Every finding on record at Lofland Park Center

Based on observation, interview, and record review, it was determined that for four (R5, R26, R38, and R86) out of four residents reviewed for respiratory care the facility failed to ensure respiratory equipment for R5, and R86 were stored in plastic bagging when not in use, in addition, the facility failed to clean R26 and R38's oxygen concentrator filters weekly as ordered. Findings include:1. R26's clinical record revealed: 9/22/22 – R26 was admitted to the facility. 4/14/26 1:11 PM - A physician's order for R26 documented Clean external filter on oxygen concentrator as needed. 4/15/26 11:00 PM - A physician's order for R26 documented Clean external concentrator filter every night shift on Wednesday. 6/23/26 9:47 AM - An observation of R26's oxygen concentrator revealed layers of dust attached to the external filter. A review of review of R26's TAR documented the filter was last cleaned on 6/17/26. 06/23/26 1:30 PM - During an interview E2 (DON) reported filters should be cleaned weekly and as needed. E2 confirmed that R26's filter is dirty and removed the filter to clean it. 2. R38's clinical record revealed: 1/27/26 R38 was admitted to the facility. 4/8/26 11:00 PM - A physician's order for R38 documented clean external concentrator filter every night shift Wednesday. 6/23/26 10:15 AM - An observation of R38's oxygen concentrator revealed layers of dust attached to the external filter. A review of R38's TAR documented the filter was last cleaned on 6/17/26. 6/23/26 1:30 PM - During an interview E2 (DON) reported filters should be cleaned weekly and as needed. E2 confirmed that R26's filter is dirty and removed the filter to clean it. 3. R86's clinical record revealed: 10/1/25 - R86 was admitted to the facility. 10/2/25 11:38 AM - A physician's order documented Albuterol Sulfate nebulization solution 2.5mg/3ml) 0.083% 3 ml inhale orally via nebulizer every four hours as needed for shortness of breath. 6/23/26 1:09 PM - An observation revealed R86's nebulizer equipment was sitting on a black stand in the room; the T-adapter and tubing was dated but was not enclosed in a plastic bag. During an interview E2 (DON) confirmed the nebulizer equipment had not been placed in a bag. R86 stated, They don't come back and put it in a bag, the only way they could put in a bag is if they came back to do it. E2 then stated, I will take care of this. 4. R5's clinical record revealed: 5/26/26 - R5 was admitted to the facility. 5/30/26 – A physician's order for R5 documented nightly application of BiPAP therapy with pressure settings of 4–20 cmH O and supplemental oxygen delivered at 2 L/min. 6/23/26 9:45 AM - An observation revealed R5's BIPAP mask lying on the bedside table, with the tubing on the floor. 6/23/26 10:00 AM - Confirmed with E4 (RN) that the CPAP tubing lying on the bedside table was not stored properly and was not placed in the designated storage bag. 6/30/25 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents. Findings include: 6/23/26 9:08 AM - During the initial kitchen tour, an observation of an open bag of cheese cubes with no open date or discard date. Additionally, an observation of a container of thickened juice with no open date or discard date noted. 6/23/26 9:20 AM - During an interview, E7 (Cook) confirmed the aforementioned items were not dated or labeled. E7 discarded those items in the trash during the interview. 6/30/25 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R122) out of eleven residents reviewed for accidents, the facility failed to consult the physician when R122 experienced a change in condition. Based on review of the facility's evidence of correction, the deficient practice was determined to be Past Noncompliance, with substantial compliance achieved effective April 20, 2026. Findings include:Review of R122's clinical record revealed:3/10/26 - R122 was admitted to the facility.3/21/26 7:20 PM - A facility reported incident documented that R122 was found on the floor in his room after an unwitnessed fall and reported to staff that he hit his head during the fall. Staff (RN) completed an assessment and initiated neurological assessments at this time. 3/21/26 9:25 PM - An SBAR communication form documented that R122 had an unwitnessed fall and was reported to the provider. The SBAR documented that R122 denied pain, no injury noted, and provider advised continuing neurological assessments. 3/22/26 9:00 AM - A nursing progress note documented that PT stated he seems off and had a physical decline during PT, not able to walk and less steady on his feet. 3/22/26 11:59 AM - A physical therapy (PT) progress note documented that R122 was having difficulty standing and was tolerating standing for 30 seconds before requesting to sit. The note documented that nursing was notified of R122's change in functional status. 3/22/26 6:40 PM - An SBAR communication form documented that R122 had a fall with complaint of knee pain of 10/10. On call provider was notified at approximately 7:00 PM with the following orders: x-ray of left knee, Tramadol 50 mg for pain and lidocaine patch to knee. 6/29/26 2:19 PM - During an interview, E4 (RN) stated the expectation would be to consult the provider of a change in condition and on the weekend to call the on-call provider. E4 stated that if the provider was notified a progress note or SBAR would have been completed. 6/30/26 9:15 AM - During an interview, E9 (PA) stated the expectation for a change in condition would be to notify the provider and continue to monitor resident. E9 stated that a resident post fall with a change in mentation would require a call to the provider for possible further evaluation. 6/30/26 11:55 AM - During an interview, E1 (NHA) stated that the facility recognized post fall change in condition were a focus of the IDT team and the facility had implemented the following: facility provided education on recognizing a change in condition, education on notifying the provider specifically on off hours and weekends, and also initiated ongoing audits for any residents who experienced a change in condition and outcome.Based on the facility's investigation, review of the event, implementation of corrective actions, staff education regarding recognition of changes in condition and timely physician notification (including after-hours and weekend notification procedures), and implementation of ongoing audits to monitor compliance, it was determined the facility returned to substantial compliance effective April 20, 2026.6/30/25 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R28) out of five residents sampled for medication review, the facility failed to document the rationale for a contraindicated GDR (gradual dose reduction) of a psychotropic medication. Findings include:Review of R28's clinical record revealed:9/26/18 - R28 was admitted to the facility. 7/10/24 - A physician's order documented divalproex sodium (anticonvulsant) 500 mg give one tablet daily at bed time for bipolar mood stabilization.10/2/24 - A physician's order documented buspirone 15 mg (anti-anxiety) twice a day for anxiety. 10/7/25 - A monthly medication regimen review (MRR) documented a recommendation to attempt dose reduction on divalproex to 250 mg. 10/2025 - A review of provider progress notes for the month of October lacked evidence of a rationale or contraindication for a GDR of the aforementioned medication. 1/8/26 - A MRR documented a recommendation to attempt dose reduction of buspirone to 10 mg. 1/2026 - A review of provider progress notes for the month of October lacked evidence of a rationale or contraindication for a GDR of the aforementioned medication. 6/26/26 11:41 AM - During an interview, E2 (DON) reviewed providers progress notes and confirmed that the progress note lacked evidence of a rationale or contraindication for GDR's. 6/30/25 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interviews and record review, it was determined that for one (R16) out of 10 residents reviewed for Activities of Daily Living (ADL's). The facility failed to ensure that a resident who was dependent on staff for ADL's received the necessary assistance with personal care. Due to the facility's corrective measures following the incident this is being cited as past non-compliance with a correction date of 9/5/25, which was verified by interviews and review of facility records. Findings include: Record review for R16 revealed: 8/8/25 - R16 was admitted to the facility. 8/15/25- R16 's MDS admission assessment documented a BIMS score of 9, indicating cognitive impairment and was partial to moderate assistance for toileting. 8/29/25 - A review of the CNA task flow sheet documented bathing, toileting and hygiene lacked evidence of completion.9/5/25 - A review of the facility's five-day follow-up investigation revealed the allegation of neglect was verified. The investigation documented that E13 (CNA) reported R16 was asleep in the morning. E13 acknowledged that R16 did not receive incontinent care, turning and repositioning, or hydration until approximately 1:30 PM, about seven hours into the scheduled shift. The investigation concluded that required resident care had not been provided. Additional interviews obtained after the exit: During an interview, E11 (RN) stated that if she is notified that a resident did not receive required ADL care, she would immediately direct the nursing assistant to provide the care and notify the unit manager of the concern. During an interview E12 CNA, stated that when we are unable to provide care to a resident, she notifies the charge nurse. During an interview, E10 (Unit Manager) confirmed that on 8/29/25, a telephone interview was conducted with E13 (CNA) as part of the facility's investigation. E10 stated that E13 reported arriving for her scheduled 6:00 AM to 2:00 PM shortly after 6:00 AM. E13 stated she entered R16's room around breakfast time and, with the assistance of another CNA, repositioned the resident while the resident was sleeping. E13 stated the next time she entered R16's room was approximately 1:00 p.m. to prepare the resident for discharge after the family had arrived. When asked whether she had provided incontinent care before that time, E13 stated, I'm not going to lie, no I didn't. The facility's Plan of Correction documented that the resident had been transferred to the hospital prior to implementation of corrective actions. The facility placed the CNA on administrative leave pending the outcome of the investigation. Identification of other residents potentially affected, the facility completed head-to-toe skin assessments for residents requiring incontinent care and reported no additional skin concerns. Certified Nursing Assistants received re-education on the facility's Continence Management and Perineal Care policy. The facility implemented weekly skin audits of ten residents requiring incontinent care. The Nursing Home Administrator and Director of Nursing were designated responsible for oversight of the corrective actions. Interviews, documents and observations verified the facility had met the requirements for past noncompliance as of 9/5/26.

Based on interviews, record review and review of other facility records, it was determined that for one (R25) of eleven residents reviewed for accidents, the facility failed to provide an accident-free environment. R25 fell from a Hoyer lift onto the floor during a transfer due to improper use of the lift by two staff members. The Hoyer lift fell on R25's right knee. R25 complained of pain and was sent to the hospital for further evaluation and treatment. Due to the facility's corrective measures following this incident, this deficiency is being cited as past non-compliance with a corrected date of 1/9/26, which was verified through interviews and review of facility records. Findings include:10/22/25 - R25 was admitted to the facility.1/8/26 6:30 PM - A review of a facility incident report submitted to the Division documented R25 fell from the Hoyer lift at this time.1/8/26 9:38 PM - A review of a facility incident report to the Division documented CNA notified nursing that [R25] had fallen from the Hoyer. Further review of the report indicated R25 complained of feeling a snap in the back, and right knee pain due to the Hoyer lift falling on the R25's right side.1/14/26 - A review of the facility's five day follow up submitted to the Division documented that E5 (CNA) reported assisting E6 (CNA) with transferring R25 from the chair to the bed. R25 was placed on the Hoyer pad and raised to waist level while E6 guided R25's legs. E5 further reported closing the base of the Hoyer lift slightly because the room was tight, causing Hoyer to tip over. E5 stated an attempt was made to reopen the Hoyer, but the attempt was unsuccessful. E5 further reported that R25 landed on the floor and the bars of the Hoyer lift struck R25's legs.1/8/26 6:46 PM - A facility SBAR (Situation, Background, Assessment, and Recommendation) form documented recommendation to perform neurological checks and send R25 to the hospital.1/8/26 11:30 PM - R25 returned to the facility.1/9/26 3:17 AM - A facility progress not for R25 documented, Pain, right lateral thigh; pain score 2; aching; non radiating R25 position was changed. Non medication interventions provided relief.1/9/26 6:03 AM - A review of R25's hospital Xray results of the right knee documented No acute fracture or dislocation. Degenerative changes primarily involving the medial compartment.6/29/26 12:42 PM - During a telephone interview E5 (CNA) reported [E6] (CNA) asked for assistance transferring [R25] to bed. I was operating the lift, and it was hard to move. The roommate's recliner chair was in the way, so I slightly opened the base of the Hoyer lift so [E6] could navigate the lift to the bed. [E6] was holding [R25's] legs while guiding the transfer. I noticed one wheel of the Hoyer lift lifted off the floor, and I tried to widen the base, but I couldn't. [R25] was waist high in the lift and I was turning it, the lift tipped over onto [R25]. I went down too while trying to prevent the fall. I was removed from the unit and received hands on training for the lift and safety.6/29/26 1:55 PM - During an interview, E6 reported I called [E5] to assist with putting [R25] back into the bed. [E5] was operating the Hoyer lift while I guided [R25's] legs. We didn't realize the other resident's recliner chair was in the way. The Hoyer started to tip over, and we both tried to stop it, but [E5] ended up going down on the floor too. The nurse was notified right away. E6 then stated, I was not allowed to assist another resident until I completed Hoyer lift and safety training and demonstrated competency.6/30/26 10:34 AM - During a telephone interview, E8 (RN) reported That was a long time ago I don't remember all the details. What I do recall is that I was immediately notified by one of the CNAs. although I don't remember which one. I assessed [R25], provided education to [E5, E6] and other staff, and documented that education in my statement. I completed the SBAR form, and I know that [R25] was sent to the hospital. However, since this occurred in January, I don't recall all of the detail.6/30/26 9:15 AM- During an interview, E2 (DON) reported I was notified immediately. [E5 and E6] were removed from the unit. I wasn't sure whether the Hoyer lift malfunctioned, so the equipment was removed from the unit and tagged for inspection by maintenance. [E5 and E6] were not allowed to return to the floor until they completed and demonstrated competency in the use of the Hoyer lift.The facility's immediate action included:1/8/26 6:30 PM - The attending on-call provider was notified.1/8/26 6:37 PM - R25 was transferred to the hospital by 911.1/8/26 6:45 PM - R25's family was notified.1/8/26 - A facility form titled Quality Assurance & Assessment was completed by E5 and E6.1/8/26 - The mechanical Hoyer lift was removed from the unit, and a lockout/ tagout device was applied pending inspection by maintenance. on the lift for maintenance to inspect.1/9/26 - E5 and E6 completed hands-on training, a skills check list, return demonstration, and re-education on the proper use of the Hoyer lift, gait belt, and safe resident handling using mechanical lifts.1/9/26 1:19 PM - A maintenance work order documented, Lift needs inspected for safety function. The lift was inspected, no defects were identified and the lift was returned to service.6/30/26 - The facility's response to R25's fall, which resulted from the improper use of the Hoyer lift by staff, included removing the Hoyer lift from service for inspection. E8 documented education provided to E5, E6 and other staff assigned to the unit following the incident. E5 and E6 were removed from resident care duties, until they successfully completed hands-on competency training for Hoyer lift transfers and gait belt use. Interviews with E5 and E6, along with review of facility records, confirmed that the required education and competency validation had been completed.6/30/25 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E3 (ADON) during the exit conference.

Based on record review and interview, it was determined that for one (R28) out of five residents reviewed for medication review, the facility failed to ensure the provider documented that irregularities were reviewed. Findings include:Review of R28's clinical record revealed:9/26/18 - R28 was admitted to the facility. 7/10/24 - A physician's order documented divalproex sodium (anticonvulsant) 500 mg give one tablet daily at bed time for bipolar mood stabilization.10/2/24 - A physician's order documented buspirone 15 mg (anti-anxiety) twice a day for anxiety. 10/7/25 - A monthly medication regimen review (MRR) documented a recommendation to attempt dose reduction on divalproex to 250 mg. The MRR lacked physician's signature and acknowledgement the recommendations were reviewed. 1/8/26 - A MRR documented a recommendation to attempt dose reduction of buspirone to 10 mg. The MRR lacked physician's signature and acknowledgement the recommendations were reviewed. 6/26/26 11:41 AM - During an interview, E2 (DON) stated the expectation is for the provider to complete and sign the MRR recommendation form and if changes need to be made the provider would document those changes in the EMR (electronic medical record). E2 confirmed the aforementioned MRR forms were not signed and the provider progress notes lacked evidence of acknowledgement of the recommendations. 6/30/26 12:00 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) during the exit conference.

Based on interview and record review, it was determined that for one (R79) out of five residents sampled for medication review, the facility failed to discuss the risk and benefits of proposed care. Findings include: Review of R79's clinical record revealed: 9/12/24 - R79 was admitted to the facility. 9/18/24 - An admission MDS documented R79 was a BIMS of 6 indicating severe cognitive impairment. 2/13/25 - A physician's order was written for buspirone (anti-anxiety) 5 mg give one tablet by mouth every morning and and at bedtime for anxiety. 3/3/25 - A physician's order was written for lorazepam (anti-anxiety) 0.5 mg give one tablet by mouth every six hours for generalized anxiety disorder for 14 days. 3/9/25 - A physician's order was written for haloperidol (anti-psychotic) 5 mg/mL inject 5 mg/mL intramuscularly every four hours as needed for agitation. 6/11/25 1:41 PM - During an interview, E11 (RN) stated the expectation is to review each new medication (psychotropic) risk versus benefits with the resident if cognitively intact or with the resident's representative. E11 also stated the facility had a form that would be completed when discussing the treatment options. 6/12/25 10:19 AM - During an interview, E6 (RN) confirmed that R79's medical record lacked evidence of a Psychotropic Medication Administration Disclosure for the buspirone, haloperidol, and ativan medication. E6 also confirmed that the physician's progress notes lacked evidence of the risk versus benefit documentation regarding the aforementioned medications. 6/12/25 12:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate).

Based on interview and record review, it was determined that for one (R79) out of five residents sampled for medication review, the facility failed to limit a PRN psychotropic medication to 14 days. Findings include: Review of R79's clinical record revealed: 9/12/24 - R79 was admitted to the facility. 3/6/25 - A quarterly MDS assessment documented that R79 was a BIMS of 9 indicating that R79 was moderate cognitively impaired. 3/9/25 - A physician's order was written for haloperidol (anti-psychotic) 5 mg/mL inject 5 mg/mL intramuscularly every four hours as needed for agitation with an indefinite stop date. 3/31/25 - A physician's order was written for lorazepam (anti-anxiety) 0.5 mg give one tablet by mouth every six hours as needed for generalized anxiety disorder for 180 days. 6/12/25 10:19 AM - During an interview, E6 (RN) stated the expectation for PRN medications have a 14 day stop date so the provider can evaluate resident for usage of the medication. E6 confirmed that the lorazepam and haldol did not have the 14 day stop date. E6 also confirmed the physician's progress note did not have a rationale to extend the lorazepam order for 180 days. 6/12/25 11:15 AM - During an interview, E1 (NHA) stated that the expectation was a 14 day stop date on PRN medication and the provider will evaluate the usage. E1 confirmed that the lorazepam order was written for 180 days. 6/12/25 12:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate). 6/13/25 9:25 AM - During an interview, E1 confirmed that R79 was evaluated for use of PRN lorazepam and confirmed the physician's progress notes lacked evidence of rationale to extend medication for 180 days. E1 stated that R79 was not using the lorazepam consistently and would discuss with the provider about discontinuing medication.

Based on interview and record review it was determined that for two (R9 and R58) out of two residents reviewed for bowel and bladder, the facility failed to initiate antibiotic therapy for signs and symptoms of a UTI. For R9 with a urinary catheter who met criteria of a positive urine culture and for R58 without a urinary catheter who met criteria of a positive urine culture. Findings include: 1. Review of R9's clinical record revealed: 10/4/18 - R9 admitted to the facility with diagnoses including, but not limited to, thoracic spinal cord injury. 2/25/25 - An annual MDS documented R9 having an indwelling urinary catheter. 4/11/25 11:31 PM - A nursing note documented Obtain UA [urinalysis] and C&S [culture and sensitivity] for urinary discomfort .reported done on day shift. 4/11/25 11:50 AM - A specimen tracking report provided by E9 (Hospital Lab Supervisor) revealed the urine sample for UA and C&S was obtained. 4/11/25 3:38 PM - A specimen tracking report provided by E9 revealed the urine sample for UA and C&S was received from the facility and a urinalysis and urine culture was completed. 4/12/25 1:56 PM - A lab report in the hard copy medical record revealed abnormal UA results with cloudy clarity, 2+ [moderate] blood, positive nitrates, and 3+ [large] white blood cells and an E. Coli count > 100,000 cfu/ml indicating a positive urine culture. 4/12/25 1:56 PM - A specimen tracking report provided by E9 revealed the abnormal UA and the preliminary positive urine culture results were filed to R9's chart. 4/13/25 7:04 AM - A specimen tracking report provided by E9 revealed susceptibility results from the positive urine culture was filed to R9's chart. 4/14/25 5:50 PM - An order documented: Cipro Oral Tablet 500 MG (Ciprofloxacin HCl) Give 1 tablet by mouth every 12 hours for UTI for 5 days . 6/10/25 11:36 AM - During an interview, E16 (RN) stated that when a resident shows symptoms of a UTI, the nurse will take vital signs to check for fever, assess urine color and clarity, note any foul odor, and notify the physician of the findings. The facility does not perform in-house urine dipstick tests; instead, urine specimens are sent to the hospital lab. Lab results are faxed back to the facility, and any nurse on the unit can contact the physician with the results. Some physicians initiate prophylactic antibiotics immediately, while others prefer to wait for susceptibility and sensitivity results before starting treatment. 6/11/25 1:24 PM - During an interview, (E9) confirmed the accuracy of the data in the specimen tracking report provided. E9 further explained that upon receipt of a specimen by their laboratory, a urinalysis and preliminary urine culture are performed and the results are uploaded to R9 ' s chart. If further testing is indicated, such as susceptibility testing for a positive urine culture, the urine specimen is then shipped to a larger reference laboratory, where it is plated and incubated for susceptibility analysis and the are results uploaded to R9's chart. R9 had a positive urine culture and met the minimum criteria for initiating antibiotic therapy as a resident with a urinary catheter. However, the facility failed to initiate antibiotics on 4/12/25 when R9 met the criteria of a positive urine culture. 2. Review of R58's clinical record revealed: 7/7/22 - R58 admitted to the facility with diagnoses including, but not limited to, spastic quadriplegia cerebral palsy. 5/13/25 2:30 PM: An order documented, Obtain UA [urinalysis] /C&S [Culture and Sensitivity] for altered mental status. 5/13/25 2:15 PM - A lab report in the EMR revealed that a urine sample for urinalysis (UA) and culture and sensitivity (C&S) was obtained, and at 3:56 PM, the same report showed that the sample was received by the laboratory. 5/14/25 3:36 PM - A faxed lab report in the hard copy medical record revealed a Poteus mirabilis colony count >100,000 cfu/ml indicating a positive culture. 5/15/25 7:17 AM - A faxed lab report in the hard copy medical record revealed culture sensitivity results were reported to facility. 5/15/25 - 11:40 AM - An order documented: Amoxicillin-pot Clavulanate 875/125mg. Give one tablet by mouth BID [two times daily] x 10 days for UTI .[administration times 9 PM and 9 AM R58 had a positive urine culture and met the minimum criteria for initiating antibiotic therapy as a resident without a urinary catheter. However, the facility failed to administer antibiotics on 5/14/25 after R58 met the criteria of a positive urine culture. 6/12/25 12:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate).

Based on interview, observation and record review, it was determined that for one (R346) out of one residents reviewed for respiratory care, the facility failed to change oxygen tubing weekly per plan of care. Findings include: 1. Review of R346's clinical record revealed: 7/20/24 - R346 admitted to the facility with diagnoses including but not limited to COPD and Centrilobular Emphysema. 7/20/24 4:05 PM - An order documented, Oxygen tubing change weekly on 11-7 [PM] Wednesdays .Label each component with date and initials. 6/5/25 10:34 AM - Observation of R346's continuous oxygen tubing label was dated Saturday, May 24, 2025 and nebulizer tubing dated Thursday, May 29, 2025. 6/5/25 3:15 PM - A subsequent observation of R346's continuous oxygen tubing label dated Thursday, June 5, 2025. 6/5/25 3:18 PM - During an observation interview E8 (LPN) confirmed that she changed R346's continuous oxygen tubing at the start of their shift [3 PM to 11 PM] on Thursday, June 5, 2025 and that R346's nebulizer tubing was dated Thursday, May 29, 2025. E8 further stated that R346's nebulizer tubing should have been changed and that she would change the nebulizer tubing. The facility changed R346's oxygen tubing after 11 days, failing to follow the physician's order for weekly oxygen tubing changes. 6/12/25 12:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate).

Based on interview and record review, it was determined that for one (R98) out of six residents reviewed for unnecessary medications, the facility failed to ensure a resident on insulin had adequate monitoring of blood sugar levels R98. Findings include: A review of R98's clinical record revealed: 11/25/24 - R98 was admitted to the facility, with diagnoses including diabetes mellitus. 11/25/24 - A physician's order for Humalog solution 100 unit /mL Inject 5 units subcutaneously in the evening for diabetes mellitus. 12/5/24 - A physician's order for Insulin glargine subcutaneous solution pen-injector 100 unit/mL, inject 15 units subcutaneously one time a day for diabetes mellitus. 6/9/25 - The EMR lacked evidence of a physician's order for blood sugar monitoring for R98. 6/9/25 11:48 AM, an interview with E6 (RN) confirmed that when a resident is receiving insulin, E6 obtains a physician's order to monitor a resident's finger stick blood sugar level. 6/9/25 1:10 PM - An interview with E4 (RN) confirmed that upon resident admission, finger stick blood sugars are monitored for three days if blood glucose levels exceed 200. The physician is notified, and E4 would obtain an insulin order and enters it into the computer system, which then prompts a choice between sliding scale or non-sliding scale insulin. However, E4 confirmed that the EMR did not include an order for finger stick blood sugar monitoring for resident R98. 6/10/25 10:45 AM - An interview with E5 (NP) confirmed that if a resident is receiving insulin on admission, finger sticks are ordered for three days in the AM to monitor the finger stick blood sugar level. If the resident is controlled, then the order would be discontinued. E5 confirmed it would be a separate order. 6/12/25 12:45 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (Corporate).

Based on record review and interview, it was determined that for four (R2, R11, R76 and R100) out of thirty-two residents reviewed for care plans, the facility failed to meet professional standards of the Delaware Board of Nursing Scope of Practice by having LPN's and a SW complete the admission assessments. Findings include: Delaware State Board of Nursing - RN, LPN and NA/UAP Duties 2023 . Admission Assessments * - RN . *= Once a care plan is established, the LPN may do assessments . 1. Review of R2's clinical record revealed: 5/15/24 - R2 was admitted to the facility. 5/15/24 - E5 (LPN) completed the following assessments: Elopement Evaluation, Bed Rail Evaluation, Clinical Admission, Braden Scale Evaluation and Lift Transfer Evaluation. An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R2. 2. Review of R11's clinical record revealed: 3/4/24 - R11 was admitted to the facility. 3/4/24 - E6 (LPN) completed the following assessments: Elopement Evaluation, Bed Rail Evaluation, Clinical Admission, Fall Risk Evaluation and Lift Transfer Evaluation. An LPN, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R11. 3. Review of R76's clinical record revealed: 2/22/24 - R76 was admitted to the facility. 2/22/24 - E7 (LPN) completed the following assessments: Bed Rail Evaluation, Clinical Admission, Fall Risk Evaluation and Lift Transfer Evaluation. 2/22/24 - E8 (Dementia Program Director/SW) completed the Elopement Evaluation. An LPN and a SW, not an RN, as required by the Delaware State regulation for Board of Nursing Scope of practice, completed the admission process for R76. 7/2/24 10:15 AM - In an interview, E2 (DON) confirmed that LPN's are not to do initial assessments and that they should be completed by an RN. 46988 4. Review of R100's clinical record revealed: 7/26/23 - R100 was admitted to the facility. 7/26/23 - E12 (LPN) completed the following admission assessments: bed rail evaluation, oral health evaluation, and lift transfer evaluation. 7/2/24 10:15 AM - In an interview, E2 (DON) confirmed that LPN's are not to do initial assessments and that they should be completed by an RN. 7/2/24 10:30 AM - An interview with E3 (RN Director UM) confirmed the following admission assessments are expected to be completed at the time of admission by an RN: admission assessment, bed rail, Braden, incontinence, lift evaluation, AIMS (if needed), elopement, fall risk, and pain. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for the staff. Findings include: 6/24/24 11:24 AM - A large section of the floor in the service area between the entry doors to the kitchen and the entry door to the ware washing room was covered with standing water. Water was dripping from the ceiling area adjacent to the interior hallway doors onto the floor. An additional area of water was dripping from the ceiling near the entrance to the ware washing room onto the floor and into a mop bucket that had been placed under a portion of the dripping area. 6/24/24 1:46 PM - During an interview, E1 (NHA) confirmed the dripping and standing water and stated that the water had come from the second-floor shower room, passed through a managers' office located on the first floor, and dripped into the service area on the ground floor. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on interview and record review, it was determined that for one (R100) out of two residents reviewed for change in condition, the facility failed to consult the Physician when R100 experienced a change in condition. Findings include: Review of R100's clinical record revealed: 7/26/23 - R100 was admitted to the facility. 8/1/23 - An admission MDS revealed that R100 had diagnoses including but not limited to hypertension and atrial fibrillation. 8/3/23 - A careplan for R100 revealed resident is exhibiting or at risk for cardiovascular symptoms or complications related to hypertension, atrial fibrillation, hypotension, stroke, and electrolyte imbalance. Interventions included but not limited to administer medications as ordered and monitor for side effects and effectiveness, report any abnormalities to the physician. Also observe for mental status and report any changes to the physician. 9/12/23 - A physician's order was written for metoprolol 50 mg give one tablet twice daily for hypertension and hold for systolic blood pressure less than 110 mg/dL. A review of R100's MAR for December 1 to December 15, 2023 revealed that the metoprolol 50 mg tablet was held twenty out of thirty opportunities for systolic blood pressure under 110 mg/dL. 6/28/24 11:43 AM - An interview with E4 (MD) revealed that as a provider he would expect nursing to notify him or any provider of an established pattern occurring over five to seven days of low blood pressure or medication held. The process would be once the provider is notified of the change they would monitor the resident more closes. E4 confirmed he was unaware of R100's medication being held twenty times in fifteen days in December 2023. The progress notes lacked evidence that anyone notified the provider of the change in condition. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on observation, interviews, and record review it was determined that for one (R37) out of 32 residents reviewed for care plans the facility failed to update and revise a care plan. Findings Include: Review of R37's clinical record revealed: 12/11/23 - R37 was readmitted to the facility from the hospital. 12/16/23 - A quarterly MDS assessment documented . 1. Yes, a hearing aid or other hearing appliance was used to complete the assessment for hearing. 1/18/24 9:00 PM - An order for R37 documented to insert hearing aids in the AM and remove at bedtime. Wipe clean daily. 3/20/24 8:16 PM - A care plan evaluation note by E2 (DON) documented, Resident seen by audiology for hearing impairment. Resident has hearing aides (sic) to assist [with] his impairment. Care plan reviewed and remains appropriate - continue current [plan of care]. 6/6/24 1:41 PM - R37's care plan documented impaired communication as evidenced by impaired hearing. 6/15/24 - A significant change MDS assessment documented . 1. Yes a hearing aid or other hearing appliance was used to complete the assessment for hearing. 6/26/24 1:00 PM - Review of the TAR (Treatment Administration Record) revealed E9 (LPN) signed that R37's hearing aids had been inserted. 6/26/24 1:08 PM - During an interview E13 (CNA) stated, [R37] was not wearing his hearing aids right now, most of the time he doesn't like wearing them. 6/26/24 1:11 PM - During an interview E9 stated, [R37] usually puts his hearing aids in, but most of the time he doesn't like wearing them. E9 also confirmed, nursing signs for inserting and removing hearing aids. In addition, E9 stated, Well most of the time [R37] takes them out and you might find them in his bed or somewhere, he did have them in this morning. 6/26/24 1:25 PM - A second interview and observation with E9 revealed R37 did not have his hearing aids inserted. 6/26/24 1:53 PM - During an interview E3 (RN-UM) confirmed that R3 is not care planned for hearing aids and that R37's care plan had not been revised to reflect him refusing to wear his hearing aids. E3 RN-UM confirmed that hearing aids would be added to R37's care plan. 7/1/24 12:15 PM - During an interview E1 (NHA) confirmed R37's care plan was not revised. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on interviews and record review it was determined that for one (R99) out of nine residents reviewed for skin conditions, the facility failed to assess a surgical site. Findings include: Review of R99's clinical revealed: 8/25/23 - R99 was admitted to the facility with diagnoses including but not limited to third degree burn to left hand and donor graft site to left thigh. 8/25/23 - A physician's order documented to cleanse left hand with soap and water, apply xeroform gauze, then wrap with kling dressing and ACE (elastic wrap), every evening shift. The order for the left thigh wound as follows: do not remove xeroform from thigh wound. Allow to fall off/lift off on its own. May trim away edges as it lifts. as needed for graft extraction site. 8/30/23 - An admission MDS revealed R99 had a surgical wound and burn of second or third degree with treatments of surgical wound care and applications of non-surgical dressings. 8/30/23 - A care plan revealed that R99 was at risk for skin breakdown related to recent surgery, actual skin break down related to left hand burn, and left thigh graft. Interventions included but not limited to provide wound care as ordered, observe skin condition daily with ADL care and report abnormalities, and observe for signs and symptoms of skin break down. 8/30/23 1:40 PM - A skin and wound evaluation revealed a third-degree burn, present on admission, no location indicated, no odor, light exudate, and serosanguineous drainage. A review of the skin and wound tab of the electronic records revealed an image of R99's left hand burn. 9/6/23 - A progress note revealed R99 had a follow up appointment with burn center. The facility lacked evidence of record of follow up visit with burn center on 9/6/23 regarding the progress of left hand burn and left thigh surgical graft site. 9/12/23 - A physician's order revealed to monitor xeroform to left thigh donor site daily (3-11) every evening shift for donor site. 9/13/23 - A progress note revealed that R99 was going to an appointment with a family member to follow up for burns. The facility lacked evidence that R99's post surgical graft site was monitored from 8/25/23 through 9/12/23. 6/28/24 - An interview with E11 (RN UM) revealed that the physician's notes from the 9/6/23 follow up appointment were not in the medical record and she would continue to look for them. 7/1/24 10:20 AM - An interview with E9 (LPN) revealed that when a new resident is admitted the nurse will complete a head to toe assessment and document it. If the resident has a complex wound the nurse would contact the Wound Care nurse and she will complete initial wound assessment. E9 stated as the nurse she would document daily in the skilled charting what she observes daily in relation to wounds even if order says not to remove dressing. 7/1/24 2:05 PM - An interview with E10 (WC RN) revealed that she will try to complete the admission skin assessment if she is present during admission, if not the assigned nurse is responsible. E10 stated she will remove the dressing to complete the assessment even if the orders stated not to remove. E10 stated that she is not responsible for monitoring graft sites or surgical wounds unless they dehisce. 7/2/24 10:30 AM - An interview with E3 (UM Director RN) revealed the expectation is for the nurses to document exactly what they see during an assessment. The nurse completing the admission is expected to look for treatment orders and if unable to locate those orders, to follow up with physician via telephone. If no treatment orders are found, the expectation is the nurse to document the condition of the dressing daily at minimum. In reference to physician appointments outside of the facility, the resident would take an envelope with all the necessary paperwork for the provider and if no papers are returned, the expectation is for the nurse to call the provider and have the notes sent over. The nurse should document the call and details about it in the progress notes. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based on record review and interview, it was determined that for one (R11) out of five residents reviewed for medication review, the facility failed to ensure that an order for a PRN medication for anxiety was re-evaluated after 14 days. Findings include: 3/4/24 - Resident admitted to the facility. 3/18/24 - A Physician's order was entered into the MAR: clonazepam Oral Tablet 1 MG (Clonazepam) *Controlled Drug* Give 1 tablet by mouth as needed for anxiety May take 3x/day as needed. The facility lacked evidence that a PRN order for anxiety was re-evaluated by a provider after 14 days of being ordered. 7/1/24 1:33 PM - In an interview, E4 (MD) stated that usually a new PRN order for an anti-anxiety medication is evaluated 14 days after the patient first starts, but not thereafter. E4 stated that this will be fixed. 7/2/24 1:50 PM - Findings were reviewed with E1 (NHA) and E2 (DON) at the exit conference.

Based interview, record review and review of other documentation it was determined that for one (R2) out of three residents reviewed for resident rights, the facility failed to protect privacy and confidentiality of R2's medical record. Findings include: 10/11/22 11:35 AM - An incident that occurred on 10/7/22 was reported in an email from the E1 (NHA) to the corporate HIPAA contact, that R1 was sent home with R2's medications. The email indicated the medications labels had identifying information about R2 and the facility wanted to make sure that they reported. The information on the medication card identifies the residents name, date of birth, name of medication, dosage and why R2 was taking the medication. 10/11/22 - The facility used the root cause analysis to identify the issues that contributed to sending R1 home with R2's medications. 10/11/22 - An Inservice Sign In Sheet provided by the facility outlined the new process on discharging patients with medications. All nursing staff were educated on this new process outlined below on 10/11/22: - An Inservice on Resident Discharge Process and Organization of Medication Carts was developed and implemented. The education included: Discharge Transition Plan will be reviewed with and given to the patient and or resident representative along with the Discharge Packet upon discharge. In the event the Discharge Transition Plan is prepared and completed in advance of discharge, the nurse discharging the resident and reviewing the instructions is responsible of ensuring all medication are reconciled correctly, the correct amount and correct medications indicated on instructions are being sent home with resident. - All residents being discharged need to have a discharge order in PCC and progress note at time of discharge to include that discharge instructions were reviewed with patient and or caregiver, who accompanied resident on discharge. - Resident medication should be properly stored in medication cart sequence by room #. Medication carts will need to be adjusted appropriately to ensure the blister card are n sequence by room # when room changes and/or adjustments to group assignments are made based on census. 7/19/23 around 3:00 PM - During an interview with E3 (UM) it was confirmed that R1 was sent home with R2's medications. It was revealed that E3 called R1's contact between 5:00 PM and 6:00 PM to let R1 know that they had mistakenly sent R2's medications home with R1. Furthermore, E2 described the new process and education that was put in place because of the incident and to prevent it from happening again. 7/19/23 around 3:30 - During an interview with E1 it was confirmed that the facility had self-reported the breach of confidentiality, they completed a root cause analysis, developed a new process and provided education and have been free of occurrence based on their daily audits since 10/7/22 demonstrating their past noncompliance. 7/20/23 3:40 PM - Findings were reviewed with E1 and E2 (DON) at the Exit Conference.

Based on observation and interview it was determined that the facility failed to ensure that a qualified person in charge of the kitchen was present during all hours of operation. Findings include: 5/4/23 10:37 AM - During an interview, E17 (Kitchen Supervisor) and E18 (Cook) disclosed that no members in the facility's food service department possessed valid Food Protection Manager certificates from an Accredited Food Safety Program.

Based on record review and interview it was determined for one (R203) out of 39 sampled residents the facility failed to accurately assess R203 in accordance with the professional standard of practice, delaying care and treatment, resulting in a decline in R203's condition. Furthermore, the facility failed to ensure immediate transfer to the hospital based on signs and symptoms indicating the need for a higher level of treatment. Findings include: Policy Falls Management Last revised [DATE] - Follow Guidelines for Managing a Fall if staff member is present when the fall occurs. Utilize the Fall Response Protocol for both witnessed and unwitnessed falls. Perform Neurological Assessment for all unwitnessed falls and witnessed falls with head injury. Document accident/incident: As a new event in the Risk Management System; On a change of Condition Note; On the 24-Hour Report; Investigation using the Fall Investigation/Quality Assurance and other appropriate tools in Risk Management System. Update care plan to reflect new interventions. Fall Response Protocol last revised ,[DATE] provides direction in response to a fall: Evaluate and Monitor Patient for 72 hours Evaluate patient's airway, breathing, and circulation, summon help. Evaluate patient's level of consciousness and vital signs. Immediate Intervention: Did patient sustain injury? Look for laceration, abrasions, and obvious deformities. Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. Initiate first aid if minor injury. If emergency situation, initiate Emergency Medical response system (911), contact physician and family, and remain with patient until Emergency Medical Personnel arrives. Communication: Notify charge nurse. Notify family/responsible party and attending physician of fall and any resulting injury, notify above the following morning. Guidelines for Physicians Advanced Practice Provider Notification Last revised [DATE] - Urgency grid used as a general reference (to determine if a resident should go to a hospital). Clinical judgement along with patient base line would ultimately determine notification of the physician and or advance practice nurse. A fall is considered urgent if an injury or change in status has occurred for any resident on a blood thinner. A fall is considered routine if it is a fall without injury. [MEDICATION NAME] has effects similar to those of a blood thinner, and taken with aspirin, increases the risk of major bleeding. [MEDICATION NAME] taken with [MEDICATION NAME], also increases the risk of bleeding (U. S. Department of Health and Human Services, (YEAR)). Review of R203's clinical record and review of other facility records revealed the following: [DATE] Admission to the facility. [DATE] R203 was taking the following medications: [REDACTED]. [DATE] - [DATE] - Progress Notes: - Resident readmitted to facility from hospital - Ambulating with assist of one - Verbal - Agitated Progressive improvement was noted: -Ambulating with walker without assistance -At times walking slowly with walker. -Walking independently 50 feet without difficulty The following behaviors were also identified: - Increased verbal tone - Resisting care - Excessive worry or concern [DATE] 6:24 PM - Progress Note: - BIMS score of 9.0 (moderately impaired cognitively). - Resident Mood Interview score of 2.0 (minimally depressed). [DATE] 6:00 PM - Progress Note: Resident up and out of bed throughout shift. Dressed in day clothing and pleasant. Noted napping in chair throughout however resident was able to ambulate to and from dining independently with walker, no shortness of breath. Resident was able to walk the distance to room (50 feet) with ease. Allowed CNA to assist with evening care. Resident showed no signs of agitation this evening toward staff or others. [DATE] 6:00 PM - Progress Note: Resident up and pleasant throughout shift. No shortness of breath, resident ambulating independent with walker. Present at dinner and accepted snack. Resident was social in TV room throughout shift napping at times in chair. Was able to take self to bathroom to void. Confusion at times. [DATE] - A written statement from E5 (LPN) revealed at 1:45 AM R203's roommate came to the desk and said R203 was on the floor. E5 found R203 next to bed, slumped in water. R203 was alert but refused care, and unable to get up on her own. Vital signs and assessment completed no injuries found. E5 and E6 (CNA) picked R203 up and put her on the bed and changed her into dry pajamas. No signs and symptoms of injury. R203 was offered Tylenol for general discomfort and refused. [DATE] 2:30 AM - Progress Note: A change in condition has been noted. The symptoms include: Falls at night. [DATE] - Neurological Assessments performed at 1:45 AM, 2:15 AM, and 2:45 AM and documented by E5 (LPN) on the Neurological Assesement Flow Sheet were incomplete and all included the following information. -Alert -Pupils equal and reactive to light -Pupil response in the left and right eye nonreactive -Movement of all extremities The flow sheet is marked refused at 3:45 AM documented the resident as alert but refusing the assessment. Documentation at 4:45 AM indicated that R203 was alert but the assessment was incomplete. There was not an assessment documented at 5:45 AM. E5 failed to accurately assess R203 as evidenced by the neurological flow sheet indicating the pupils were equal and reactive to light and at the same time there was no response to the left and right pupil. E5 (LPN) failed to accurately assess R203 as evidenced by the neurological flow sheet indicating the pupils were equal and reactive to light and at the same time there was no response to the left and right pupil. According to the neurological assessment completed on R203 the pupils were nonreactive to light and this was an indication for immediate action. About 3:00 AM R203 became restless normal overnight behavior setting off bed alarm multiple times disturbing roommate. E5 and E6 put R203 in a wheel chair and took her to a quiet room provided a blanket and soon after R203 was sleeping. Around 5:00 AM E6 noted an odor and E5 and E6 returned R203 to room to provide incontinence care. At this time when putting R203 in bed. E5 and E6 discovered her right foot was rotated outward when putting her in bed. When the pajamas were removed a large bruise and hematoma on right side and hip was noted. R203 would not look at E5 or respond to questions. At this time E4 (RN, Charge Nurse) was called. [DATE] 6:30 AM - Progress Note: Upon reassessment a large bruise, large hematoma on right hip. Right foot rotated out. Resident showing signs of pain, grimacing and moaning. According to [DATE] statement of E5: - R203 was unable to get off of the floor on her own and had to be lifted by staff - this was a change of status. - R203 required assistance with a stand and pivot transfer when being taken to the quiet room - this was a change of status. - R203 was unable to walk to the quiet room - this was a change in status. There were three opportunities to call E4 for assistance and transfer R203 to a higher level of care. First, assistance in completing the neurological flow sheet accurately. Second, when R203 was found she was unable to get up on her own and had to be picked up; a progress note states the resident had walked independently at dinner and E6 (CNA) stated R203 was walking about the room going through dressers disturbing the roommate. Third, when R203 was brought to the quiet room she required assistance with a stand in pivot transfer by E6 and she did not walk but was transported there by a wheel chair. Information in the Event Summary Report: [DATE] 7:05 AM - Transferred to hospital. [DATE] 10:55 AM - Progress Note Physician Notified at 6:30 AM [DATE]- Hospital Discharge Summary: A specialized x-ray of the head revealed a subarachnoid and [MEDICAL CONDITION], a brain bleed. A brain surgeon was consulted and the family did not want a transfer to a brain surgery unit. R203 had a (unspecified) fracture seen by orthopedics who recommended conservative management. R203 was not responding to voice or painful stimuli. R203 was having shortness of breath and [MEDICAL CONDITION] with heart failure requiring a diuretic. Palliative care discussed with family and decided R203 would benefit from this type of care. [DATE] - Witness Statement for E6 (CNA) explains that around 11:30 PM R203 had removed the bed alarm, was walking around in room, removed alarm and had been going through the dresser. At that time, R203 was toileted, returned to bed and alarm was attached. Around 11:45 PM E5 was leaving another resident's room and R203 was sitting on the floor next to the bed. E5 assessed R203, vitals were taken, asked if there was any pain. R203 stated no pain and I did not need any pain medicine I can take care of myself R203 did try to get up on her own but E5 and E6 had to help R203 to her feet and get R203 to bed. Pants removed they were wet and E5 and E6 assessed R203 again for marks and bruises none seen. At about 2:50 AM the alarm went off again and R203 was trying to get out of bed. Roommate complained that R203 was keeping her from sleeping. E5 and E6 got R203 to a wheelchair and took her to the quiet room. E6 stood and pivoted R203 to another chair covered with a blanket, patient continued to be restless for about 20 minutes. About 4:30 - 4:50 E6 asked R203 if they had a bowel movement on themselves (sic) and R203 did not respond. E6 did not think anything of R203 not responding because R203 does ignore us at times. R203 was taken to the room to be changed E5 and E6 got her in the bed and removed clothing and noticed a bruise on her hip and foot turned out. E4 (RN, Charge Nurse) was called to assist. The statement from E6 (CNA) above indicates that there were other indications of a change in status that would have required notification to the RN and Physician or APN: - The resident was trying to get out of bed but could not get out of bed on her own. - The resident was taken by wheel chair to quiet room. - The resident did not respond to questions. [DATE] - Letter from the State Coroner's Office requesting documents: History and Physical, Recurring x-ray results and any other diagnostic studies, falls with injuries and injuries occurring in the past 30 days. The letter states R203 suffered a fall on [DATE] transported and admitted to the hospital and released to another facility on ,[DATE] and died on ,[DATE]. Her death was determined to be due to injuries sustained from her fall. [DATE] Death Certification - Immediate Cause of death - a result of [MEDICATION NAME] impact injuries. [DATE] 6:12 AM - Phone interview with E6 (CNA) confirmed the statement written on [DATE]. [DATE] 8:30 AM - Interview with E4 revealed that E5 called for assistance with sending R203 out to the hospital. E4 (RN Charge Nurse) was not required to write a statement at the time because she was ot a witness. This writer asked if E4 was educated on fall policy and protocol; E4 confirmed by stating yes. This writer asked if E4 confirmed by stating yes. This writer asked if E4 was educated on side effects or precautions of anticoagulant and antiplatelet medications. E4 confirmed and stated she would have called the physician at the time of fall based on the medications that R203 was receiving. E4 further revealed that the neuro checks could have been completed. Even though R203 refused you would still be able to assess changes in neurological function even without vitals. [DATE] 11:05 AM - A Phone interview with E5 (LPN) about the fall revealed: R203 was found on the floor with her head near the bed side table and feet at the foot of bed. There was water on the floor and R203 clothes were wet. R203 wanted to stand but could not do it on her own. E5 and E6 got R203 up and put her in bed. While E5 and E6 were putting R203 back to bed, E5 assessed the entire body including the joints, skin, and head and inquired about pain. At that time E5 determined that there were no signs or symptoms of injuries or pain. This writer inquired about the neuro checks for R203 and E5 stated that she could not remember everything but did believe the neuro checks were completed. This writer told her that neuro checks were completed from 1:45 AM to 2:45 AM for 1 hour and after that R203 refused. E5 replied If that is what I wrote then that is what happened. [DATE] 2:10 PM - Interview with E2 (DON) revealed that after their investigation of the incident, the post fall protocol had been followed. It was further revealed that only [MEDICATION NAME] is a drug for concern for bleeding as far as qualifying a fall for emergent transfer to the hospital. E2 also stated the LPN can perform observations and the RN can perform assessment. The facility failed to: - Recognize a change in condition resulting from a fall. - Document accurate and complete neurological assessments. - Recognize that the resident was taking 3 medications that could increase the risk of bleeding. - Report a change in status to the RN, MD or APN. This delay resulted in a decline in the resident's condition prior to transferring R203 to a higher level of care. These findings were reviewed with E1 (NHA), E2 and E3 (ADON) on [DATE] at 4:30 PM.

Based on record review, observation and interview it was determined that the facility failed to provide care and services in a manner to restore as much urinary function as possible and prevent urinary tract infections for two (R9 and R40) out of 39 sampled residents. For R9 the facility failed to identify a decline in urinary continence, failed to assess and failed to implement measures to improve the continence status resulting in harm. R9's urinary continence fluctuated between a high of 82.4% to a low of 75.3% for (MONTH) - (MONTH) (YEAR). In December, however, R9's urinary continence declined to 47.3% and by February, (YEAR) was 37.2%; a total decline of 45.2% in 8 months. For R40, the facility failed to ensure the urinary drainage bag was not touching the floor on multiple occasions. Findings include: On 1/2/18, the POA for R9 filed a complaint with the State Agency that staff will not take the time to feed or change the resident. The complaint included that the POA had been informed that he was incontinent but s/he felt staff was refusing to toilet him. Review of facility policies revealed: 6/1/96 (revised 3/1/18) Facility policy entitled Continence Management included that a urinary incontinence assessment and/or bowel incontinence assessment and the Three-Day Continence Management Diary will be completed if the patient is incontinent upon admission or re-admission and with a change in condition or change in continence status. Continence status will be reviewed quarterly and with significant change as part of the nursing assessment. Review of R9's clinical record revealed: 11/2/15 - Admission to the facility with multiple [DIAGNOSES REDACTED]. 11/10/15 - Care plan problem (last revised 4/9/18) that R9 had the capacity and motivation to improve function but exhibits or is at risk for decreasing ability to perform ADL in bathing, grooming, dressing, eating, bed mobility, transfer, locomotion, toileting due to stroke. Included interventions: Provide assistance and/or cueing to maximize current level of function; stand on weaker side of resident; encourage active participation of resident; assist with ADL's as needed. 11/19/15 - Care plan problem (last revised 10/26/17) for incontinent of urine due to stroke and dementia with potential for improved control or management of urinary elimination. Included the goal that R9 would experience less than 3 incontinent episodes per day. Interventions included: complete voiding diary and evaluate for patterns of incontinence at appropriate intervals; complete an incontinence assessment according to policy and procedure; encourage resident to use toilet/empty bladder upon wakening, before meals, bedtime and as needed. 7/10/17 and 10/8/17 - Quarterly MDS Assessments documented R9 was occasionally incontinent of urine. R9 required extensive assistance with bed mobility, transfer to/from chair/bed, dressing and toilet use. 1/8/18 - Quarterly MDS Assessment documented R9 was frequently incontinent of urine. This was a decline in continence from the previous two quarterly MDS Assessments. R9's level of assistance with bed mobility, transfer to/from chair/bed, dressing and toilet use remained unchanged (extensive assistance). 1/18/18 - Care plan evaluation note by E9 (former UM) documented for R9's urinary incontinence care plan that the resident was having some difficulty using the urinal due to left arm weakness which may cause incontinence. Care plan reviewed. Continue with plan of care. No new interventions were implemented as all interventions were dated 11/3/15. Analysis of CNA documentation for urinary continence found R9 was continent the following percentage each month: July (YEAR): 82.3% August (YEAR): 82.4% September (YEAR): 75.3% October (YEAR): 78.4% November (YEAR): 81.8% December (YEAR): 47.3% January (YEAR): 54.3% February (YEAR): 37.2% There was no evidence that the facility conducted a urinary incontinence assessment and a three-day continence management diary, both required by the facility policy titled Continence Management, in response to R9's change of urinary continence status as documented on the 1/8/18 MDS Assessment and the 1/18/18 care plan evaluation note. During an interview with the POA on 4/11/18 at approximately 1:50 PM the POA expressed concern over R9's decline of continence. The POA stated that R9 was embarrassed about the decline of continence. During an interview with E2 (DON) on 4/17/18 at 12:13 PM to discuss the process when decline of continence occurs, E2 said the RNAC emails the unit manager and DON about the decline. E2 added that, after notification, we do a bladder assessment and a 3 day voiding diary and determine which interventions would be implemented. During an interview with E7 (RNAC) on 4/17/18 at 12:30 PM in the DON's office, E7 confirmed R9's decline of urinary continence was not identified and the request to schedule an assessment was not done. During the exit conference on 4/18/18 at approximately 4:50 PM, E1 (NHA) referred to the care plan evaluation where the former UM indicated the resident spilling urine from the urinal may have been identified as incontinence. The former UM had actually documented that the resident was having some difficulty using the urinal due to left arm weakness which may cause incontinence. The note did not address spillage. The facility failed to address this concern in the resident's care plan by altering the level or frequency of assistance to improve continence. The facility failed to: identify a decline in urinary continence (82.4% continent to 37.2% continent); assess the decline in urinary continence; and, implement measures to improve the continence status. These failures led to a decline in continence and embarrassment for the resident. 2. Review of 40's clinical record revealed: 1/20/2000 - Admission to facility with multiple [DIAGNOSES REDACTED]. 1/15/14 - Care plan problem for suprapubic catheter due (revised 3/8/18) included the intervention to keep bag off floor. April, (YEAR) - Observations of R40 in bed and the urinary drainage bag touching the floor and/or the fall mat placed on the floor next to the bed: - 4/10: 9:32 AM and 3:33 PM. - 4/11: 10:21 AM. - 4/13: 8:30 AM and 12:39 PM. - 4/16: 2:40 PM. During an interview with E2 (DON) on 4/16/18 around 2:40 PM, E2 confirm the urinary drainage bag was touching the floor. E2 used alcohol to clean the drainage spout, emptied the bag and positioned the bag on the resident's bed so it did not touch the floor. 4/18/17 (8:40 AM) - Resident being fed breakfast with urinary drainage bag touching the floor, no fall mat next to the bed. These findings were reviewed with E1, E2 and E3 (ADON) on 4/18/18 at 4:30 PM.

Based on observation, record review and interview it was determined that the facility failed to ensure that two (R8 and R212) out of 32 sampled resident received the services necessary to prevent the development of avoidable pressure ulcers (PU-an area of skin that breaks down when something keeps rubbing or pressing against the skin) and provide the necessary treatment and services to existing PU to promote healing, prevent infection and prevent PU from developing. R8 was admitted to the facility with three stage I (non-blanchable(which mean that it will appear white and pale and if you press on it) redness of a localized area usually over a bony prominence) PU. As a result of the failure to adequately assess and monitor these wounds R8's PU progressed to be unstageable (tissue loss in which the actual depth of the ulcer is unable to be determined) with eschar (dead tissue that falls off from healthy skin) and slough (yellow, tan gray, green or brown dead tissue). R212 was admitted to the facility from the hospital following surgical repair of a broken right hip. As a result of the multiple failures to adequately assess, care plan, implement interventions, and monitor R212, the resident had a new, stage II (skin blisters or skin forms an open sore. The area around the sore may be red and irritated) PU of the right heel which worsened to be an unstageable PU with eschar. Findings include: 1. R8 was admitted to the facility for rehabilitation on 6/29/13 after a hospital stay for a fractured leg. The facility's Skin Care Protocol included in R8's clinical record with the physician's orders [REDACTED]. The Nursing Admission Assessment for R8 dated 6/29/13 described the following skin impairments; center coccyx/sacral (tailbone) 2 x 1 centimeter (cm) red, non-blanchable, skin intact; right buttock 4 x 2 cm red, non-blanchable, skin intact; left buttock 5 x 3 cm red, non-blanchable, skin intact. These descriptions are consistent with stage I pressure ulcers. The Braden Score (tool to determine PU risk) was 17 indicating mild risk. A skin integrity and treatment report dated 6/29/13 was initiated for each of the identified areas. The primary type of wound was identified as pressure but the staging was left blank. A care plan for R8 for actual skin breakdown related to impaired mobility was initiated on 6/29/13 and includes the interventions: -apply barrier cream with each cleansing -assist resident in turning and repositioning every 2 hours-float heels while in bed -monitor skin signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche easily -observe skin condition with ADL (activities of daily living) care daily and report abnormalities -provide incontinence care as needed -weekly skin assessment by licensed nurse The admission physician orders [REDACTED]. The weekly skin assessment document completed by nursing on 7/6/13 stated that the resident had a previously noted skin injury. No further description of the skin injury was noted. R8's Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident was cognitively intact, required extensive assistance with bed mobility and transfers, was frequently incontinent of bowel and bladder and incorrectly identified the resident as having no unhealed pressure ulcers. The MDS resulted in Care Area Assessment trigger for pressure ulcers and the facility indicated they would proceed with care planning. A Nursing assessment dated [DATE] inaccurately documents skin impairments including foot problems, surgical wounds [MEDICAL CONDITION] were not present. The Braden score was 17 indicating mild risk for PU. No weekly assessment could be found for the three skin areas identified on admission. On 7/9/13, 11 days following admission, a "Change of Condition Skin" form was initiated documenting that the left buttock had an open area 3.5 cm by 2 cm and the right buttock had an open area 2 cm by 2cm. The note indicated that the physician had been notified. No new orders were initiated. The facility initiated change of condition charting for 72 hours which included nursing documenting about the skin breakdown each shift for 3 days. New skin integrity and treatment reports were initiated on 7/9/13 but not fully completed for both buttock areas. The left buttock sheet indicated the area was from pressure but the right buttock did not indicate the source of the wound. Neither documented a staging of the wounds. Both wounds were described as having a 0.1 cm depth and scant blood drainage with no odor. A Wound Management Tracking Tool, dated 7/10/13, documents that on 7/9/13, E8 had an in house acquired pressure area to the buttocks that was a stage II. The interventions were to reposition the resident and apply moisture barrier cream. The interventions did not include consult WOCN or application of Hydrogel as the protocol requires for a stage II PU. No additions were made to the care plan. There were no new physician's orders [REDACTED]. On 7/14/13, medical record indicated that the Braden score was now 13 indicating moderate risk for PU. No additions were made to the care plan. There were no new physician's orders [REDACTED]. A "Change of Condition" note dated 7/15/13 and timed 1:46 PM documents that the nurse observed the sacral area. The note described the sacral area as having increased redness, being painful to touch with yellow and necrotic eschar. It continued to document that R8 was being turned side to side. A "Change of Condition Follow-up" note, dated 7/15/13, documents; resident exhibited reddened inflamed sacral/buttock areas. Yellow slough to coccyx, necrotic areas approximately 1 inch in diameter to both sides of sacral areas near coccyx, painful to touch, yellow-green drainage from wound areas. Cleansed site, applied barrier cream, sent patient to (name of hospital emergency room ) due to decreased intake/output, no voiding and signs and symptoms of infected wound. Review of the medical record lacked evidence that R8 was ever put on a side to side turning schedule for the CNAs to follow. The physician discharge note, dated 7/15/13 at 5:22 PM, documented that the discharge to the emergency room [DIAGNOSES REDACTED]. The physician also documented that the resident came in with a non blanchable sacral PU and today (7/15/13) she was weak without appetite, no intake by mouth the whole day and her sacral PU was found to be open with yellowish drainage. The doctor documented R8 was likely septic from a sacral PU infection. An interview with E7, Wound Nurse on 11/22/13 around 1 PM revealed that she was never made aware of R8's skin breakdown that was observed on admission. She further stated that she was also not made aware of the change in the PU that was found on 7/9/13. E7 was not aware of the PU until after the resident had left the facility. She stated that the nurses should have put a communication form in her folder and sent her an e-mail to look at the wound. An interview on 11/25/13 at 12:22 PM with E24, Medical Doctor, revealed that she did not look at R8's wounds until 7/15/13 before R8 was transferred to the hospital. E24 stated that she did not remember the resident and was relying on her progress notes from the facility. She did state that the continued use of barrier cream on a stage II PU was appropriate despite the interventions listed in the facility protocol. E24 also shared that R8 had poor control of her diabetes, weakness and a poor appetite that may have contributed to the breakdown of the pressure ulcer. Record review revealed that the physician did not mention the PU until the 7/15/13 assessment when R8 went out to the hospital. An interview on 11/25/13 around 1 PM with E2, Director of Nursing, revealed that on 7/15/13 when R8 left the building with the necrotic, draining PU the facility realized there was a problem with wound management. E2 revealed that a full body skin check was done of the entire facility population and residents' skin sheets were compared with actual observation. The facility also provided education to all the nurses. E2 provided the sign-in sheets and the materials from the education. E2 also revealed that if side to side turning had been implemented to relieve pressure it should have been added to the aides tasks in the medical record. It was confirmed that this approach was not in the aides documentation. These findings were reviewed with E1, Administrator, and E2, on 11/26/13 at 10 AM. 2. R212 was admitted to the facility on [DATE] from the hospital following repair of a broken right hip. Review of the admission nursing assessment dated [DATE] documents that R212's both heels were soft and did not have any pressure ulcer (PU-an area of skin that breaks down when something keeps rubbing or pressing against the skin). The facility's policy and procedure titled Skin Integrity Care Delivery Process indicated that all residents will be assessed for potential loss of skin integrity by using the Braden Scale (tool to determine PU risk) on admission/re-admission, quarterly, and with any significant change in condition. Record review lacked evidence that the Braden Scale was completed upon R212's admission. The admission physician's orders [REDACTED]. - Bilateral (both) heels: apply barrier cream every shift and as necessary. - Float (elevate) heels at all times when in bed. - Turn and reposition every two hours. The initial physical therapy evaluation dated 10/11/13 documented that R212 required moderate assistance of staff for bed mobility. Review of the five day Minimum Data Set (MDS) assessment dated [DATE] documents that R212 was moderately impaired for daily decision making, required extensive assistance of two plus staff persons for bed mobility, and did not ambulate. In addition, R212 was at risk for developing PU, but did not have a PU on the right heel at the time of the assessment. The MDS resulted in Care Area Assessment (CAA) being triggered for PU and a care plan was initiated. The initial Braden Scale dated 10/18/13, completed by E9, Licensed Practical Nurse/LPN, incorrectly rated R212 as 19 indicating that he was not at risk for developing a PU. The above Braden Scale dated 10/18/13 was inaccurately documented indicating that the resident was slightly limited for bed mobility. The care plan, created, and initiated on 10/22/13, documents that R212 was at risk for skin breakdown due to limited mobility and included a goal that R212 will not show signs of skin breakdown for 90 days. Interventions included: - Apply barrier cream with each cleaning (bathing) -observe for redness of heels and report same. - Monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanche (which mean that it will appear white and pale and if you press on it, you will notice that the skin does not regain its normal color redness of a localized area usually over a bony prominence easily). - Braden assessments per policy. - Observe skin conditions with daily care. Report abnormalities. - Weekly skin assessment by licensed nurse. Although the facility implemented the above care plan, the facility failed to incorporate the admission physician's orders [REDACTED]. Review of the Certified Nurse's Aides' (CNA) records from admission, 10/11/13 through 10/27/13 documents that heels are to be floated while in bed. Documentation by the CNAs, however, indicates that heel protectors were applied for 41 out of 47 shifts. While applying heel protectors reduce pressure, they do not relieve pressure as does floating the heels. The Treatment Administration Record (TAR) for October 2013 lacked evidence that a weekly skin check was completed on 10/25/13. In addition, there was no documentation in the 10/25/13 Nurse's Note (N.N.) indicating that a weekly skin check had been performed. The N.N. dated 10/27/13 and timed 6:36 PM by E19, Registered Nurse (RN), documents that R212 had an open area of the right heel approximately 2.5 centimeters (cm.) in diameter and that heel bows (heel protectors) were applied due to R212's non-compliance with elevating feet. Per the facility's Skin Integrity policy, when a skin integrity impairment was identified the following processes are to be initiated: - Complete a "Skin Integrity Report." - Interdisciplinary care plan (ICP) to include approaches to stabilize or improve co-morbidities and interventions limiting the effects of risk factors associated with PU. - Notify dietician for actual wounds. On 10/27/13, a Skin Integrity Report was initiated by E19, which documented a new skin impairment of the right heel as an old blister that opened. The facility failed to identify the type of wound. The wound appearance was intact, circular wound of 2.5 cm, no drainage, healthy surrounding tissue, and no odor. Despite the fact R212 had a new, stage II PU (skin blisters or skin forms an open sore. The area around the sore may be red and irritated) of the right heel on 10/27/13, record review lacked evidence of notification of the dietician. In addition, the facility failed to review and revise the above care plan to include approaches to stabilize or improve co-morbidities and interventions limiting the effects of risk factors associated with PU. Due to these failures, the facility failed to identify that the heel protectors being applied by the CNAs would not provide floating of the heels. On 11/13/13, E7, wound care nurse, completed a Skin Integrity Report which documented that the right heel wound was an unstageable (Full thickness skin or tissue loss where the base of the wound is obscured by slough and eschar. E7 verbalized that she was not notified of the new PU on 10/27/13 and that she was out of the facility from 10/29/13 until 11/13/13. E7 verbalized that in her absence the unit manager was assuming the role of the wound care nurse. E7 confirmed that there was no evidence of the PU assessment between 10/27/13 and 11/13/13, approximately 16 days. Record review revealed a new care plan was created and initiated on 11/17/13 (approximately 21 days after the new onset of the PU) for actual skin breakdown related to limited mobility to the left heel (the PU was actually on the right heel). Interventions included the application of barrier cream with each cleansing, assisting the resident to turn and reposition every 2 hours, and floating the heels while in bed. A Skin Integrity Report were completed by E7 on 11/20/13 indicated that the PU remained unchanged with eschar. During treatment observation on 11/20/13 at approximately 10:30 AM, E31, RN, pulled back R212's bed covers and it was noted that R212's right heel was directly on a flat pillow and not floated as ordered. There was eschar covering the entire wound bed of this unstageable PU. The surrounding tissue was inflamed with dark pink discoloration. When E31 pressed slightly on the skin around the PU, R212 verbalized onset of pain. After the treatment, E31 folded the pillow to float R212's bilateral heels. On 11/20/13, at approximately 2 PM, an interview with E9, Licensed Practical Nurse, who completed the Braden Scale on 10/18/13 revealed that she had assessed R212 as slightly limited in his ability to change and control body position based on her understanding. An interview with E6, Registered Dietician, on 11/21/13 at approximately 11 AM, confirmed that E6 was not notified or consulted when R212 developed a new PU on 10/27/13 and further verbalized that she was not aware until this interview with the surveyor at the time of the survey. During an interview with E19, RN, on 11/22/13 at approximately 10:30 AM, she recalled that she observed a blister which opened on 10/27/13. E19 verbalized that she applied the heel bows to provide cushion to the heel since R212 was non compliant with the use of a pillow to float the heels and that she notified E7 via electronic mail. During the survey on 11/22/13 at approximately 1:30 PM, E5, Manager of Clinical Operations verbalized to the surveyor that she observed R212's PU today and that the scab (rough protective crust that forms over a cut or wound during healing) came off of R212's heel and visually, it was a stage II PU. (E5 disagreed with E7's 11/13/13 assessment as unstageable). An interview with R212's attending physician, E26, on 11/25/13 at approximately 10 AM, revealed that he was not notified when R212 acquired a stage II PU on 10/27/13 or any time thereafter. An interview with E18, CNA, on 11/25/13 at approximately 11 AM, revealed that she used pillows to float R212's heels and recalled that E7 instructed her not to use the heel protectors for R212. E18 verbalized that R212 was compliant with the use of the pillows to float his heels. An interview with E7, on 11/25/13 at approximately 11:15 AM revealed that the facility utilized pillows or heel protector to relieve pressure on the resident's heels. Interview with E20, RN, on 11/25/13 at approximately 2 PM revealed that pillows were utilized to float the heels. E20 further verbalized heel protectors would not be used to float the heels since it was a device to reduce pressure and not relieve pressure. In addition, heel protectors would require a physician's orders [REDACTED]. E20 verbalized that it appeared that the facility's electronic medical record (eMR) on 10/11/13 automatically included the use of the heel protectors for the intervention to float the heels. An interview with the facility's wound care consultant, E22, on 11/25/13 at approximately 2:15 PM revealed that she observed R212's right heel PU once the eschar fell off on 11/22/13 and assessed the PU as stage II. E22 verbalized that heel protectors would not be utilized for heel suspension or floating of the heels. Above findings were reviewed with the Administrator, E1, Director of Nursing, E2, Clinical Operations Nurse, E5, Registered Dietitian, E6, and Nurse Practice Educator, E30 on 11/26/13 at approximately 10:00 AM. An interview with E29, CNA, on 11/27/13 at approximately 1 PM, revealed that she used pillows to elevate R212's heels and also applied the heel protectors. E29 verbalized that the heel protectors did touch the mattress "slightly." An interview with E30, Nurse Practice Educator on 11/27/13 at approximately 1:40 PM revealed that the facility identified at the time of the survey that the facility's eMR system on 10/11/13 automatically and incorrectly included the use of heel protectors for R212's heels. E30 verbalized that the facility will be educating the licensed staff to prevent this re- occurrence. The facility failed to provided R212 the appropriate treatment and services to prevent a new PU from developing and from worsening into an unstageable PU with eschar.

Based on record review and interview it was determined that the facility failed to ensure the appropriate treatment and services to restore and/or maintain bladder function were implemented for one (R127) out of 32 sampled residents who was continent of bladder function on admission and declined to occasionally incontinent. Findings include: The facility's policy and procedures for continence management documented that if a patient is incontinent a urinary incontinence assessment should be completed, then address the transient causes for the incontinence. Finally, initiate a three-day continence management diary and develop a plan of care based on information from assessments and three-day continence management diary. R127 was admitted to the facility on [DATE]. Review of R127's Certified Nurse's Aide (CNA) bladder continence documentation sheet revealed R127 was continent of urine from 6/20/13 through 6/30/13. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed R127 was cognitively intact for decision making, was continent of urine and required extensive assistance with one person to physically assist her with toileting. On 7/14/13, R127 was transferred to the hospital with a [DIAGNOSES REDACTED]. On 7/19/13, R127 was readmitted back into the facility. Review of the CNA bladder continence report revealed R127 was incontinent of urine 4 times from 7/19/13-7/26/13. Review of R127's readmission MDS dated [DATE] documented she was occasionally incontinent of urine and was not on a toileting program. Review of R127's CNA bladder continence report for the month of August 2013 revealed R127 had 22 incontinence episodes out of 93 opportunities (23.6%). For September 2013, R127 had 19 incontinence episodes out of 90 opportunities (21%). For October 2013, R127 had 21 incontinence episodes out of 93 opportunities (22.6%) . R127's quarterly MDS assessment dated [DATE] stated R127 was occasionally incontinent of urine and was not on a toileting program. The MDS also documented R127 required extensive assistance with one person to physically assist her with toileting. Review of R127's record failed to contain evidence that a urinary incontinence assessment was completed, a three day diary was completed or a plan of care to address R127's incontinence was completed. The record also lacked evidence that interventions were put in place to restore R127's bladder function. Review of R127's record with E4, Unit Manager on 11/20/13 at 1:25 PM confirmed the facility failed to address R127's decline in continence. The facility failed to perform a urinary incontinence assessment, address the transient causes for the incontinence, initiate a three-day continence management diary and develop a plan of care based on the information to restore her bladder function. These findings were reviewed with E1, Administrator and E2, Director of Nursing on 11/26/13 at 10 AM.

Based on observation, record review and interviews it was determined that the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (R50) of 32 sampled residents. The facility failed to consistently provide foods that were safe for R50 to eat and failed to provide R50 with appropriate substitutes. The facility failed to honor R50's request for food substitutions even though R50 was knowledgeable of her medical conditions and potential for aspiration. The facility failed to put effective interventions in place for R50 who was legally blind, an aspiration risk and experienced a severe weight loss. These failures resulted in the severe weight loss of 9.4% for R50. Findings include: Cross refer F309 example #3 and F366 R50 was admitted to the facility on [DATE] after having abdominal surgery with [DIAGNOSES REDACTED]. On 10/14/13 the physician wrote an order "Aspiration Precautions" for R50. On 10/14/13, the facility sent a diet order communication to dietary indicating R50 was on aspiration precautions (precautions taken by facility to decrease the chance the resident will inhale food or drink into the windpipe and lungs). On 10/17/13 another diet communication form was sent indicating R50 needed her food cut up and told what was on her plate as she was legally blind. On 10/17/13, E6, Dietitian completed a nutrition assessment for R50. The assessment documented R50 was a nutritional concern and complained of difficulty and pain when swallowing. It also stated that R50 had an elevated body mass index (body fat) and her food intake was low at 25 percent (%). R50's 10/13/13 admission weight (wt.) was 195.4 pounds (#). E6 failed to identify the fact that R50 was visually impaired and required assistance with eating. On 10/17/13, E6 documented a nutrition assessment was completed for R50 and there was a nutrition concern. R50 told E6 that she had lost some weight recently. E6 obtained food preferences and forwarded it to dietary. R50 requested softer foods, especially meats. R50 was encouraged to eat foods high in protein to help with wound healing. E6 recommended changing R50's diet to a regular/liberal diet with ground meats and added vitamins and minerals. E6 failed to document R6 was missing most of her teeth and refused to wear her false teeth or bridges. On 10/18/13 a Modified [MEDICATION NAME] Swallow Evaluation report was completed indicating R50 had a study on 10/11/13 with recommendations that included mechanical soft solid diet with thin liquid, alternate small bites/sips, and aspiration precautions. R50's nurses' notes documented on 10/18/13 new orders to change diet to advanced dysphasia (difficulty swallowing) with thin liquids. Small bites and sips with meals. Start patient on aspiration precautions. R50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed R50 was cognitively intact for decision making, vision was severely impaired (no vision or sees only light, colors or shapes; eyes do not appear to follow objects), and required extensive assistance with one person to physically assist her with eating. On 10/22/13, R50 weighed 193 #. On 10/28/13, R50 weighted 184.3 # indicating she had a significant weight loss of 5.6% since her admission to the facility. There was no evidence that the facility addressed R50's documented significant wt. loss. On 10/30/13, (13 days after the dietitian suggested the diet change for R50) an order was written for R50's diet to change to a regular liberalized diet with chopped meat. On 10/31/13, the nurse's notes timed 1:20 PM documented that R50 had over a 5% weight change in over 30 days (not accurate resident had not been admitted for 30 days). R50's meal intake was variable. Resident's food preferences were noted and continue to encourage food intake. On 11/1/13, E6 documented R50 had a significant wt. loss since admission. R50 received a regular/liberalized diet with chopped meats. Her meal intake was variable but R50 stated she tried to eat at least 50% or more of her meals. E6 documented she encouraged R50 to request alternative options at meals if she does not like what is served. R50 told E6 she liked egg salad sandwiches. E6 informed R50 that the facility always had egg salad available for her. E6 documented her action was to encourage intake of meals, snacks and fluids daily. On 11/4/13 the physician wrote an order again stating that R50 was on aspiration precautions. Review of the certified nurse's aide's tasks document revealed R50 was blind and staff needed to cut up her food into bite size pieces for each meal. It continued to document that R50 was on aspiration precautions-no straws. On 11/8/13, R50's weight was 178.8 # (8.4% severe wt. loss over 30 days). On 11/8/13, E6 documented R50 had an additional wt. loss. R50's meal intake had improved, averaging 71% over the past week. R50 received a regular/liberalized diet with chopped meats. E6 documented she continued to encourage intake of meals, snacks and fluids. If R50's wt. does not stabilize a supplement may be needed. The facility failed to recognize that R50 had a severe wt. loss and the facility failed to evaluate the effectiveness of their interventions and implement individualized interventions with consideration to her visual impairment to prevent further weight loss. On 11/14/13, R50's wt. was 177 # (9.4% severe wt loss). The record lacked evidence that E6 or the physician addressed R50's severe weight loss. There was no evidence that the facility evaluated their interventions or implemented new interventions to address R50's severe weight loss. On 11/15/13 the physician wrote a progress note documenting R50's weight but did not address her severe weight loss or implement interventions to address her weight loss. On 11/15/13, two surveyors observed R50 in her room sitting at her table. At approximately 1:15PM, E9, Licensed Practical Nurse, brought R50 her lunch tray. R50 requested a substitute for her chips and soup. E9 failed to honor R50's request for a substitute and failed to describe the location of R50's food. R50 was given a whole sandwich that was not cut in half. Review of the certified nurse's aide's documentation sheet revealed R50 ate only 50% of her lunch on 11/15/13. On 11/19/13, R50's weight was 175.8#. (10% severe wt. loss since admission). On 11/20/13, R50 weighted 175.8#. The record lacked evidence that the facility evaluated their interventions or implemented new interventions to address R50's severe weight loss. Review of R50's meal percentages consumption from 10/28/13-11/20/13 revealed that she consumed: -100% of her meals 25% of the time -75% of her meals 19% of the time - 50% of her meals 31% of the time - 25% of her meals 22% of the time -no food consumption 1% of the time. On 11/21/13 at 9:15 AM R50 was observed eating breakfast in her room and was not aware of the banana sitting on her table. R50 stated she was not aware the facility brought her a banana. On 11/21/13, an interview with E6 at 12:05 PM, confirmed she did not initiate supplements to address R50's severe weight loss because she wanted to add it as a last resort. E6 stated she preferred residents receive their calories from their meals. E6 continued to state that she feared the supplements would prevent R50 from eating. Above findings were reviewed with the E1, Administrator, and E2, Director of Nursing, on 11/26/13 at approximately 10:00 AM.

Based on record review and interview it was determined that the facility failed to ensure sufficient fluid intake was provided to maintain hydration and health for one (R8) out of 32 sampled residents. R8 had declining food and fluid intake that was not detected by nursing staff resulting in a hospitalization with dehydration. Findings include: Cross refer F314, example #1. R8 was admitted to the facility on [DATE] for rehabilitation after a broken leg. The resident's admission minimum data set assessment ((MDS) dated [DATE] indicated the resident was independent with daily decision making and required supervision with one person to physically assist with eating. The initial nutritional assessment dated [DATE] documented incorrectly under skin integrity that R8 did not have a pressure ulcer (an area of skin that breaks down when something keeps rubbing or pressing against the skin), the resident was admitted with 3 stage I (non-blanchable redness) pressure ulcers, however that dietitian (RD) did comment in her summary that the resident had three open areas to the buttocks (the back of a hip that forms one of the fleshy parts on which a person sits). The resident's average meal intake since admission was about 63%. R8 was calculated at needing 1925 calories a day and 1925 ml (milliliters) of fluid a day. The RD documented that the patient was not meeting her estimated needs at that time and that the patient stated that she had lost her appetite since she has been in the nursing home and didn't feel like eating. The RD also documented that the resident had recent abnormal lab values of BUN (test measures the amount of nitrogen in your blood that comes from the waste product) 35 mg/dL(milligrams per deciliter) (reference range 7-18), creatinine (a breakdown product of [MEDICATION NAME], which is an important part of muscle) 1.44 mg/dL (reference range 0.67-1.17), these labs are indicators of fluid imbalance and renal function. There was no other discussion of the adequacy of R8's fluid intake. There was no care plan specific to hydration initiated. The RD did initiate a nutritional care plan on 7/8/13 that included the approaches: monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food service and nutrition/physician as indicated and offer alternate food choices if <50% consumed at mealtime. Review of fluid consumption daily for R8's admission: 7/1/13 900 ml 7/2/13 480 ml 7/3/13 640 ml 7/4/13 840 ml 7/5/13 720 ml 7/6/13 420 ml 7/7/13 1260 ml 7/8/13 1040 ml 7/9/13 920 ml 7/10/13 1160 ml 7/11/13 360 ml 7/12/13 840 ml 7/13/13 580 ml 7/14/13 660 ml 7/15/13 220 ml (prior to going to hospital) Review of the meal intake for the following days documented: 7/10/13 breakfast 25%, lunch 25%, dinner 50% 7/11/13 breakfast 25%, lunch 100%, dinner 25% 7/12/13 breakfast 25%, lunch refused, dinner refused 7/13/13 breakfast refused, lunch refused, dinner 50% 7/14/13 breakfast 25%, lunch 50%, dinner 25% 7/15/13 breakfast 0%, lunch 0% Review of the interdisciplinary progress notes lacked evidence that anyone noticed the low fluid intake and decreasing meal intake until 7/15/13. No new interventions were put in place. There was no evidence that additional fluids were being provided or alternate meals being offered. A nursing change of condition note dated 7/15/13 and timed 1:46 PM documented that the resident had no food or fluid intake this shift with no voiding since the beginning of the shift. The resident complained of abdominal and sacral (lower spine) pain. The nursing (hospital) transfer note dated 7/15/13 and timed 2:23 PM documented that the resident had an elevated blood sugar reading, signs and symptoms of dehydration, an infected wound (pressure ulcer to buttocks area) and signs and symptoms [MEDICAL CONDITION] (infection moving through body). The preliminary history and physical report from the hospital dated 7/15/13 documented the resident had nausea for the last couple of days and was having very poor oral intake. That she did not have any urine output since the end of night shift. The patient had been complaining of pain in her tailbone for the last 2 to 3 weeks, and was found to have a pressure ulcer and the ulcer got worse per the nurse. The emergency department documented R8's laboratory results were significantly abnormal. Her creatinine was high at 6.15 and her BUN was high at 170. Under impression and plan the hospital physician documented; -acute [MEDICAL CONDITION], most likely it is because of dehydration. Nephrology (kidney specialist) was consulted and advised the patient could be continued on IV (intravenous) fluids. -dehydration/[MEDICAL CONDITION] (low blood pressure) -possible urinary tract infection -diabetes -sacral (tail bone) ulcer that was getting worse and antibiotic started -advanced age (90) An interview on 11/25/13 at 11:30 AM, with E2 Director of Nursing revealed that if a resident is documented in the task manager as consuming 0-25% an alert would go to nursing on the computer's dashboard. This would prompt the nurse to look and see what was going on. E2 stated that low fluid intake does not populate on the dashboard as an alert. She stated the aides and nurses would have to monitor it themselves. An interview on 11/25/13 at 12:22 PM with E24, Medical Doctor, revealed that she did not specifically remember the resident and was relying on her progress notes. She stated on 7/11/13 she documented that the resident was complaining of weakness and poor appetite. E24 also stated that the resident's "blood sugars were running high between 200-300" and she had poor control of her diabetes. The doctor stated that she discontinued the resident's oral diabetic medication because her creatinine had gone up and put her on sliding scale insulin. E24 stated that the diabetes, weakness and poor appetite may have contributed to the resident's [MEDICAL CONDITION] and breakdown of the decubitus (pressure ulcer). There was no evidence that facility staff were monitoring R8's poor and declining food and fluid intake. There was no evidence that the resident was being assessed and new interventions were being put in place to increase intake. R8 showed a decline in intake from Friday July 12th through Monday July 15th, 2013. This resulted in the resident becoming absent of urinary output and being transferred to the hospital with dehydration which required medical intervention. Above findings were reviewed with E1, Administrator and E2, Director of Nursing on 11/26/13 at approximately 10:00 AM.

Based on record review and staff interviews, it was determined that for three (3) of seven (7) residents reviewed (R1, R2, and R3) the facility failed to ensure that the residents were free from significant medication errors. R1 received multiple doses of three different medications ([MEDICATION NAME], and [MEDICATION NAME] 70/30 insulin) that were erroneously ordered for her based on another person's discharge summary which was erroneously sent by the hospital to the long term care facility. As a result of these medications (multiple doses of each were administered to R1), R1 required hospitalization and treatment for [REDACTED]. R2 failed to receive blood pressure medications as ordered (was ordered twice a day but given only once on multiple consecutive days). R3 was erroneously given a dose of insulin on one occasion which was six times the dose she was supposed to receive. The facility identified these errors and reported them to the State survey agency. Findings include: 1. R1 was re-admitted to the facility on [DATE]. According to the admission orders [REDACTED]. The inclusion of these three medications on R1 ' s admission orders Clinical Discharge Summary " sent by the hospital to the facility on [DATE]. This summary was sent to the facility along with a discharge summary for R1 but actually belonged to another hospital patient (had another person ' s name on it, not R1 ' s name). (Additionally another discharge summary with R1's name on it was also sent to the facility.) R1 was not intended to receive the three medications listed on another person ' s discharge summary which were: [MEDICATION NAME], Losartan ([MEDICATION NAME]), and [MEDICATION NAME] 70/30. R1 was previously a resident of the facility and a Minimum Data Set (MDA) assessment completed on 5/5/11 did not include a [DIAGNOSES REDACTED]. The MDs completed on 7/5/11, however, did identify that R1 had a " [MEDICAL CONDITION] disorder " . It was not clear whether this [DIAGNOSES REDACTED].[REDACTED]. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Kepra 500 mg on 6/24/11 at 9 PM, 6/25/11 at 9 AM and 9 PM, 6/26/11 at 9 AM and 9 PM, and 6/27/11 at 9 AM (6 total doses); -Losartan ([MEDICATION NAME]) at 9 AM on 6/25/11, 6/26/11, and 6/27/11; and -[MEDICATION NAME] 70/30 24 units given on 6/25/11 and 6/26/11 at 7 AM and 9 PM and at 7 AM on 6/27/11. On 6/25/11 at 9:55 AM, a nurse documented in a nursing note that R1 was " very hard to arouse this morning " and " falls back to sleep very quickly " when staff attempted to get her to drink juice. On 6/26/11 at 10:30 AM, a nurse documented that R1 " is not alert, she (R1) is very sleepy " . An untimed nursing note on the morning of 6/27/11 described R1 as " sleepy most of shift " . At 11:55 AM on 6/27/11 a nurse documented that R1 was " found unresponsive " and her blood sugar was 21 mg / dl. R1 ' s blood pressure was also low with only a systolic blood pressure of 40 mmHg being obtained. R1 was sent to the hospital via 911. Prior to transporting R1 to the hospital via 911 on 6/27/11, there was no clinical record documentation or other indication that possible reasons for R1 ' s sleepiness on 6/25/11 and 6/26/11 were evaluated by the nursing staff or discussed with the attending physician. A history and physical completed at the hospital on [DATE] indicated that R1 had: - " [DIAGNOSES REDACTED] secondary to insulin overdose from medication error " ; - " [MEDICAL CONDITION], secondary to most likely [MEDICATION NAME] and possibly above ([DIAGNOSES REDACTED]). The patient (R1) maintained on [MEDICATION NAME] drip at this point " ; and - " mental status change most likely secondary to above as well as given a total of 6 doses of [MEDICATION NAME] for [MEDICAL CONDITION] disorder along with the other medications that she takes. This could easily account for this. The patient (R1) had CT scan of the head which showed no acute changes. Will admit to intensive care unit (ICU) " . The hospital discharge summary dated 6/29/11 indicated that it was determined that while in the nursing home R1 " was administered some medications which had not apparently been ordered upon discharge, including [MEDICATION NAME] 70/30, [MEDICATION NAME] (Losartan), and [MEDICATION NAME] " and R1 " was found to be profoundly hypoglycemic as well as hypotensive " . During the exit conference on 9/12/11 at approximately 12:20 PM, E1 (Director of Nursing) told the surveyor that the facility and hospital had worked together to review the medication errors involving R1 resulting in a new procedure for information transfer when a hospital patient was transferred to the facility. E1 stated that the nursing home staff now directly accesses and prints whatever medical / discharge information they need from the hospital without hard copies (paper) being sent by the hospital. 2. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. After 3 missed doses of [MEDICATION NAME], the facility identified and corrected this error on 5/31/11. According to a nursing note dated 5/31/11 and timed 9:55 AM, R2 ' s blood pressure had been elevated at 220/104 mmHg that morning. For the [MEDICATION NAME], however, ten doses were missed before the facility identified and corrected the error on 6/8/11. 3. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a nursing note dated 11/4/10 and timed 2 PM, R3 " inadvertently received 30 units of Regular insulin " . The physician was contacted and treatment and monitoring for potential [DIAGNOSES REDACTED] was initiated. Facility investigation documents revealed that the nurse who administered the excessive amount of insulin had been distracted and realized and reported her mistake immediately.

Based on record review, interviews and observation it was determined that two (R28 and R131) out of 33 sampled residents failed to receive the care and services necessary to ensure adequate pain relief. It was determined that the facility failed to reassess and failed to monitor the effectiveness of R28's pain management interventions related to lower back pain and knee pain. This failure and the failure in contacting the attending physician each time the medication was not effective resulted in the pain level remaining at unacceptable levels between 8 and 10. The facility failed to reassess and monitor the effectiveness of R131's pain management interventions as it related to resident's goals and current standards of practice. Findings include: 1. R28 was readmitted [DATE] post hospitalization following back surgery (microdiskectomy for L4/5 on 1/18/10). The resident's [DIAGNOSES REDACTED]. Hospital discharge orders for pain medications were [MEDICATION NAME] 10/325 mg 1 tab q 4 hours for pain and [MEDICATION NAME] 300 mg prn for pain. The resident's initial pain medication orders were [MEDICATION NAME] 10 mg bid (twice a day) for pain, [MEDICATION NAME] 5/325 mg 1 tab for moderate pain or 2 tab for severe pain Q 4 - 6 hours prn as needed, and [MEDICATION NAME] 300 mg prn for pain (resident never requested or received dc'd 2/2/10). R28 was alert and oriented. The resident admission MDS dated [DATE] documented the resident had pain and identified the sites as the back, joint and other unspecified sites with a frequency as daily and an intensity that was horrible to excruciating. The resident's admission pain assessment (unsigned and undated) indicated the resident had daily pain to the lumbar back area that was throbbing and sharp. The resident rated her pain as a 10 on a 0 to 10 scale. R28 indicated her acceptable level of pain was a 3 - 4 and her goal was to be 0 -1. The current pain management was listed as [MEDICATION NAME] every 12 hours and [MEDICATION NAME] as needed for breakthrough pain that was effective. An interdisciplinary care plan was implemented on 1/20/10 for pain related to (facility did not identify). The care plan failed to identify the source of the resident's pain and failed to be revised when R28 developed a second source of pain. The expected outcome was "Resident name" will verbalize effectiveness by a decrease of pain by rating of one point according to the pain scale within 30 minutes after intervention. This was not the same goal assessed on the admission pain assessment of having her pain at an acceptable level for 3 -4 with a goal of 1 - 2.. Approaches included assessing effectiveness of pain control relief using 0 - 10 pain scale and record on MAR/24 interdisciplinary progress record after 30 minutes. On 1/27/10 the resident was sent to the emergency room to have her left knee evaluated for swelling and pain. No injuries were identified to the left knee. On this same day the physician added a [MEDICATION NAME] to the lower back on 12 hours off 12 hours for pain relief. R28 received prn medication for complaints of knee pain on an almost daily basis. At times two to three times a day. There was no pain assessment documented for this new onset of knee swelling with pain. The facility's policy for Pain Management indicates a new assessment will be done with any new onset of pain. The pain management standards were approved by JCAHO in July 1999 and the same guidelines were approved by the American Geriatrics Society in April 2002 which include: -appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. The facility failed to use a quantitative pain assessment to evaluate the level of pain and effectiveness of the treatment. The facility failed to describe the pain and failed to differentiate between pain sources with individual assessments. The facility's pain scale contained in the Pain Management and Assessment Procedure documents 0 = no pain, 2 = mild, 4 = discomforting, 6 = distressing, 8 = terrible, and 10 = excruciating. An interview on 3/2/10 at 11 am with a nurse E15 , revealed that the practice of the facility is to rate pain with the scale, give the medication and go back in about an hour and use the scale again to rate the pain. The facility documented pain every shift using the pain scale on the MAR. For the month of February 2010 the resident's pain was rated between 8 -10 for 50 out of the 84 opportunities or 60% of the time. During the Month of February 2010 R28 received 61 doses of prn pain medication ([MEDICATION NAME] and/or [MEDICATION NAME]) for breakthrough pain. For 30 of those doses her pain level was rated at a 10, 11 doses at a level of 9, 10 doses at a level 8, 2 doses at a level 7, 3 doses at a level 6, 1 dose at a level 5 and 4 doses in which the level was not documented. Review of the February 2010 MAR indicated [REDACTED]. For 11 out of 61 (6%) of the prn medications the resident rated pain after administration at a 6 - 8 (distressing to terrible). The resident's acceptable pain level is 3 - 4. On 2/11/10 R28's every 12 hour [MEDICATION NAME] dose was increased from 10 mg to 20 mg for pain. This was administered twice daily at 9 AM and 9 PM. On 2/14/10 a heat pack (kmod) was ordered for use on the resident's lower back to relieve pain. There was also an order [REDACTED]. On 2/21/10 R28 had two falls landing on her knees. X-rays were obtained but were negative for fracture. The resident's twice a day [MEDICATION NAME] was increased from 20 mg to 40 mg for pain. The [MEDICATION NAME] as needed order remained in place and was requested every 6 hours by R28. On 2/25/10 at 9 am R28 verbalized pain at a 10/10 and was not due for an as needed dose of [MEDICATION NAME]. The nurse called the physician and obtained a one time order for [MEDICATION NAME] 5/325 mg 2 tabs now. Later that day the [MEDICATION NAME] prn was discontinued and [MEDICATION NAME] 10 mg q 6 hours as needed for pain was initiated. The resident continued with [MEDICATION NAME] 40 mg bid for pain. From March 1 - March 4, 2010 review of the MAR indicated [REDACTED]. Six out of ten doses were for pain at a level of 8 -10. Two doses of medication had no scaled assessment before administration. Only 2 out of ten doses used the scale to evaluate the effectiveness of the medication. On 3/2/10 a one time order of [MEDICATION NAME] 10 mg was administered at 11:50 am due to pain at a 10/10 level when the resident was not due for her ordered prn dose. The 9 PM dose of [MEDICATION NAME] was increased to 60 mg. However, with these medication adjustments the resident continued to have pain at a level of 10/10. On 3/3/10 the resident had a EMG of the left knee. Knee and back x-rays were ordered to be done on 3/4/10. Follow-up visits with the orthopaedist and neurosurgeon were scheduled for the next week. No results were available at the conclusion of the survey. Use of hot or cold therapy had been put on hold by the neurosurgeon. On 3/4/10 at 9:20 am the resident stated her pain remained a 10/10 and she had her last dose of prn [MEDICATION NAME] at 7 am. The facility's pain policy stated that any resident who states or displays evidence of ineffective pain management the attending physician is to be notified as well as completion of the appropriate pain assessment. The policy also stated that a pain scale rating prior to and after administration of an [MEDICATION NAME] and as necessary will be documented to the back of the MAR. The facility was not using an assessment or pain scale to determine the level of pain for the administration of [MEDICATION NAME] bid only for the prn doses of [MEDICATION NAME] or [MEDICATION NAME]. There was not an assessment in place to evaluate the effectiveness of the routine pain medication. The facility was also failed to differentiate between the site of pain and often documented "lower back / knee" when administering prn pain medication. Conversations by surveyors with the R28 on 2/24/10 and 3/1 - 3/4/10 revealed her pain level was at a 10. She further revealed that the pain medications she was on were not giving her relief and she had told this to the doctor last week. She also stated that the nurses did not always use the numerical scale to rate her pain and/or medication effectiveness. Review of nurses notes described the residents pain and frustration with lack of pain management; - On 2/24/10 during an interview the resident stated that her medication had just been changed from 20 mg to 40 mg ([MEDICATION NAME] BID 2/23) but has not helped yet. She further stated that she had told the doctor and the nurses that the medication was not helping her pain calm down. - Observation on a medication pass on 2/24/10 at 12:05 PM the resident rated her pain as a 10/10. Her last dose of prn [MEDICATION NAME] was at 6:15 am for pain at a 10/10. There was no documentation of the relief from that dose. The relief from the 12:05 PM dose was 7/10 (distressing to terrible). - On 3/1/10 at 2:30 PM the resident told the surveyor that the pain meds do not give her relief and she told this to the doctor last week. She also stated that the pain scale is not always used and the staff don't always come back to see if the pain medication was effective. - Nurse's note 3/2/10 7:30 am "states constant pain is starting to get to her...frustrated at present". - On 3/2/10 R28 told the surveyor that her pain medications were not working. At 11 AM her nurse E15, stated that it seems her every 6 hour prn pain medication was not holding her since she has had it at 7 am and was going to call the doctor to ask for something else for pain. The doctor gave a one time only order for 10 mg of [MEDICATION NAME] that was administered at 11:50 am. No documentation could be found to evaluate if this was effective. - Nurse's note 3/2/10 11:50 am "patient continues to have pain current pain management is not effective for her pain awaiting MD response". - Nurse's note 3/2/10 9:40 PM "pain medications ineffective. patient found crying in bed r/t pain. (Doctor name) paged". - Nurse's note 3/2/10 10:11 PM "Doctor returned phone call. Change in medication dosage ordered... Patient dissatisfied stating she wants to speak to doctor re: pain MD made aware". - Nurse's note 3/3/10 8:30 am "Resident medicated x2 for breakthrough pain this shift. States is effective sometimes, but mostly it is not. Stated she was upset about constantly being in pain and needed something done". - Nurse's note 3/3/10 8:30 am "concerned about what is going to happen to decrease pain levels". (different nurse) - 3/3/10 9:15 am the resident was observed with tears in her eyes, complained about pain and medications not working and was upset the physician never came in to talk to her last night about her pain. - Nurse's note 3/3/10 8:58 PM "Doctor in to see patient tonight to discuss pain...No new orders. Will see how [MEDICATION NAME] increase works and will continue to reassess pain" - Nurse's note 3/4/10 8:35 am "[MEDICATION NAME] IR given x 2 this shift and had some effect for pain. Resident states she needs something else but will wait until seeing ortho Friday". - On 3/4/10 at 9:20 am the resident stated her pain was a 10/10. Her last dose of [MEDICATION NAME] 10 mg prn was at 6:50 am (no effect documented) and her routine dose of [MEDICATION NAME] 40 mg was at 9 am. She stated the doctor increased her 9 PM [MEDICATION NAME] to 60 mg on 3/2/10 but she was still waiting to see the effect of it. - Review of therapy notes and interview with therapy staff E9 and E10 3/4/10 revealed that R28 participates in therapy despite her pain issues. The resident was working on ambulation, transfers, and muscle strengthening. The resident did complain of not feeling well 3/2/10 and returned to her room before the end of the therapy session. Therapy has been using electrical stimulation to help with the pain. An interview with the ADON E3, on 3/3/10 revealed that the facility had become aware of the increased pain in the last week and called to get an earlier appointment with the surgeon. X-rays of the knee and back were also ordered to be done on 3/3 or 3/4/10. An interview with the physician E18 on 3/8/10 at 1:30 PM revealed that R28 was a post-op short term rehabilitation patient that had been back to the orthopaedic doctor 3 times since admission for pain to knees and back with no resolution. All testing so far has only shown [MEDICAL CONDITION] joint disease. Pain medications have been increased several times. At this point he has her on [MEDICATION NAME] 60 mg bid and 15 mg prn q 4 hours for pain. His worry now is overdose of medication with these significant increases. He stated that her pain complaints may be exaggerated based on her lack of response to the significant medication increases. He stated that when she finishes her work up with the orthopedist and the neurosurgeon and completed her therapy rehab she may need to be seen by a pain management specialist. Although the facility initially assessed R28's lower back and knee pain and implemented new interventions for pain management, the facility failed to reassess and monitor the effectiveness of these interventions as it related to the resident's goals and current standards of practice. From 2/24/10 - 3/3/10 nurses notes document the resident's ongoing concerns about pain and lack of physician accessibility to the resident. The facility failed to communicate with the physician when the resident's pain was not adequately managed. Due to these multiple failures, R28 was found to be in terrible to excruciating pain during the survey. 2. R131 was originally admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The admission and 14 day Minimum Data Set (MDS) assessments dated 2/8/10 and 2/15/10 noted R131 did not have any impairment in daily decision making and experienced moderate intensity of pain less than on a daily basis in her back. Review of the admission pain assessment dated [DATE] indicated R131 was experiencing pain in her right hip and could verbalize pain on a scale of 0-10 and R131's acceptable level of pain was "6" and her goal for pain control was "2." A care plan for pain related to arthritis and chronic back pain implemented on 2/1/10 stated expected outcomes included alternative methods of pain management would be assessed for and utilized through the confinement. In addition, R131 would verbalize effectiveness of the intervention by decrease of pain rating by one point on the pain scale. Interventions included staff to assess for level of pain using 0-10 pain scale, every shift if patient/resident complains of pain or receives [MEDICATION NAME]. Although R131 conveyed her acceptable level of pain and goal for pain control, the care plan failed to incorporate this into the care plan. Review of the February 2010 MAR indicated [REDACTED]. by mouth for complaints of pain. Out of the 32 doses, pain scale to assess for the effectiveness of the medication was only utilized for seven administrations. In addition, the assessment failed to include the location of the pain for which the medication was given. Review of the facility ' s policy titled " Pain Management and Assessment " indicated through a collaborative interdisciplinary approach, effectiveness of pain management will be assessed on an ongoing basis. Review of physical therapy (P.T.) note dated 2/24/10 documented that R131 was unable to tolerate standing due to right hip pain. Review of the "Subacute transduction team care plan conference" note dated 3/1/10 lacked evidence that pain interventions were discussed even though R131's level of pain, as noted on the 2/24/10 P.T. note was impacting her ability to participate in therapy. Additional review of P.T. note on 3/2/10 documented that R131 was unable to participate in therapy due to right hip pain on a pain scale of "6." The current pain management standards by the American Geriatrics Society includes: - appropriate assessment and management of pain; assessment in a way that facilitates regular reassessment and follow-up; same quantitative pain assessment scales should be used for initial and follow up assessment; set standards for monitoring and intervention; and collect data to monitor the effectiveness and appropriateness of pain management. Although the facility thoroughly assessed R131's right hip pain on admission and implemented interventions, the facility failed to reassess and monitor the effectiveness of R131's pain management interventions as it related to resident's goals and current standards of practice. Above findings were reviewed with administration on 3/4/10 at approximately 2:25 PM.