on 09/23/25. When asked if there was a change in condition done for the significant weight loss the resident, she stated I don't see one in the computer, but I will talk to the Director of Nursing (DON). When asked was the weight loss discussed in the care plan meeting, she looked in the record and stated, On 09/25/25 there was an IDT meeting and it stated the diet, weights, medications were discussed, and no changes were made. When asked was the daughter present, she stated, Yes the resident and daughter was present. When asked what interventions were done for the weight loss and when were they initiated She stated on 10/1/25 the dietician ordered weekly weights, medpass and fortified foods. Review of a weight change note dated 10/01/25, the Registered Dietitian (RD) documented a weight of 144.5 and her response was that the resident reported his usual body weight was approximately 137 lbs, he had good oral intake, and she will add fortified food, med pass (oral supplement) twice a day and continue weekly weights.During an interview on 10/15/25 at 12:20 PM, when asked are you familiar with Resident #4, the Registered Dietitian (RD) stated, Yes. When asked when she was made aware of the resident's weight loss that was documented on 09/23/25, she stated, I reviewed his weight on 09/30/25. When asked if she attended the care plan meeting on 09/25/25, with the resident and his daughter, she stated, No. When asked how are you made aware of a resident who has a significant weight change, she stated, I review the weights weekly. When asked do you receive any type of alert of a resident's significant weight change, she stated No. When asked what did you do when you were aware of the weight change for Resident #4, she stated I requested a reweight and his weight was 142 pounds. When asked so the reweigh wasn't done until 7 days later, she stated I'm guessing yes. When asked what intervention was done for the weight loss, she stated I added fortified foods (more calories), med pass (supplement) and ordered weekly weights on 10/01/25. When asked did you speak with the family about the significant weight loss, she stated No, because I figured because he had a BIMS of 14, it was ok for me to just speak with him. During an interview with the MDS Coordinator on 10/15/24 at 1:10 PM, when asked what was discussed at the care plan meeting with Resident #4 and his daughter on 09/25/25, the MDS Coordinator went to the progress note in the record and stated, Therapy progress, medication, care plan was discussed. When asked who was present, she showed the care plan conference record which was signed by the Speech Therapist and Activities Director. When asked was his weight discussed, the MDS coordinator stated Not in detail. Not any that was of concern.

Based on interview and administrative and clinical record review, the facility failed to provide evidence of a thorough investigation, assessment of the resident, and internal and federal reporting of an incident of a resident with reported new bruises of suspected origin. This failure affects 1 of 3 sampled residents reviewed (Resident # 1).The findings included: Review of the he facility's policy regarding Incident and Reportable Event Management, reviewed 09/25/2024, documented regarding Alleged Violations - Investigate/Prevent/Correct: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.Procedure:The Five I's to Event Management, To help reduce the risk of an event, all residents receive assistance and supervisions as addressed in their care plan. If an event occurs, the facility will follow the 5 i's in an effort to minimize the potential recurrence. Incident (what happened or was reported as happening)Injury (provide care and document the injury)Interview (who saw the resident last or at the time of the event)Investigate (why did it happen)Intervention (what mitigation effort are we using)Incident/InjuryThe licensed nurse should evaluate the resident and render first aide if needed 2. The licensed nurse should create an event note and include the following details a. The assessment details of the resident (including the details of the resident) b. Presence or absence of injury, and any treatments rendered. c. If resident is able to report what occurred, this should be included in the notes d. Notification of family or responsible party e. Notification of physician and any orders received. 3. The licensed nurse should create a risk report in the electronic system and identify the most appropriate type of event from the available options in the in the system. 4. The licensed nurse should also notify the following in accordance with state and federal requirements. a. Supervisor on duty and/or DON (Director of Nursing)/ED (Executive Director) Review of the clinical record for Resident # 1 revealed that the resident was admitted to the facility on [DATE] and was discharged at the time of the review on 09/10/25. Resident # 1 was admitted to the facility for Nondisplaced intertrochanteric fracture of right femur. The 02/14/25 Minimum Data Set Assessment (MDS) cognitive function, documented a BIMS score of 15 (Brief Interview for Mental Status) score ranges from 0 to 15 and a score of 15 would indicate that the resident is mentally intact). Further review of the facility's administrative records regarding an occurrence for Resident # 1 failed to provide documented evidence that there was an incident that occurred for Resident # 1. Review of the clinical record for Resident # 1 failed to provide an assessment of the resident's injury or that an incident occurred. There is no evidence of facility or federal reporting of the incident for Resident # 1. An interview was conducted on 09/10/25 at approximately 12:15 PM with the Administrator regarding an incident occurring involving Resident # 1. The Administrator then reported that he did report an incident to the State Agency regarding an incident with Resident # 1. He did not have evidence of the information provided to the State Agency but provided the surveyor with a confirmation email dated February 23, 2025, at 1:46 PM which documented, Based on the information provided, a report for investigation has been accepted regarding Resident # 1. This was processed by Hotline Counselor. This information is confidential pursuant to section 39.202 and section 415.107, Florida Statutes, and can only be released as specified in the statute. The Administrator then reported that he submitted the report to the State Agency prior to interviewing the resident. After he interviewed the resident, he said that the resident felt that the aide was rushed during her transfer, but she didn't want the aide to get in trouble. However, the resident did request that the aide no longer work with her. So, they removed the aide from that assignment. He further stated that because the resident did not feel that the aide intentionally did anything, he did not report the incident to the Federal Agency. The surveyor then questioned the Administrator regarding not having the resident's name listed on the requested logs for reporting, i.e. incident reports, reports to the state and federal agencies. The surveyor then requested any reports or information of what was investigated regarding the incident with Resident # 1 and any subsequent education provided to the staff associated with the February 23rd reported incident for Resident # 1. He then reported that the Risk Manager is on vacation, and he is trying to get in the RM office to see what she has. The Administrator later reported that he did not have an incident report or any evidence of an investigation. Review of a State Agency's report revealed the following documentation, On 02/22/2025 during the 3pm to 11pm shift, Resident # 1 received two (2) bruises during a stand pivot transfer from the wheelchair to bed. The resident has fragile skin and during the transfer the resident stated to please stop but the aide continued to transfer. This was a single time occurrence and there is no prior history of occurrences. Resident # 1 did not want the aide to get in trouble, but she did not want to have the aide take care of her anymore. The aide was contacted for a statement but did not return the call. The aide was suspended pending an investigation. No recommendations were needed to be given as additional training was provided to the AP, and facility-wide training was conducted for staff on proper lifting techniques. The resident is an [AGE] year-old female who has capacity, who has been diagnosed with Intertrochanteric fracture of right hip, high blood pressure and diabetes. The resident requires assistance with her ADL's (activities of daily living) and IADL's. The facility's director confirmed that the allegations were found to be substantiated against the alleged CNA. The evidence presented during the investigation was sufficient to support the allegations. These findings are based on statements from the vulnerable adult, collateral statements from facility staff, and observations made by the API during the investigation. The evidence indicates that Resident # 1 did, in fact, sustain physical injuries. An act, threat, or omission (abuse) was committed, which could or is likely to cause significant harm to the victim. Resident # 1 sustained bruises from the CNA, which were noted during the investigator's visit. The bruises were visible on both of the resident's upper arms, corresponding with the hand placement that the CNA would typically use during a stand pivot transfer from a wheelchair to a bed. The allegations and medical records confirm that Resident # 1 has fragile skin, which would require extra care during handling. Resident # 1 has the capacity to understand, communicate, and make decisions, and she clearly explained to the investigator how she received the bruises. Review of the facility 's grievance log did identify a grievance on 02/23/25 at 10:30 AM, which documented that a nurse reported a concern for Resident # 1. The grievance documented the following information, the CNA was not careful during transfer from wheelchair to bed. The resident does not want the CNA anymore. The report documented that the concern was reported to the administrator on 02/23/25 at 11:00 AM. The report further noted that the Administrator spoke with the resident and staff member who took the report. The resident felt the aide rushed in transferring her. The aide was re-assigned from the resident. Additional transfer training to take place. An interview was conducted on 09/11/25 at 9:25 AM, with the Infection Preventionist, who was also the MOD (Manager on Duty) the weekend of the reported incident. The nurse stated that the Morning CNA reported to her regarding the incident, which is documented on the grievance, and so she contacted the Executive Director/Administrator. At this time, she does not remember about any injury to the resident. However, she did recall that the resident was insistent on the aide no longer working with her and was also willing to change rooms, if necessary to prevent the aide from working with her again. A telephone interview was conducted on 09/11/25 at 9:39 AM with the Certified Nursing Assistant (CNA), Staff A. She confirmed she was the CNA that reported the incident to the MOD on 02/23/25. As she recalls, Resident #1 wanted to get up and when she went to get her up, she remembered seeing bruises on her arms. She is not 100 % sure of the extent of the bruises at this time. She stated she asked the resident what happened, and the resident reported that something happened the night before with a shower or with the caregiver from the night before. She confirmed she noticed the bruises and knew they were new because she works with the resident five days a week. She stated she just reported the incident, but she doesn't recall giving a statement regarding the incident. She doesn't remember if it was the resident or daughter, who requested that the aide no longer worked with her, but remembers that one of them requested that the aide no longer care for the resident. An interview was conducted on 09/11/15 at 11:17 AM with the Licensed Practical Nurse, Staff B, who was the morning nurse on the date the incident was reported. She stated she did not think she was the nurse that the CNA reported the incident to but what she remembers is that the resident reported that the aide grabbed her rough during the transfer. She also recalled that the resident did not want that aide anymore. She thinks the resident may have had some skin issues, but she doesn't remember. The MOD then took over and reported the incident to the ED. The surveyor asked about bruises, she then stated she didn't remember and stated, let me check the record. The surveyor stated there was no assessment to identify what was observed on the resident regarding the bruises. She then stated usually, we will complete an incident report on the shift it occurred. She also thinks it may have been reported at night as well. There is no evidence that the facility followed their policy and procedure regarding Incident and Reportable Event Management concerning Resident # 1 and the incident which occurred with her.

Based on interview, record review and policy review the facility failed to timely report to the State Agency allegations of abuse for 4 of 4 sampled residents (Resident #1 and Resident #4), and (Resident #5 and Resident #6) involved in an incident. The findings included: Review of the Policy titled Abuse-Reporting and Response - No Crime Suspected, issued on 10/04/22 and revised on 06/17/24 documented, in part . Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance to State law through established procedures. Review of the record revealed Resident #1 was initially admitted to the facility 01/13/25 and discharged [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 08, on a 0 to 15 scale, indicating the resident was moderately cognitively impaired. Review of the report documented an incident had occurred on 03/23/25 involving Resident #1. The incident was reported by the Administrator as followed: Incident Date 03/23/25, Incident time 7:01 AM, Administrator became aware of the incident 8:05 AM. Allegations: Physical Abuse. Time reported to the Abuse Registry 8:25 AM. This report was not submitted to the State Agency until 11:02 PM, approximately 16 hours after the incident occurred. During an interview on 04/01/25 at 11:20 AM, when asked why the abuse report for Resident#1 was not submitted timely, the Administrator stated that he was not aware he had to report it to the State Agency within 2 hours of the incident. He stated he thought he only had to report it to adult protective services within 2 hours. After a side-by-side review of the timeframes and regulation, he agreed that he should have completed the immediate report to the State Agency within 2 hours. Review of the record revealed Resident #4 was admitted to the facility 01/10/25 and discharged [DATE]. Review of the MDS assessment dated [DATE] documented Resident #4 did not have a BIMS score, indicating the resident was unable to answer any of the interview questions. Review of the report documented an incident occurred on 01/15/25 involving Resident #4. The incident was reported by the Administrator as followed: Incident Date 01/15/25. Incident time 10:04 AM. Administrator became aware of the incident 10:56 AM. Allegations: Physical Abuse. Time reported to the Abuse Registry 12:11 PM. This report was not submitted to the State Agency until 01/16/25 at 3:44 PM, more than a day after the incident occurred. Review of the record revealed Resident #5 had a re-entry admission to the facility on [DATE] and discharged [DATE]. Review of the MDS assessment dated [DATE] documented Resident #5 had BIMS score of 12, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the record revealed Resident #6 had a re-entry admission to the facility on [DATE]. Review of the MDS assessment dated [DATE] documented Resident #6 had BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the abuse incident that occurred on 12/11/24 documented an incident that had occurred between Resident #5 (the perpetrator) and Resident #6 (the victim.) The incident was reported by the Administrator as followed: Incident Date 12/11/24. Incident time 6:14 PM. Administrator became aware of the incident on 12/11/24 at 6:33 PM. Allegations: Physical Abuse. Time reported to the Abuse Registry 7:40 PM. This report was not submitted to the State Agency until 12/15/24 3:37 PM, approximately 4 days after the incident occurred. During a follow-up interview on 04/01/25 at 12:45 PM, when asked why the incident for Resident #4 and the Resident-to-Resident incident between Resident #5 and #6 was not reported timely, he repeated he was not aware of needing to report the incidents to the State Agency within 2 hours.

Based on observations, interviews, and clinical and administrative record review, the facility failed to provide evidence of providing the necessary care and services to ensure that adequate monitoring of temperatures of hot beverages were consistently completed after an incident of a resident experiencing a burn from a hot beverage; failed to ensure hot liquid temperatures above the stated range, according to the facility's Food Temperature Log, Temperature Standards for hot foods should be at 140-170 degrees Fahrenheit were adjusted prior to serving; and failed to ensure the physician prescribed wound care orders were performed as prescribed, affecting 1 of 6 sampled residents ( Resident #1). The findings included: Review of the facility's policy regarding Hot Liquids, revised 01/21/2025 documented, the food provided by the facility should be palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction, while minimizing the risk for scalding and burns. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. The table below illustrates damage to skin in relation to the temperature of the water and the length of time of exposure. Water temperature/Time required for a third degree burn to occur: 155 F [Fahrenheit]- 1 second 148 F - 2 seconds 140 F - 5 seconds 133 F - 15 seconds 127 F - 1 minute 124 F - 3 minutes 120 F - 5 minutes 100 F - see below Note: Burns can occur even at water temperature below those identified in the table above, depending on the individual's condition and length of exposure. 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included displaced commuted fracture of the left tibia. The resident's cognitive status according to the 02/04/25 Minimum Data Set (MDS) assessment, recorded a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Further review of the clinical record revealed the resident sustained a burn on 02/16/25, apparently from being exposed to hot tea being spilled on him during the dinner meal. The resident was sent to the hospital for further evaluation on 02/16/25 and returned to the facility later that same evening. Review of the hospital emergency room record for 02/16/25 documented the resident was presented to the ER and upon exam the physician noted the resident had blistering with pain covered with superficial partial thickness burn. An observation and interview were conducted on 02/19/25 at 11:24 AM with Resident #1, who was served his lunch tray. There were no hot beverages given to the resident for this meal. The resident was provided with a bowl of soup, and the aide removed the lid on the soup and placed the soup at the top of the tray. The interview with the resident revealed his accounting of the incident on 02/16/25, during the dinner meal and stated he had asked the aide for a cup of hot tea. He stated the aide set up the tray and the hot tea. He stated the aide put the tea on the end of the table, and the aide's foot hit the table and knocked over the hot tea off into his bed. He said that there were two aides in the room. One was trying to line up his bed table. One of the aides kicked the table and knocked the cup over. An interview was conducted on 02/19/25 at 4:09 PM with the Certified Nursing Assistant, Staff B, who reported that on the day of the incident, Resident #1's tray table was in front of him. She had set up the resident's tray and he then asked for hot tea. She stated she went to get the resident some hot tea and she put the tea on the tray. The resident then asked for salt and pepper, so she went out of the room to the cart in the hallway, to get the salt and pepper, when she heard the resident scream, mommy, I'm burning. She further stated that he said, he poured soup on him. But when she looked, the soup had not been touched. She stated she had the resident turn to the side and when she turned the sheet, she saw the empty cup. She stated when the resident turned at that time, his skin was attached. She removed the sheets and sat them on the floor. She stated she then ran to get the nurse. An interview was conducted with the Wound Care Physician on 02/20/25 beginning at 8:43 AM. The physician reported that he saw the resident on Tuesday, 02/18/25, and the resident's burns were second degree burns, involving the epidermis and blistering. He noted the resident did not have any infection or necrosis in the burns, so he changed the dressing to Xerofoam dressing, because the Xerofoam won't stick to the area. He stated the resident did not complain of any pain while we were performing the wound care. He was conversing with us that he wanted to go home. An interview was conducted on 02/20/25 at 9:15 AM with the Registered Nurse, Staff C. She reported that she was on another unit when the incident occurred with Resident #1. She stated Staff B came running toward her, stating that Resident #1 had been burned. His skin was burned on the side. The aide had already removed everything when she had arrived to see Resident #1. She further stated that at the time she was unaware of what had caused it. She said the resident did not want to be touched and wanted 911 called. She stated that from her skin assessment, she could see that the skin was mostly intact but wrinkled. There was a small part of the skin that was open on the hip about 3 inches. She was unaware of the amount of time which had elapsed. Review of the facility's investigation revealed the facility interviewed the staff who were involved in the incident to determine how the hot tea was spilled but there is no evidence of the staff monitoring to determine the probable temperature of the liquid served from the canister used to serve the resident. There was no evidence of the facility conducting further monitoring of hot beverages being served on the various nursing units to prevent future reoccurrence of the incident. An interview was conducted on 02/20/25 at 11:16 AM with the Assistant Director of Nursing / Risk Manager. The facility's investigation reviewed the disparity in accounting of the incident from Resident #1 and the staff involved. Interviews were conducted with the staff involved. The facility determined there was one staff member on the unit at the time of the incident. The second aide was in the dining room and the nurse was on another unit. She also noted the temperature documented on the Temperature log from the kitchen for 02/16/25 at dinner was 145F (Fahreneit). She further stated she would have preferred that staff would have tested the curio (container used to store hot liquid for transport to the nursing units) for the water temperature, but she confirmed this did not happen. The surveyor also reviewed the Temperature log documentation for February 2025 and noted there were several entries where the documented temperature exceeded the acceptable range of 140-170 F. degrees and there was no apparent follow-up to the high temperature. An observation in the facility's kitchen during the lunch meal preparation was conducted on 02/19/25 beginning at 11:15 AM. Upon entering the kitchen, the surveyor observed 5 carts with hot beverage canisters already stored on top of the cart. An interview was conducted with the Dietary Aide, Staff A, who confirmed the canisters contained hot coffee or hot water. Staff A further stated, she had already tested the coffee. The surveyor then inquired about the documentation regarding the temperature checks. She then referred the surveyor to the cook. An interview was then conducted with the cook, Staff E, who stated she was the one to note the temperatures of the food and beverages. She also stated she had gotten the temperature of the hot beverages, but she was unable to state what the temperatures were when tested . Upon further investigation, it was noted that the sheet for the documentation for food and beverages was blank for 02/19/25 for the lunch meal. It should be noted that the hot beverages were already in the containers on each of the carts and there was no evidence the temperatures were checked prior to the hot beverages being placed into the containers or were going to be checked prior to beverages leaving the kitchen. The staff on the floor do not check the temperatures on the unit, prior to serving. The surveyor was informed that the staff tests the temperature from the brewing machine, and they document the temperature on the log. On 02/19/25 at approximately 11:40 AM, a test of the coffee coming from the brewing machine tested at 169 degrees Fahrenheit. The staff then stated we will have to put ice in it to lower the temperature before serving. The surveyor requested the staff test the hot beverage content already in the canisters. Temperature checks of the hot beverage content in the canisters on the carts ranged from 122.8 F to 158.9 F. The Food Temperature Log documented the following: Temperature Standards: Cold foods should be at 40 degrees Fahrenheit or below, and hot foods should be at 140-170 degrees Fahrenheit. Temperatures are recorded before food is served. If food temperatures are not within ranges, corrective action must be taken before food is served to residents. Record below the temperature of all hot and cold foods, including modified textures and alternatives. Further review of the Food temperature log for February 2025 revealed multiple entries where the temperature documented for the hot beverage exceeded the above stated range: 02/19/25 - breakfast - 194F. 02/18/25 - breakfast - 178F. 02/09/25 - breakfast - 178F. 02/10/25 - lunch - 181F. 02/08/25 - dinner - 173F. An interview was conducted on 02/19/25 at approximately 11:40 AM with Cook, Staff F, who stated the temperature is checked by obtaining a cup of hot liquid from the brewing machine and is documented on the log. They had no explanation as to why there was no information documented for 02/19/25 and the hot beverages were already in canisters and ready to be sent to the floor. She further stated the aides on the floor distribute the trays and pour the hot liquid into the cups, they do not test the hot liquids. This is done in the kitchen. An interview with the Dietary Manager was conducted on 02/19/25 beginning at 12:00 PM. The surveyor inquired about the staff checking the temperature of the hot liquids. She stated that the staff usually test in the kitchen prior to serving. An interview was conducted on 02/19/25 at 1:29 PM with Cooks, Staff E and Staff F. The [NAME] does the temperature, right before serving. She tests the food and liquid. She tests from the brewing machines. Closer observation of the brewing machine did not indicate a temperature setting for liquid being dispensed. If the temperature is above the stated limit, they are supposed to put ice in the drink. They document the temperature from the Brewing Machine. They do not test the liquids in all the canisters. Another observation was conducted on 02/20/25 at 7:30 AM in the kitchen. Again, the food carts had hot beverage canisters already stored on the carts and the surveyor had been informed that one cart had already gone to the unit. The surveyor again requested to see the Temperature log for the hot beverages. Again, the log was incomplete for the temperature of the hot beverages. 2. Review of the facility's policy regarding Area of Focus: Basic Skin Management, revised 11/21/2024, documented All residents have a head-to-toe skin inspection upon admission/readmission, then completed weekly, and as needed by nursing. It is documented into PCC (Point Click Care). Further review of the clinical record for Resident #1 revealed the resident had an external fixator secondary to fracture tibia. The physician prescribed wound care for the area as follows: a. On 02/01/25, the physician prescribed clean pin sites (8) R/T [related to] external fixator on left leg with Betadine solution, pat dry and leave open to air every day-shift. b. On 02/01/25, the physician prescribed clean staples on the left upper thigh (near abdominal fold) with wound cleanser, cover with bordered Telfa dressing every day-shift. c. On 02/01/25, the physician prescribed clean stitches on left outer lower leg with wound cleanser, pat dry, cover with bordered Telfa dressing every day-shift. Review of the February 2025 Treatment Administration Record revealed the staff failed to place their initials in the appropriate box to indicate the treatment was performed as follows for the above 3 treatment orders: Monday, 02/03/25; Friday, 02/07/25, Monday through Wednesday, 02/10 - 02/12. An interview was conducted on 02/20/25 at approximately 3:30 PM with the Wound Care Nurse, Staff D, who performs treatments Monday through Friday. The surveyor inquired about the wound care being done. She stated, the girls usually tell me that I missed. Review of the Weekly Skin Checks revealed the staff conducted a skin check on admission, 01/31/25. There were no further weekly skin checks until 02/14/25. There was no documented weekly skin check for 02/07/25. An interview was conducted with the Director of Nursing on 02/20/25 at approximately 4:00 PM, who reported the weekly skin check apparently did not populate in PCC (Point Click Care).

Based on clinical and administrative record review and interview, the facility failed to ensure 1 of 3 sampled residents (Resident #1) grievance was acknowledged and an effort was made to promptly resolve the grievance. The findings included: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with a diagnosis which included Radiculopathy, lumbar region and she left the facility AMA (Against Medical Advice) on 10/15/24. The resident is alert and oriented in all spheres and is able to make needs known. The progress note dated 10/15/24 at 6:42 PM documented that the resident stated, I cannot be here anymore. During the administrative record review, a review of the facility's grievance log from October 2024 to December 2024, revealed no evidence of a grievance filed for Resident #1. An interview was conducted on 12/04/24 at approximately 11:25 AM with the Social Services Director (SSD). The SSD stated that she did not recall Resident #1 and acknowledged that she did not have a grievance and/or room change request for Resident #1. An interview was conducted on 12/04/24 at approximately 12:40 PM with the Licensed Practical Nurse, Staff A. The nurse confirmed that Resident #1 had expressed dissatisfaction with her roommate and the resident's constant yelling. She also recalled that the resident wanted another room. The resident would sit up at the nurse's station to get out of the room. She stated she would inform the SSD verbally or complete the form. She didn't recall what method she did or when she did it, however, she confirmed she did not see any documentation that she reported the resident's complaint. She further thought that a room change was made in reference to the roommate but didn't recall what happened with this situation. She further recalled that Resident #1 left the facility AMA.

Based on policy review, interview, and record review, the facility failed to ensure care and services were provided in a dignified manner for 6 of 9 sampled residents reviewed with dignity concerns (Residents #26, #49, #54, #74, #3, #372). The findings included: Review of the policy Dignity reviewed 09/25/23 documented, Policy: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. Review of the Grievance Log for the month of July 2024 revealed six customer service concerns. These concerns were related to inappropriate comments toward a family member, in front of residents, by a Certified Nursing Assistant (CNA) on 07/08/24; staff failing to introduce themselves at the beginning of the shift and being left in the shower alone when assistance was needed on 07/10/24; inappropriate comment by a CNA on 07/11/24; inappropriate comment and actions by the Activity Assistant on 07/18/24; a staff member grumbling in a foreign language after a resident request for care and witnessed altercation between staff and another family in the common area on 07/19/24; and complaints about a CNA during a shower on 08/08/24. 1) Review of the record revealed Resident #26 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a range of motion impairment to one arm and required substantial to dependent assistance for all Activities of Daily Living (ADLs). Although the Brief Interview for Mental Status (BIMS) score was documented as a 6, on a 0 to 15 scale, indicating some cognitive impairment, Resident #26 could hold a conversation to make her needs known and to express her feelings. Review of the current care plan initiated on 05/01/24, and revised 06/07/24, documented Resident #26 needed ADL assistance to maintain or attain her highest level of functioning. During an interview on 08/05/24 at 1:20 PM, when asked if staff treat her with respect and dignity, Resident #26 stated about two thirds (2/3) of staff are OK and the others have an attitude, especially when they clean me up. The resident stated sometimes it's just a look. Resident #26 volunteered that she has both Tylenol and ibuprofen, and that once she asked for an ibuprofen and the nurse wouldn't go get it stating she didn't have an order, adding that the nurse was nasty, referring to the nurse's attitude. Resident #26 finally stated she told the Unit Care Coordinator for the 200 unit, who told her she gets that a lot. During an interview on 08/08/24 at 11:27 AM, when asked if she had spoken with Resident #26 about staff having poor or nasty attitudes, the Unit Care Coordinator denied speaking with the resident about any staff concerns. When asked if she told the resident that she gets a lot of complaints about the staff, the Unit Care Coordinator stated she did not say that. 2) Review of the record revealed Resident #49 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of this same MDS documented the resident's prior functioning was independent, but upon admission needed partial to substantial assistance from staff for all ADLs except eating. Review of the current care plan initiated on 05/03/24 and revised on 05/07/24 documented Resident #49 needed ADL assistance to maintain or attain her highest level of functioning. During an interview on 08/05/24 at 3:15 PM, when asked if staff treated her with respect and dignity, Resident #49 stated, They are understaffed. The CNAs (Certified Nursing Assistants) are overworked and always running. When I was not as mobile, I had an accident (referring to an incontinent episode) because the CNA didn't come when I called. When I'm in bed and they ask me to turn, if I don't do it quick enough, they just push me over. Resident #49 clarified that the majority of staff are fine, but a minority are the problem. Resident #49 further volunteered, once when she returned to her room from therapy, she was in pain and asked to go back to bed. The resident stated the CNA responded with, as soon as I get back from my break. 3) Review of the record revealed Resident #54 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS documented the resident's prior functioning was independent, but upon admission needed the partial to moderate assistance of staff for mobility. Review of the current care plan initiated 07/19/24 documented Resident #54 needed ADL assistance to maintain or attain her highest level of functioning. During an interview on 08/05/24 at 10:45 AM, when asked if staff treat her with respect and dignity, Resident #54 stated, They have an attitude, like they don't want to be here. When I ask to get back into bed they say, 'I'll be back in two hours.' When I ring the bell for help, they come in, turn it off and say, 'I'll be back' or 'I'm busy. I have 10 other patients to take care of.' Resident #54 further stated when she is trying to talk to an aide, they don't listen to her and or she can't understand them. The resident further explained when staff come in to answer the call light, as they are turning it off, her roommate gets their attention, and they ignore her. Resident #54 stated their attitude is, don't bother me. The resident stated when she asked to go to the bathroom the other night before bed, the CNA stated, Why? You've already been three times. Resident #54 stated, That's none of her (the CNA's) business . so what. Resident #54 finally stated, It's always cold in here. And when they change me, they let me lie here half naked. 4) Review of the record revealed Resident #74 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 14, on a 0 to 15 scale, indicating he was cognitively intact. This MDS documented the resident had range of motion impairment on one side of both his upper and lower extremities and needed substantial to maximum assistance for all ADLs except eating. Review of the current care plan initiated on 12/06/21 documented Resident #74 had an ADL self-care performance deficit related to a stroke with left sided hemiplegia, and that his left upper extremity was flaccid (unable to move independently). During an interview on 08/05/24 at 11:31 AM, when asked if staff treat him with respect and dignity, Resident #74 stated, Staff are grumpy at night when I need to be changed. When I call for assist, staff come into my room and say, 'What do you need?' with an attitude. If I say I need to be cleaned up after a BM, they tell me they will come back later. By the time they get to it, it's hard and stuck to me, and feels like a 'grill brush on my butt.' Resident #74 also complained of the lack of fingernail care, stating he had been begging for his nails to be cut and trimmed for two weeks. An observation at that time revealed the fingernails were long and dirty. The nails to his left hand, with his fingers curled up due to his stroke, revealed the nails were nearly cutting into his palm. On 08/08/24 at 12:53 PM, Resident #74 was sitting up at his bedside, in a wheelchair, speaking with a friend. With permission from the resident to ask questions, when asked if the issue with his fingernails was just recently, as his usual aid had been on vacation for the past two weeks, Resident #74 stated it has been an ongoing problem. The resident then stated, My aid was not happy with me. She came back in and said, why do you tell them I don't cut your nails. I cut your nails. The surveyor had questioned the aid about the nail care process earlier that day. During this interview, the friend described a time when she was trying to call Resident #74, but he was not answering. The friend stated she then called the main number, the receptionist transferred the call to the nurses' station, she waited a bit and all the nurse said was, (Name of resident) doesn't want to talk to you, and then click, the nurse hung up on her. When asked if he said he didn't want to speak with his friend at any time, Resident #74 stated, I always want to talk with her. The friend further stated, The staff should know to put his phone and tablet where he can reach it when he gets up. He shouldn't have to tell them every day to put them nearby. He can't use his left hand. An observation at that time revealed the resident's tablet and phone, with the cords entangled, was stuck in his top drawer on the opposite side of the bed. Resident #74 again stated the aides have an attitude, especially when he needs to be cleaned up. 33103 5) Review of Resident #3's record revealed the resident was admitted to the facility on [DATE] with a diagnoses to include Major Depressive Disorder, Emphysema, and General Weakness. A review of the resident's Quarterly MDS (Minimum Data Set) assessment dated [DATE] documents her BIMS (Brief Interview for Mental Status) score of 8, which indicates she has moderate cognitive impairment. She requires Partial/Moderate assistance for toileting, upper body dressing, and personal hygiene. She requires substantial/maximum assist for lower body dressing, putting on and taking off shoes and to roll left and right. (The ability to roll from lying on back to left and right side and return to lying on back on the bed). On 08/05/24 at 2:30 PM, Resident #3 was observed lying in bed leaning towards the right side of the bed. The Surveyor asked her if she was uncomfortable in that position. She stated, yes and attempted to straighten herself up in bed but was unable to. The Surveyor put her call light on to have an aide come to her room to assist her. At 2:55 PM Staff E, CNA (Certified Nursing Assistant) walked into the room. The Surveyor stated the Resident in Bed B needed assistance in repositioning. Staff E, CNA then stated, I have already been in here four times today and repositioned her. 39142 6) Record review revealed Resident #372 was a new admission, who was admitted to the facility on [DATE], with his comprehensive assessment still in progress. Resident #372 was assessed for his Brief Interview of Mental Status (BIMS). Resident 372 had a BIMS score of 12/15, indicating moderate cognitive impairment. Section D, Mood, revealed a score of 00, which indicated no issues with mood. Section E, Behaviors, indicated Resident #372 had no behavioral issues. Section I, Pertinent Diagnoses, revealed the resident had the following: 1. Cancer 2. Coronary Artery Disease (CAD) 3. Hypertension (HTN) 4. Multi Drug Resistant Organisms (MDRO) 5. Diabetes Mellitus (DM) 6. Stroke 7. Parkinson's disease Resident #372 was identified to need mobility devices that included a wheelchair and walker. On 08/06/24 at 10:32 AM, an interview was conducted with Resident #372. When the resident was asked about his care he expressed that staff took too long to respond to the call light. When asked to explain, Resident #372 stated he has to wait for help to go to the bathroom and he had an accident in his pants, multiple times. Resident #372 stated he did not remember how many times. When asked how he felt about that Resident #372 stated the staff ignores me, I feel ignored.

Based on observations and interviews the facility failed to provide a safe, clean, comfortable homelike environment 3 of 3 units (Unit 100, 200 and 400). The findings included: During observations on 08/05/24, 08/06/24 and 08/07/24, the following environmental concerns were noted in the facility: Rooms: 103-Observations made on 08/05/24 at 9:05 AM, the ceiling vent showed rust and dust. 104-Observations made on 08/06/24 at 10:43 AM, there was a stain on the wall under the window that appeared to be liquid splashed that was dripping down on the wall. 105-Observations made on 08/05/24 at 9:45 AM, the ceiling vent showed rust and dust; The floor was scuffed and paint peeling behind the bed. 106-Observations made on 08/05/24 at 9:23 AM, there was paint peeling from the wall behind bed. 110-B Observations made on 08/06/24 at 10:55 AM, there was a hole in the wall by the window and by the dresser across from bed-B. 111-Observations made on 08/06/24 at 11:15 AM, there was paint peeling from the wall across from bed-A and at the entrance of the room; The ceiling vent was rusted. 112-A Observations made on 08/05/24 at 11:22 AM, the resident's closet door hinge was broken. The seat pad in the bathroom was torn. 113-B Observations made on 08/05/24 at 10:50 AM, the light behind the bed had no string for the resident to turn the light on; The paint on the walls were peeling. 114-B Observations made on 08/05/24 at 2:30 PM, the wheelchair pad was torn. 115 Observations made on 08/06/24 at 11:11 AM, the ceiling vent was rusted and dusty. 123-B Observations made on 08/06/24 at 12:16 PM, the ceiling vent was rusted and dusty. This was observed after Resident # 13's daughter pointed to the AC ceiling vent, which was noted with blackish/brownish discoloration. 126-B Observations made on 08/06/24 at 9:31 AM, the ceiling vent was noted with blackish/brown discoloration. 128-B Observations made on 08/06/24 at 9:34 AM, the ceiling vent was noted with blackish/brown discoloration. 203-B Observations made on 08/05/24 at 11:44 AM, the floors were dirty, and the resident stated it rarely gets cleaned up; The walls were in disrepair; and in need of a deep clean; Observations made on 08/06/24 at 12:10 PM, the ceiling vent was dusty. The vinyl base on the bottom of the wall behind bed A was peeling away from the wall. 206-B Observations made on 08/06/24 at 12:14 PM, the ceiling vent was dusty 207-B Observations made on 08/06/24 at 12:15 PM, the ceiling vent was dusty and rusted. 400-unit rooms-Observations made on 08/06/24 at 12:10 PM, ceiling vents were dusty. The 400-unit light by the entrance to the unit was very dusty. Observations made on 08/05/24 at 1:05 PM, the hallway by rooms 107-116, the handrail had brown paint peeling off and exposed wood that was not smooth; and a resident may get a splinter from the wood. The vinyl at the base of the wall was peeling away from the wall. Observations made on 08/06/24 at 12:20 PM, the ceiling vent in the laundry room, over the clean area by the dryers was dusty. A follow-up tour was completed on 08/07/24 at 10:08 AM with Director of Environmental, the Director of Maintenance and Regional [NAME] President. The tour included the 100, 200 and 400 units. The 400 unit which has 12 rooms was toured to check the ceiling vents and found the ceiling vents were very dusty. The Director of Maintenance stated the walls are the way they are because of residents hitting their wheelchair or furniture hitting the wall. He stated they will go around to all the rooms and check all ceiling vents.

Based on record review and interview, the facility failed to ensure adequate staffing to provide nursing and related services to meet the resident's needs and in a manner that promotes each resident's rights, physical, mental and psychosocial well being for 13 of 24 sampled residents. This failure was evidenced by verbal complaints of a lack of staff by Residents #57, #54, #12, #74, #18, #26, #29, #3, #49, #40, #34, #372, #366, or their family members. This was also evidence by the lack of dignified care for Residents #3, #26, #49, #54, #74, and #372. The findings included: 1) During interviews by the survey team on 08/05/24 and 08/06/24, the following concerns were voiced by residents and families. a) On 08/05/24 at 10:17 AM, Resident #57, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact, stated that the Certified Nursing Assistants (CNAs) rush during care to get done and go to the next resident. The resident stated they don't have enough time to get their work done, providing the example that it took them a week of the resident requesting for them to help her with a broken fingernail to get it trimmed. The resident stated she doesn't get the care that she needs as staff are too busy to get her up as she wants, and has been in bed too much the past month and is generally declining. Resident #57 explained she believes they now transfer her with the mechanical lift because they were rushing her during the sit to stand lift transfers, not allowing time for her body to adjust when going from a lying to sitting position. This led to her feeling a head rush and becoming lightheaded. The resident voiced she is terrified of the mechanical lift. The use of a mechanical lift requires two staff. The census at the time of the survey was 108, with 52 residents on Riverwatch, the unit where Resident #57 resides. Of the 52 residents on that unit, 25 required two person assistance for either care, transfers, or both. b) On 08/05/24 at 10:45 AM, Resident #54, who was cognitively intact with a BIMS of 14, stated sometimes staff tell her they will be back in two hours or I'm busy I have 10 other patients to take care of. The resident explained her call bell will either ring for hours or they come in and turn it off and say they will be back. c) On 08/05/24 at 11:15 PM Resident #12, who was cognitively intact with a BIMS of 12, complained there was not enough staff to care for him timely. The resident stated it takes 30 to 60 minutes for staff to answer call lights. The resident stated when he fell on ce it took 30 minutes to help him after the fall, even with him yelling out for help. d) On 08/05/24 at 11:42 AM, Resident #74, who was cognitively intact with a BIMS of 14, stated that staff are always running, and they tell her they never get breaks and that they are short staffed. e) On 08/05/24 at 11:57 AM, Resident #18, who was cognitively intact with a BIMS of 15, stated it can take up to two hours for staff to answer the call light. f) On 08/05/24 at 1:23 PM, Resident #26, who had some cognitive impairment with a BIMS of 6, but could hold a conversation, stated she felt they could use a little more staff. The resident stated she can sometimes tell when she has to go to the bathroom, but by the time the aide arrives she has gone in her diaper. when asked how that makes her feel, Resident #26 stated, terrible. g) On 08/05/24 at 1:51 PM, a family member of Resident #29 stated there was not enough staff on all shifts, and that the weekends are the worse. h) On 08/05/24 at 2:30 PM, when asked if there was enough staff, Resident #3, who had some cognitive impairment, stated there was not, explaining she needed help repositioning and staff take a long time to answer the call bells. i) On 08/05/24 at 3:15 PM, Resident #49, who was cognitively intact with a BIMS of 15, stated the facility was understaffed, the CNAs were overworked, and they were always running. Resident #49 stated she was not as mobile as she was now, she had an accident (voiding incontinence) because it took too long for the CNAs to answer the call light. The resident further explained if she does not turn quickly enough when they ask her to while in the bed, the CNAs will just push her over, and not very gently. j) On 08/06/24 at 8:35 AM, Resident #40 who was cognitively intact with a BIMS of 15, stated there was not enough staff, and that they are under paid and over worked on all shifts. Resident #40 stated she waits an hour for staff to assist her, and by that time she has soiled my diaper. j) On 08/06/24 at 9:56 AM, Resident #34, who was was cognitively intact with a BIMS of 15, stated there was not enough staff and stated he thought it was a corporate issue for not bringing in the staff. k) On 08/06/24 at 10:38 AM, Resident #372, who was cognitively intact with a BIMS of 12, stated staff do not answer call bells timely and he feels ignored. The resident further stated the staff do not answer the call bell timely, so he ends up being incontinent instead of helped to the bathroom. l) On 08/06/24 at 1:19 AM, Resident #366, who was cognitively intact with a BIMS of 14, stated he waits a long time for assistance to get out of the wheelchair and back to bed. During an interview on 08/08/24 at 12:29 PM, the Director of Nursing (DON) stated they have plenty of CNAs, but the weekends are a challenge because they work every other weekend. The DON was made aware of the number of complaints related to staffing and agreed something needed to be done. 2) The survey process revealed the facility failed to ensure care and services were provided in a dignified manner for Residents #3, #26, #49, #54, #74, and #372 (Refer to F550). These residents stated there was not enough staff to care for the needs of residents and that the care they did receive was often in an undignified manner.

Based on policy review, observation, record review, and interview, the facility failed to ensure of proper nail care for 1 of 3 sampled residents reviewed for Activities of Daily Living (ADL's) (Resident #74). The findings included: Review of the policy Nail Care reviewed 08/23/23 documented, Policy: The resident will receive assistance as needed to complete activities of daily living (ADLs). Procedure: For general fingernail care for most residents, the following procedure will be followed: 1. Ensure fingernails are clean and trimmed to avoid injury and infection. Review of the record revealed Resident #74 was admitted to the facility on [DATE] with a diagnosis to include hemiparesis secondary to a stroke. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. Further review of this MDS documented Resident #74 needed substantial to maximum assistance with bathing, showering, and personal hygiene. Review of the current care plan initiated on 12/06/21 documented Resident #74 had an ADL self-care performance deficit related to a stroke with left sided hemiparesis with his left arm being flaccid. This care plan instructed staff to check the resident's nail length and to trim and clean them on bath days and as necessary. Review of the Certified Nursing Assistant's (CNA's) documentation in the electronic medical record revealed the shower schedule for Resident #74 was every Monday and Thursday during the 7 AM to 3 PM shift. Further review of the documentation for the past two weeks revealed the resident received a shower on 07/29/24, 08/01/24 and 08/05/24, along with bed baths on 07/22/24, 07/25/24, 07/27/24, 08/03/24, and 08/04/24. This would have provided 8 opportunities during the past two weeks for staff to trim and clean the resident's fingernails with bathing and showering. During an interview on 08/05/24 at 11:28 AM, when asked how he was doing, Resident #74 stated in a frustrated tone, that he had asked everyone, CNAs, nurses, and even the maintenance man, about getting his fingernails trimmed, as he held up his right hand. An observation of his fingernails revealed they were long, extending past the end of each finger, with a black substance under the nails. Observation revealed the resident's left fingers were curled up, and the fingernails were long and nearly digging into his palm. An observation and interview on 08/06/24 at 9:50 AM, revealed the resident's fingernails had been trimmed, although some black substance was still noted under a few of the nails. Resident #74 stated he did not understand why it took so long, again stating he had been asking constantly for the past couple of weeks. The resident stated, I get my toe nails trimmed every two months like clockwork. Why can't I get my fingernails done routinely as well. During an interview on 08/08/24 at 11:13 AM, when asked the process for trimming and cleaning a resident's fingernails, Staff A, CNA, stated she trims and cleans the nails whenever they need to be done. When asked about how often she trimmed and cleaned the fingernails for Resident #74, the CNA stated about once a week. When told he had been asking for the past two weeks, Staff A stated she had been on vacation the past two weeks. During a follow-up interview on 08/08/24 at 12:53 PM, when asked if the issue getting his fingernails trimmed and cleaned was just over the past two weeks, Resident #74 stated it had been an ongoing issue.

Based on record review and interview, the facility failed to respond to and honor request for insulin sensor use for 1 of 6 sampled residents reviewed for choices (Resident #54). The findings included: Review of the record revealed Resident #54 was admitted from the facility's associated Independent Living (IL) facility, to the skilled nursing facility, on 07/18/24 with a diagnosis of Diabetes. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scaled, indicating she was cognitively intact. Review of the current orders revealed as of 07/18/24 staff were to complete an accucheck twice daily for diabetes. This process is completed by obtaining blood via a finger stick to obtain a blood sugar level. Review of a progress note written on 07/27/24 by the Nurse Practitioner documented, The patient is unsure about the facility's protocol for glucose monitoring and would like to have her sensor replaced and used for monitoring. (The sensor is attached to the resident's arm and is read by a monitor to obtain a blood sugar level, without having to do a finger stick, that can often be painful). During an interview on 08/05/24 at 11:10 AM, when asked if she was receiving insulin, Resident #54 stated she was. The resident further stated she had a blood sugar sensor in her left arm, that was up two weeks ago, but that the facility would not replace it or use it. During an interview on 08/08/24 at 9:35 AM, when asked about the insulin sensor for Resident #54, the 200 Unit Care Coordinator stated, She doesn't have her monitor. It's next door at (name of IL). When asked if someone could get it for her, the Unit Care Coordinator stated she could call over to the IL and try to get the monitor for Resident #54. The Unit Care Coordinator later informed the surveyor the items needed to do the sensor blood glucose level were on the way over from next door.

Based on observation, interview, policy review, and manufacturer's instructions, the facility failed to follow manufacturer's instructions for disinfection of the glucometer (a device used to obtain a blood sugar level from a resident's blood sample) before use for 2 of 3 sampled residents observed. On 01/04/21 Staff B, a Registered Nurse (RN), used Clorox Clean-Up Disinfectant Cleaner with Bleach spray, which was a non-approved disinfectant as per the manufacturer's instructions for the glucometer as per the EPA number, for the blood glucose monitoring of Resident #55. On 01/05/21 Staff C, an RN, cleaned a glucometer with an alcohol wipe and then attempted to use the same glucometer that had not been disinfected to obtain a blood glucose level for Resident #19. After surveyor intervention, Staff C then obtained a Clorox Clean-Up Disinfectant Cleaner with Bleach spray, the non-approved disinfectant, and failed to follow the manufacturer's instructions for that disinfectant. The facility failed to attempt to order an alternate approved disinfectant as per the manufacturer's instructions when their usual brand (Super Sani-Cloth Germicidal Disposable Wipes) was on back order. Staff D, a Certified Nursing Assistant (CNA) who was also the designated Central Supply person, did not call the supply company when the ordered Super Sani-Cloth wipes were not delivered, failed to promptly inform anyone at the facility of the lack of delivered disinfectant, and failed to order a manufacturer's instruction listed alternative. The facility put in place for the nursing staff, at an unknown time for an unknown amount of time, the use of BruTab [MEDICATION NAME] Disinfectant Tablets, another non-approved disinfectant as per the glucometer's manufacturer's instructions. The facility put in place for the nursing staff, at an unknown time for an unknown amount of time, the use of Clorox Clean-Up Disinfectant Cleaner with Bleach spray, another non-approved disinfectant as per the glucometer's manufacturer's instructions. The failure to disinfect the glucometer between residents poses a likelihood of transferring blood borne infections. This practice increases the likelihood for cross contamination and increased risk for exposure to [MEDICAL CONDITION] through contaminated equipment and supplies. The facility had seven medication carts. On 01/05/21, two of the seven medication carts lacked any type of disinfectant, and three of the seven carts had the non-approved Clorox Clean-Up spray available for use. The facility had 25 residents who received blood glucose monitorings, five of whom resided on units where the normally used medication carts lacked any disinfectant (Residents #12, #18, #19, #76, and #79). The facility failed to ensure nursing staff did not handle pills with their bare hands for 1 of 5 sampled residents observed during the medication pass observations (Resident #63), and during one random observation for Resident #51. The facility failed to ensure hand hygiene between residents during the delivery of lunch trays on 01/04/21 on one of three units (Riverwalk), affecting Residents #60, #66, and #77. A Immediate Jeopardy (IJ) Removal Plan was received on 01/07/21 at 6:13 PM. Based on the review and verified implementation of the IJ Removal Plan the scope and severity was decreased to a (D) for no actual harm with a potential for more than minimal harm that is not immediate jeopardy. The findings included: 1) During a medication pass observation on 01/04/21 at 11:52 AM, Staff B, a Registered Nurse (RN), gathered supplies to perform an blood glucose level for Resident #55. The RN obtained a 4-ounce plastic cup with two tissues and a bottle of Clorox Clean-Up Disinfectant Cleaner with Bleach, and sprayed the tissues with the disinfectant. The RN stated out loud she did not believe that would work, and replaced the tissues with two paper towels. The RN followed manufacturer's instructions during this observation, but it was later determined the Clorox Clean-Up Disinfectant Cleaner with Bleach was not an approved product as per the manufacturer's instructions. During a medication pass observation on 01/05/21 at 4:08 PM, Staff C, a RN, obtained a glucometer from the medication cart and obtained a blood sample and blood sugar level from Resident #79. The RN returned to the medication cart and stated, I didn't have any more alcohol (while in the residents room) so I need to clean it (the glucometer) again. The RN took an alcohol swab, cleaned off the glucometer, and placed it into the plastic bag, placing it into the top drawer of the medication cart. During the continued observation on 01/05/21 at 4:29 PM, Staff C stated she needed to obtain a blood sugar level for Resident #19. The RN took the same glucometer that had been used for Resident #79, gathered the medications for Resident #19 along with the other supplies needed to obtain a blood glucose level, stated she was ready to provide the medications and do the blood glucose level, and went into the room of Resident #19. The surveyor intervened, asked Staff C to step into the hallway, and asked the RN if the glucometer was disinfected. Staff C did not answer, so the surveyor asked if the alcohol swab was what she usually used to disinfect the glucometer. Staff C stated she usually used the purple top wipes, referring to the Super Sani-Cloth brand, and further stated, But I was told it was OK to use the alcohol. When asked who told her it was OK to use the alcohol, Staff C explained she had asked the Director of Nursing (DON) earlier that day, and the DON had told her she could use the alcohol swab. During an interview on 01/05/21 at 4:42 PM, the DON explained the Super Sani-Wipes were currently on back order. The DON explained the nurses were using BruTab [MEDICATION NAME] Disinfectant for awhile, and explained it had to be mixed up/prepared and changed every 3 days, and because the bottle was too large, the top was being pushed down and leaked into the medication cart drawer when closed, so they changed to the Clorox Clean-Up Disinfectant Cleaner with Bleach spray. The DON and Administrator were asked to provide evidence as to when each product was approved for use and the timeframes in which the two non-approved disinfectants were used, and as of the exit conference on 01/08/21 neither had been provided. Staff C was then instructed by the DON and Regional Clinical Consultant to get the Clorox Clean-Up Disinfectant Cleaner with Bleach spray in order to complete the blood glucose level for Resident #19. During the continued observation with Staff C on 01/05/21 at 4:55 PM, the Clorox Clean-Up Disinfectant Cleaner with Bleach spray was found in the Oceanview unit's second medication cart. The RN used a gauze pad saturated with the disinfectant spray to wipe down the glucometer, and immediately took a dry gauze pad and dried off the glucometer. The RN confirmed she had just used a dry gauze and stated, Shouldn't I dry it off? The surveyor asked the RN to read the instructions on the Clorox spray bottle which documented, To clean and disinfect hard, nonporous surfaces: Spray product 4-6 inches from surface until thoroughly wet. Let stand 30 seconds, 1 minute for Norovirus. Wipe with a wet sponge or cloth and rinse with water. No scrubbing required. The RN stated, Oh ok, I'll wait 30 seconds. When asked when she had worked last and what disinfectant product was available, Staff C stated she had worked Saturday 01/02/21 and that she still had the Super Sani-Cloth wipes available in her medication cart. During a supplemental interview on 01/05/21 at 6:02 PM, the DON was asked what Staff C asked her earlier that day. The DON stated Staff C came to her that morning and asked, What if we don't have disinfectant to clean the glucometer, what should we use? The DON stated that she told her she would use the alcohol. The DON explained that she did not realize the nurse had actually run out of the (disinfectant) wipes or the Clorox, and explained she had failed to clarify with Staff C. The DON further stated she was thinking it was just a what if question that a surveyor may ask. The DON explained they started using the BruTab at the start of the pandemic for general cleaning, and also tried using it for the glucometers, again stating that it was leaking in the medication carts. The DON explained that a few weeks ago she noticed the Sani-wipes were getting low, and when they had no back up supply as they were on back order, the DON suggested to Staff Development to get Clorox bleach wipes or spray. The DON stated the Staff Developer called the glucometer manufacturer, who told them if they don't have any disinfectant, they need to use the alcohol swabs. During this interview the DON confirmed at the present time two of the seven medication carts lacked any disinfectant and three of the seven carts had the Clorox Clean-Up Disinfectant Cleaner with Bleach spray. Two carts, both located on the Riverwalk unit, had the Super Sani-Cloth wipes. On 01/06/21 at 9:09 AM observation and interview with Staff D, a Certified Nursing Assistant (CNA) and designated Central Supply person, revealed there were no Super Sani-Cloth wipes in the supply area, and that she had received partial or no shipments of the product in December 2020. When asked what she did when she did not receive any of the Super Sani-Cloth disinfectant wipes, Staff D stated she ordered PDI Sani-Hands Insta Hand Sanitizing Wipes to replace the Super Sani-Cloth wipes, showing the surveyor the supply of hand sanitizing wipes. The DON was present during the interview and agreed the hand sanitizing wipes were not disinfectant wipes. The DON again stated when they didn't have the Super Sani-Cloth wipes in each cart, they started using the BruTab, but the Staff Developer noticed they were leaking, so the DON suggested they get the Clorox wipes or spray. During an interview on 01/06/21 at 9:13 AM, the Staff Developer explained the BruTab was leaking into the medication carts as the bottles were too tall, and the nurses were complaining about the leaking product. The Staff Developer explained that on Monday 01/04/21, she asked the Floor Technician to give each nurse a bottle of the Clorox spray, and he must have missed one. The Staff Developer explained that she educated each nurse as to how to use the Clorox spray for the glucometers, by thoroughly spraying two paper towels for use during the process. During a supplemental interview on 01/06/21 at 9:51 AM, Staff C, the RN, clarified she used the purple top wipes (Super Sani-Cloth wipes) for the 11 AM blood glucose levels on 01/05/21, and explained that was when she went to the DON, asked the DON to get her some more, and that was when the DON said if she was out of them she could use the alcohol. On 01/06/21 at 9:53 AM the DON was asked specifically what Staff C stated the previous day. The DON stated she said, If I don't have disinfectant what should I use for the glucometers. When asked if the RN told her she was out of them or ask her to get some, the DON stated, No. The DON again stating she thought it was a hypothetically questions and stated, In retrospect, I should have delved further. An interview on 01/06/21 at 10:10 AM with the Infection Control Preventionist (ICP) revealed they found some individual packets of PDI Sani-Cloth Bleach Germicidal Disposable Wipes in one of the carts on the Bayview unit, and distributed them to the carts in the facility that had none the previous evening. An observation of the Oceanview unit medication carts at that time, the unit that housed 4 of the 5 residents who resided on a wing that had a cart with no disinfectant, revealed a bottle of the Clorox spray (non-approved as per manufacturer's instructions) on one cart and the PDI Sani-Cloth individual packets on the second medication cart. Review of the blood glucose level audit completed by the Assistant Director of Nursing (ADON) on 01/05/21 revealed Residents #18, #19, #76, and #79 resided on Oceanview and were serviced out of a medication cart that lacked any disinfectant, and Resident #12 resided on Oceanview and was serviced out of the second cart that lacked any disinfectant. This same audit revealed a total of 25 residents in the facility that currently received blood glucose levels. During an interview on 01/06/21 at 2:02 PM, the DON confirmed Staff D, the Central Supply person, did not inform her they were not receiving the Super Sani-Cloth wipes. The DON explained that on a corporate level they had decided to use the BruTab product. The DON was again asked to provide evidence of this decision and as of the exit conference on 01/08/21 it was not provided. During a subsequent interview on 01/06/21 at 3:44 PM, Staff D, the Central Supply person was asked what she would do if she didn't receive a product that she ordered. Staff D stated she would call the company, which she did today. Staff D confirmed she had not called the company prior to today as she thought they were just back ordered. Staff D stated the company for the Super Sani-Cloth wipes told her today that the order was in the system, but that she was ordering the wrong size. Staff D further stated that does not make sense as she has ordered the smaller ones in the past. Staff D also confirmed she had not notified anyone in the facility of the partial order received or the lack of a delivered order as she just assumed they were back ordered. During an interview on 01/07/21 at 8:55 AM, the ICP was asked what system or process do you have to monitor the disinfectant supply for the glucometers. The ICP stated, We normally have wipes. I don't know what happened. I always make sure the nurses have supplies. The ICP explained that she rounds every morning to speak with the nurses to ensure supplies, and the staff usually tell her when they run out. The ICP stated she does not routinely go into Central Supply, but does have access to the storage area. The ICP confirmed Staff C, the RN did not inform her she ran out of the Super Sani-Cloth wipes and Staff D, the Central Supply person did not inform her she was having problems ordering them. When asked if there is a process when an item is backordered, the ICP stated, If Central Supply would have told the Administrator the (Super Sani-Cloth) wipes were on back order, I'm sure we would have gotten something else. The ICP stated there were individual disinfectant packs in the building on other carts that she would have redistributed. Review of the facility policy Cleaning and Disinfection of the Glucometer revised 06/28/18 documented, Equipment and Supplies: Super Sani-Cloth or Sani-Cloth Plus wipe (individual wipe) or an equivalent product that kills [MEDICAL CONDITION] and blood-borne pathogens. Note the product must contain specific language addressing these two criteria. Damp paper towel for cleaning (if visible blood or body fluids are seen on the machine) . Procedure: Follow the steps below after you have taken the glucometer reading per the policy/procedure. 6. Use the damp paper towel to remove any visible blood or body fluids. Dispose of the paper towel appropriately. 7. Pick up the glucometer from the first barrier and disinfect it with a Super Sani-Cloth wipe or an equivalent product that kills [MEDICAL CONDITION] and blood-borne pathogens. Follow the manufacturer's guidelines for wet time when applying disinfectant. Note that this facility policy lacks any information related to the use of a disinfectant that has been approved by the glucometer manufacturer. Review of the manufacturer's glucometer instructions documented, Cleaning and Disinfecting the meter: To minimize the risk of transmitting blood borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The meter should be cleaned and disinfected after use on each patient. The (name of glucometer) may only be used for testing multiple patients when standard precautions and the manufacturers disinfection procedures are followed. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfecting procedure is needed to prevent the transmission of blood borne pathogens. Only wipes with EPA registration numbers listed below have been validated for use in cleaning and disinfecting the meter. Any disinfectant product containing these EPA registration numbers may be used on this device. Please read the manufacturer's instructions carefully before using their wipes on the meter. The list of approved disinfectant brand names included Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels with Bleach, Super Sani-Cloth Germicidal Disposable Wipe, and CaviWipes1. Further review of the manufacturer's glucometer instructions documented, Note: Two disposable wipes will be needed for each cleaning and disinfecting procedure, one for cleaning and a second wipe for disinfecting. Cleaning: . Step 3 Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette to clean blood and other body fluids. Disinfecting: . Step 6 Wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens. Step 8: Treated surface must remain wet for recommended contact time. Please refer to the (name of glucometer) user manual for [MEDICAL CONDITION] contact times. For all other contact times, refer to wipe manufacturers' instructions. On 01/07/21 at 1:28 PM, the Regional Clinical Consultant provided documentation from the glucometer manufacturer revised 3/20 that documented, (name of company) is aware of a potential shortage of our validated disinfectant wipes for the (name of glucometer). As a reminder, below are the wipes that have been validated and their EPA number. Note the list of approved disinfectants did not change. This memo further documented if a different wipe or disinfectant is used other than those listed due to supply issues, close monitoring of function and performance is strongly recommended. Review of the packing slips provided by Staff D, the Central Supply person revealed the last shipment of Sani-Cloth wipes received by the facility was a partial shipment of 2 of the 5 requested cases, ordered on [DATE]. Supplemental orders in December 2020 and January 2021 were not filled. Review of the policy Blood Glucose Monitoring revised 07/30/20 documented to refer to Lippincott procedure: Blood glucose monitoring, long-term care. Review of the Lippincott procedure documented to refer to the manufacturer's instructions related to calibration and quality-control testing, and that most health care facility-based glucose monitors undergo quality-control testing every 24 hours. Review of the glucometer's manufacturer's instructions lacked a specific timeframe for quality-control testing. Review of the Quality Control Records for all seven medication carts, with each cart having two glucometers, for December 2020 and January 2021, the timeframe of the back-ordered approved disinfectant, lacked evidence of quality-control testing being done consistently every 24 hours. The Riverwalk unit lacked approximately thirty-five dates for quality-control checks, the Oceanview unit lacked approximately 37 dates, and the Bayview unit approximately 38 dates. On 01/07/21 at 2:07 PM, the Administrator, DON, Regional Clinical Consultant, and Regional Operations Consultant were informed of the Immediate Jeopardy (IJ) related to Infection Prevention and Control for the failure to properly disinfect glucometers between residents as per their own policy and manufacturer's instructions. During this notification it was revealed the revised notification from the glucometer's manufacturer dated 3/20 related to the manufacturer's acknowledgement of the potential shortage of approved disinfectants, was sent to and noted by the facility's corporate personnel, but was not shared at the facility level. A Immediate Jeopardy Removal Plan was received on 01/07/21 at 6:13 PM with the following evidence of removal: a) 01/06/21 and signed 01/07/21 - Education to the DON related to clear communication with nursing staff including advise for approved disinfecting products for glucometers. b) 01/07/21 - Education to Staff D, the Central Supply person related to checking with each nurse to ensure disinfectant is available on each medication cart. Educated to inform administrator if supply orders are rejected or supplies are running low. c) 01/05/21 - Education to Staff C, the RN, as to proper cleaning and disinfection of glucometers. d) 01/06/21 and 01/07/21 - Education to 42 of 44 active nurses related to proper cleaning and disinfection of glucometers. The remaining two nurses were on leave. e) 01/07/21 - Glucometer Cleaning audits/demonstrations from 14 nurses currently at the facility. f) 01/07/21 - Medication Cart Disinfection Supply audit for all medication carts g) 01/07/21 - Supply Order audit by administrator documenting the arrival of approved disinfectant on 01/06/21 with additional supply arriving on 01/08/21. h) 01/07/21 - QAPI meeting related to the IJ removal plan with Medical Director via phone, Administrator, DON, ICP, and Risk Manager. Additional interview related to the IJ removal were conducted as follows: i) 01/08/21 at 8:21 AM - Staff D, the Central Supply person was instructed that she has to go around to each medication cart and speak with each nurse on a daily basis and every Friday evening to ensure they have enough disinfectant, and document the same. She will have them open cart and verify. If anything is back-ordered, Staff D will promptly call the company to see what the issue is and report it to the DON and Administrator. j) 01/08/21 from 10:58 AM to 11:14 AM - Interviews with 3 of 4 direct care nurses in the facility along with the Riverwalk Unit Manager revealed proper verbalization of glucometer cleaning and disinfection using the approved disinfectant, along with daily and as needed quality-control checks. The Immediate Jeopardy Removal Plan was approved by the Agency on 01/08/21 with an effective date of 01/07/21. 2) During a random observation on 01/05/21 at 9:08 AM, Staff A, a Registered Nurse (RN) was standing at her medication cart near the room of Resident #51. The nurse popped each pill from the bubble pack directly into her bare hand and then dropped them into a small medication cup sitting on top of her medication cart. The RN then crushed all the pills and entered the room of Resident #51. The RN confirmed she gave the pills to Resident #51 upon return to her medication cart. During a supplemental interview on 01/05/21 at 5:34 PM, Staff A was asked why she popped the medications for Resident #51 directly into her bare hands that morning. The RN stated she did not realize that she did that and agreed she should not be touching the pills, further stating she should pop them directly into the medication cup. During the medication pass observation for Resident #63 on 01/08/21 at 8:38 AM, Staff E, a Licensed Practical Nurse (LPN) obtained 6 pills for administration and placed them in a small medication cup. The LPN also had a small cup of applesauce, and stated Resident #63 preferred to take the pills whole in applesauce. While at the bedside, the LPN scooped out one pill at a time from the small medication cup and dropped it into the applesauce, and then scooped the pill and applesauce onto the spoon to give to the resident. During this process, the LPN spilt the small cup and one pill rolled out onto the disposable tray. The LPN picked up the pill with her bare hands and dropped it back into the medication cup. Review of the facility's policy 6.0 General Dose Preparation and Medication Administration revised 01/01/13 documented, 3.4 Facility staff should not touch the medication when opening a bottle or unit dose package. 3) An observation of the passing of lunch trays on the Riverwalk unit began on 01/04/21 at 12:35 PM. One of the staff passing out the trays was Staff F, a Certified Nursing Assistant (CNA). On 01/04/21 at 12:44 PM, Staff F served a lunch tray to Resident #4, physically assisting the resident to sit up. Staff F failed to do any hand hygiene, went directly to the food cart and delivered a tray to Resident #66, opening up all the items on the tray. Without any hand hygiene, Staff F obtained and delivered a lunch tray to Resident #60, readjusting her bedside table and looking in her closet, then washed her hands. Continued observation revealed Staff F obtained a lunch tray for Resident #53, provided it to the resident and then provided a lunch tray to Resident #77, physically assisting her to set up in the bed. Staff F did not do any hand hygiene, left the room and went directly to the clean laundry area to get a towel, when the surveyor stopped the CNA from getting into a full clean cart of linens and asked her to either wash her hands or hand sanitize. When told she was observed going between residents without hand hygiene, the CNA immediately stated, I washed my hands. When told she only washed her hands once between multiple residents, the CNA agreed she needed to do hand hygiene between every resident.

Based on observation, record review and interview, the facility failed to provide the necessary care and services for 3 of 22 sampled residents as evidenced by lack of pain management during wound care for Resident #377 who vocally complained of pain during wound care and whose family also expressed the resident's constant complaints of pain, by failure to reassess the effectiveness of pain management for Resident #363 with daily use of "as needed" pain medication and for Resident #34 with abnormal laboratory test results with no medical interventions whose pertinent [DIAGNOSES REDACTED]. The findings included: 1) Review of the clinical record for Patient # 377 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the facility with an Unstageable wound on the resident's Sacrum measuring 7 x 5.5 depth 0.2, 100% Necrotic Tissue. On 6/30/2011, the Wound sheet identified a Stage III - 5.8 x 3, 0.3, small drainage, no odor serous drainage granular underneath slough. Wound care physician evaluated the resident on 6/29/2011 and documented, "Necrotic tissue in wound, present on admission measuring 5.8 x 3 granulation unhealthy/inadequate necrotic tissue, excessive yellow tissue mild drainage; Stage III The prescribed treatment was Santyl". An interview with the resident prior to the observation of the dressing change on 6/30/2011 at 11:00 AM, who informed the surveyor she was in pain and stated that it was her bottom that was hurting. An observation of the wound care was conducted on 6/30/2011 at 11:05 AM with the Wound Care Nurse (WCN). The WCN asked the resident how was her pain, the resident stated it was a little better but her bottom was hurting. The nurse also clarified with the resident where her pain was and she specified that the pain was not from her hip but her bottom. The nurse did not ask the resident to qualify the pain on a numeric scale nor was the resident asked if pain medication was needed. The resident's daughter came into the room and requested to see the area on her mother's bottom "because my mother is constantly saying she is hurting there". The nurse proceeded to perform the dressing change. The resident was assisted to turn to the side by the aide. The aide also lifted the resident's leg to place a pillow in between her legs prior to turning her. The resident did not voice any complaints of pain. The nurse then removed the resident's old dressing. When the WCN touched and removed the dressing, the resident moaned and cried out in pain. The nurse also used a 4 x 4 soaked in Normal Saline to clean the wound surface and again the resident moaned out loud. The nurse responded, "I'm cleaning it, I'm sorry". After cleaning the wound, the nurse then applied Santyl ointment to the wound. Again, the resident moaned out loud. The nurse responded, "I'm just applying a little ointment but I have to put it on thick". Then the nurse covered the area with a 4 X 4 and taped the wound. Each time the nurse touched the wound area, the resident moaned out loud. An interview was conducted with the WCN following the wound care observation. She stated the resident told her she was in pain and wanted to be put back to bed , so she had the staff put the resident back to bed. She also asked the resident prior to the wound care and the resident stated she was a little better after she was put back to bed. After further discussion, the nurse confirmed the resident stated she was in pain, that her pain was in her bottom and that the resident moaned throughout the wound care. She further confirmed that she did not managed the resident's pain prior to performing the wound care dressing. Another interview was conducted with the resident at 11:30 AM regarding her pain. The resident was asked to qualify her pain on a scale of 1 -10. The resident stated, "I don't know. It hurts all the time". The resident was then asked about her moaning during the wound care and if that meant she was hurting. She responded, "I wouldn't be yelling if it weren't hurting." The resident's spouse was also present and she told her spouse, "It hurts like hell ". Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was medicated with [MEDICATION NAME] 50 mg one tablet at that time. Further review of the MAR indicated [REDACTED]. The entries did not include a numerical scale assessment indicating the resident's pain level. The Pain Flow Sheet documented the following entries: on 6/24/2011 4:00 PM, left hip pain aching pain level of 4; on 6/25/2011 8:30 AM same as above; on 6/26/2011 11:00 AM pain level of 5; 6/28/2011 entry as noted above. Review of the facility's Pain Management Protocol revealed the following: "Resident requiring frequent monitoring for pain or unable to communicate pain will have the 10 scale (face scale) posted for consistent monitoring. Nursing staff will monitor and document the effectiveness of the pain management program in the resident medical record (Nurses' Notes/Pain Management Flow Sheet, Medication Administration Record), as appropriate for the resident's condition. The nurse will also note daily on the 24 - hour report any resident identified as having pain management concerns. Each resident who has been identified to have pain will have their pain assessed at least once per shift to include vital signs. Documentation of this assessment and vital signs will be placed on the Pain Flow Sheet. A recommended method for monitoring all residents' pain status on an ongoing basis is to add a pain monitor approach to the MAR indicated document pain level each shift using 0-10 scale." Interviews were conducted on 6/29/2011 in the afternoon with the two nurses on the unit, who indicated if the patient's pain level is zero, they just place their initials on the MAR. However if the nurses administers pain medication, then they document on the Pain Flow Sheet. An interview was conducted on 6/30/2011 in the afternoon with the Director of Nursing (DON) and the Regional Consultant regarding the facility's pain management assessment and documentation. The DON confirmed nurses are to assess the resident for pain each shift and if the patient requires pain medication, the nurses will document on the Pain Flow Sheet. She confirmed the nurses do not place a numerical score on the MAR indicated [REDACTED]. The DON confirmed the facility staff are not documenting as indicated in the pain management protocol. The nurses are not putting zeroes. The nurses do not document the pain scale unless the resident is medicated and this is noted on the Pain Flow Sheet. The DON confirmed the nurses are to document in the progress note if the patient has pain and other interventions are noted to relieve the pain when the resident does not require medication. Another interview was conducted approximately 4:15 PM on 6/30/2011 with the Director of Nursing, Regional Consultant, WCN and the Administrator. They presented the Wound care physician's report dated 6/29/2011 noted above. The report indicated the physician noted when the wound care was done on the resident, the resident was not in pain on 6/29/2011. The surveyor did not observe the wound care on 6/29/2011 however on 6/30/2011, the resident expressed to the staff she was in pain and also moaned throughout the wound care observation. They facility further stated they were previously rubbing [MEDICATION NAME] on the resident and she didn't complain of pain. The surveyor stated the resident wound was a different stage at that point. They agreed. The facility also expressed to the surveyor they felt the resident was "putting on" because of the daughter's presence. They surveyor explained the resident expressed that she was in pain prior to the dressing change and the resident moaned each time the nurse touched her wound indicating she was hurting and the facility failed to address the resident's needs at that time. Another interview was conducted on 7/1/2011 approximately at 9:45 AM with the daughter who was present during the wound care observation. The daughter explained that her mother complains of pain everyday and continues to state that the pain is not from her hip but her bottom. She again stated that's why she wanted to see the wound on her bottom because of her mother's constant complaints. The daughter further confirmed that she has visited her mother twice daily since her mother's admissions to the facility and admitted that she never signed in the visitor's log until yesterday. She confirmed that she informed the nurses about her mother's pain and her mother also kept calling the nurses regarding her pain. She then stated, she was a little confused because her mother keeps complaining about experiencing pain and she specifically says it's her bottom and the WCN came to her on yesterday (during the daughter ' s 2nd visit for the day) and pulled her off to the side and stated that she did not think her mother was experiencing pain in her bottom. The pain was from her hip because you can't feel pain from the wound. The daughter was also questioned regarding hearing her mother making sounds during the dressing change she observed on 6/30/2011. The daughter confirmed that her mother kept moaning out loud when the nurse touched the wound. Another call was made to the daughter to clarify whom she spoke with at the facility regarding her mother's pain. She stated she spoke with several nurses and remembers speaking with the Clinical Coordinator regarding her mom having pain and told her it was on her bottom not her hip. She stated the WCN told her it wasn't possible for her mother to have pain in her bottom. The daughter also voiced a concern regarding her mother constantly lying or sitting on her bottom and the ability of the wound to heal. She stated that every time she comes in to visit her mother, her mother is sitting in her wheelchair slumped over or lying in the bed on her bottom. She again confirmed she visits twice daily at different times but usually in the morning and then later in the afternoon or evening. She brings her Dad one of those time and the next time she will come by herself. When she brings her Dad, she stays about 30 minutes because he can't stay that long and when she comes alone she stays about one hour. According to the "Wound Management and Healing, Western Schools", A Stage III wound involves "Full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Pain associated with the wound may be related to the wound itself or to the type of dressing that is being used. Removal of the dressing at the dressing change can also cause pain. Wound pain can be debilitating, affecting the patient's quality of life and general well-being. Pain is a subjective measure and there are a variety of pain scales that the clinician can utilize to document the patient's pain associated with a wound. The pain scales should be used on a routine basis to assist the clinician in evaluating the treatment plan and what deciding measures should be instituted." The facility also presented a progress note by the physician (Medical Director) documenting a 7/1/2011 9:00 AM note, " Patient is doing pretty good no complaint any pain or discomfort at this time. Small decubitus excoriation on buttock palpated and changed dressing with ? gauze and Santyl ointment. Patient did not verbalize any pain on palpitation and dressing change and tolerated well. Impression- Decubitus ulcer sacral area healing well. Plan - discontinue [MEDICATION NAME] before changing dressing no premedication needed before and after dressing changes continue present treatment." Review of the physician orders [REDACTED]." Further review of the physician order [REDACTED]. The Clinical Coordinator then presented another copy of the orders adding indication diagnosis - Wound, pain management. 2) During an interview with Resident # 363 on 6/27/2011 at 12:33 PM, the resident stated she is in pain all the time secondary to her recent back surgery. She further stated she was initially taking two [MEDICATION NAME] every 6 hours as needed and that was relieving her pain but then she started throwing up when she took the medication. The medication was decreased to one tablet every 8 hours She received Tylenol every 4 hours in between which is "not helping much". She confirmed she did not always take the medication with food or something on her stomach initially and believes that was the reason she was throwing up. She stated she now when she takes the medication she eats/drinks something. She stated her pain is about a level 8 on a scale of 1-10. She stated she was dissatisfied when the facility decreased her medication when she threw up instead of understanding that she did not have anything on her stomach and then gave her Tylenol in between which did not help. "I guess they didn't want me to become addicted to the medication". She then expressed further discontent of not seeing the physician and stated, "the doctor comes in and reads my chart and makes decision about my care and doesn't see me". Review of the clinical record for Resident # 363 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. on 5/31/2011, [MEDICATION NAME] 5/325 two (2) tablets by mouth every 4 hours for severe pain as needed and [MEDICATION NAME] 5/325 one by mouth every 4 hours as needed for moderate pain (telephone order); on 6/1/2011 Tylenol 325 mg two tablets every 4 hours as needed for pain; on 6/2/11 [MEDICATION NAME] 5/325 one or two every 6 hours as needed (actual prescription); on 6/6/2011, [MEDICATION NAME] 5/325 2 tabs by mouth now then continue with current order of every 6 hours as needed; on 6/7/2011, [MEDICATION NAME] Patch 25 mcg 1 patch topically every 72 hours, Tylenol 325 mg 2 by mouth every 4 hours as needed for pain and [MEDICATION NAME] 300 mg by mouth every 8 hours for neuralgia; on 6/22/2011, discontinue [MEDICATION NAME] 5/325 mg 1 to 2 tablets every 6 hours, start [MEDICATION NAME] 5/325 mg 1 tab every 8 hours as needed for pain and [MEDICATION NAME] 25 mg suppository every 6 hours as needed for nausea and vomiting. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] (prescribed as needed) from 6/23/11 until 6/30/2011 (7 days). The nurses are also documenting the resident's pain is ranging from 5 to 10 on a scale of 0-10, 10 indicating severe pain. An interview was conducted on 6/30/2011 at 2:20 PM with the Clinical Coordinator to discuss the pain assessment, pain management and further evaluation of the pain management. The nurse confirmed the resident complained of nausea. They contacted the physician and obtained the [MEDICATION NAME] order to treat the nausea. The coordinator confirmed the nurses conduct a pain assessment each shift and they placed their initials in the appropriate boxes. If the resident is experiencing pain, the nurse administers pain medication and then documents on the Pain Flow Sheet. The nurses do not place a pain scale numerical value on the MAR. A numerical pain scale is documented when pain medication is administered. Reviewed with the Coordinator the facility's policy which documents a different procedure. She stated she would have to review with the DON and the Staff Developer because the above stated procedure is what is utilized by the facility. The Coordinator was then questioned regarding re-evaluating the effectiveness of the pain medication. She stated the nurses evaluate the resident's pain each shift and when pain medication is administered, the nurse documents the effectiveness of the pain medication. When questioned about the resident receiving "as needed" pain medications daily and when this would be evaluated for possible changes since the resident stated she is constantly in pain that averages an 8 on the 1 - 10 scale, she stated she would discuss with the resident.