Every finding on record at Marmet Center

Based on record review and staff interview, the facility failed to designate a qualified Infection Preventionist. This deficient practice had the potential to affect all residents residing in the building. Facility Census: 88. Findings included:On 04/21/2026 at 1:36 PM, the Director of Nursing (DON) stated the facility's Infection Preventionist had resigned in February. Registered Nurse (RN) #12 provided her certificate of Infection Preventionist Training. RN #12 stated she was available for staff training in Infection Control as needed but was not involved in day-to-day Infection Preventionist activities due to her position as director of the dementia unit. On 04/22/26 at 9:26 AM, the DON stated an Infection Preventionist had been hired and had started yesterday. No further information was provided through the completion of the survey process.

Based on observation, and staff interviews. The facility failed to ensure meals were served in a sanitary manner to prevent potential foodborne illness, and that equipment was kept clean. This was found during the Annual Long Term Care Survey and had the potentail to affect all residents who received nutrition from the kitchen. Facility Census: 88.Findings include:a) Review of Policy for EnvironmentPolicy statement: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.Procedure reads in part:2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing all food service equipment and surfaces.B) Observations in the main dining room on 04/19/26 around 12:15 PM revealed that Server/Dietary Aide (SDA) #84 lacked sufficient utensils for service. SDA #84 used gloved hands to obtain dinner rolls instead of tongs. SDA #84 used a fork for the chicken. SDA #84 touched all surfaces with the gloved hands then placed the dinner roll on the plate. Lead cook (#88) verified and corrected.Observations made around 9:10 AM on 04/20/26 in the dining room revealed that the steam wells in the kitchenette contained moderate amounts of food debris-egg and oatmeal-floating in the water. Meal service had ended at 7:40 AM. On 04/20/26 at around 10:45 AM, a follow-up observation of the dining room steam wells showed that the wells still contained moderate amounts of food debris-egg and oatmeal-floating in the water. The Dietary Manager (#82) verified, reporting should have been cleaned after breakfast.On 04/20/26 at around 12:20 PM during an observation in the dining room for meal service Server/Cook (SC) #83 did not wash hands after coming from the kitchen to the serving area. She then placed gloves back on, then proceeded to begin meal service. Dietary district manager in training (DDMIT) #99 stopped SC #83 and instructed the server to wash her hands, then re-glove. During the meal service, SC #83 would use tongs to get a hamburger bun but then use gloved hands to open the bun, she did not change gloves or wash hands unless instructed. DDMIT #99 verified this practice and reported, I will educate her.On 04/20/26, around 12:50 PM, during the observation of meal service in the kitchen. [NAME] #88, using gloved hands left her serving area, obtained extra plates and bases, then returned to the area. She did not change her gloves or wash her hands before proceeding to continue on the tray line. Meal served for puree- beans ran on the plate, and the puree bread was very firm and thick in appearance. Dietary Manager DM #82 verified that [NAME] #88 did not use proper gloves or handwashing techniques, and the pureed meal was not appealing for the prescribed diets. DM #82 said, I will educate her on correct glove use, and proper plating of meals.

Based on record review, staff interviews, and policy review the facility failed to provide care and services within accepted standards of practice. Timely and consistent Abnormal Involuntary Movement scale (AIMS) assessments were not completed, and they failed to monitor peripheral intravenous (IV) access. This deficient practice applied to five (5) four of (5) five residents reviewed for unnecessary medication and (1) one of (1) one residents for antibiotic usage during the Long-Term Care Survey Process. Resident identifiers: #76, #69, #56. Facility Census: 88. Findings Include: a) Resident #76 A record review on 04/21/26 at 10:41 AM, showed Resident #76 was prescribed Zyprexa from 07/10/23 to 09/20/25. Further record review found that the only AIMS assessment completed for Resident #76 was on 01/10/24. During an interview on 04/21/26 at 10:52 AM, the Director of Nursing (DON) confirmed that the AIMS assessment should be completed every 6 months for residents on psychotropic medications. b) Resident #69 Tardive dyskinesia, involuntary movements of the face and mouth, is a potential side effect of antipsychotic medications. Abnormal Involuntary Movement Scale (AIMS) assessments are used to assess the presence or progression of tardive dyskinesia. Dyskinesia Identification System: Condensed User Scale (DISCUS) is another assessment that can identify tardive dyskinesia symptoms. Review of Resident #69's physician's orders showed the resident had been receiving the antipsychotic medication Risperdal (risperidone) since 2023 for schizophrenia as evidenced by hallucinations and delusions. AIMS assessments were performed for Resident #69 on 01/04/24 and 07/03/24. Symptoms of tardive dyskinesia were not documented. On 04/09/25, the monthly consultant pharmacist's medication regimen review stated, Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 06/07/25, the monthly consultant pharmacist's medication regimen review stated, REPEAT RECOMMENDATION FROM APRIL 2025. Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 08/21/25, the monthly consultant pharmacist's medication regimen review stated, REPEAT RECOMMENDATION FROM APRIL 2025. Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 10/29/25, the monthly consultant pharmacist's medication regimen review stated, Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 02/19/26, a Note to Attending Physician/Prescriber from the consultant pharmacist stated, Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. This resident continues on Risperdal. The last AIMS/DISCUS test located in the chart was dated 2024. An AIMS assessment was performed for Resident #69 on 03/02/26. Symptoms of tardive dyskinesia were not documented. An AIMS assessment was performed for Resident #69 on 03/23/26. The following observations were made: The resident had minimal movements of muscles of facial expression The resident had minimal tongue movements On 04/21/2026 at 10:51 AM, the Director of Nursing (DON) confirmed Resident #69 did not have AIMS assessments performed between 07/03/24 and 03/02/26. The DON stated she did not disagree with the pharmacist's statement on the monthly reports that AIMS assessments should be performed at least every six (6) months for residents receiving antipsychotic medications. AIMS policy The facility's policy titled, Behaviors: Management of Symptoms, with effective date 08/01/99 and revision date 09/15/25, stated Abnormal Involuntary Movement Scale (AIMS) would be completed per nursing schedule for patients receiving antipsychotic medications. c) Resident #56 The facility's policy titled Infusion Therapy Policy and Procedure Manual, dated October 2024, stated that transparent, semi-permeable membrane dressing for intravenous (IV) access devices would be changed a minimum of every seven (7) days. During observation on 04/19/26 at 3:06 PM, Resident #56 was noted to have a pump for administration of intravenous medications or fluids. She had an ace wrap on her right antecubital area which appeared to have Kling wrap under it. Resident #56 had been admitted to the facility on [DATE] from the hospital with orders to continue intravenous antibiotics through an existing peripheral intravenous access. Review of Resident #56's physician's orders showed an order written on 04/13/26 for cefazolin sodium, an antibiotic, intravenously every eight (8) hours. The resident had no orders for observation or care of her peripheral intravenous access. The resident's Treatment Administration Record (TAR), Medication Administration Record (MAR), and progress notes contained no documentation regarding observation or care of the resident's peripheral intravenous access. On 04/21/2026 at 11:08 AM, the Director of Nursing (DON) was asked to remove the ace bandage and Kling wrap from Resident #56's right antecubital area. The resident had peripheral intravenous access in her right antecubital area. The access was covered with a transparent dressing. The dressing was not dated to indicate when it had been applied. The DON stated she did not know if the intravenous access dressing had been changed since the resident had been admitted to the facility on [DATE]. She stated she would have the dressing changed immediately. On 04/21/26, the following order was written, IV: Change Catheter Site Transparent Dressing. Indicate external catheter length and upper arm circumference (10 cm above antecubital). Notify practitioner if the external length has changed since last measurement every day shift every 7 day(s) weekly and as needed. No further information was provided prior to the completion of the survey process. d) Resident #6 On 04/21/2026 at around 11:00 AM Record review for Resident #6 revealed that the Abnormal Involuntary Movement Scale (AIMS) assessment was not completed upon admission or at six-month intervals while on antipsychotic medication. Resident #6 received Olanzapine oral tablets (5mg) once daily at bedtime as an antipsychotic agent from 11/03/25 through 02/24/26. Then reduced to (2.5mg) one (1) time a day at bedtime for mood disorder began 10/02//26 and discontinued 03/10/26. Diagnosis on record: bipolar disorder, anxiety and mood (affective) disorder. On 04/21/26 at around 11:30AM.An interview with Director of Nursing, verified this was not completed upon admission. e) Resident #10 On 04/21/2026 at around 10:20 AM, Record review for (Resident #10) for the (AIMS) assessment revealed one was not completed upon admission,06/05/2025. (Resident #10) was receiving Zyprexa (2.5mg) one (1) time a day for target behaviors: aggression and agitation. An (AIMS) assessment was completed on 11/03/25. Diagnosis on record: unspecified dementia severe with psychotic disturbance, unspecified dementia moderate with agitation and anxiety disorder. On 04/21/26 at around 11:30 AM, an interview with the Director of Nursing verified this was not completed upon admission.

Based on record review and staff interview, the facility failed to document the percentage of a house supplement a resident consumed when that resident was experiencing weight loss. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of nutrition. Resident Identifier: #29. Facility Census: 88. Findings included: a) Resident #29 On 10/14/2025, Resident #29 weighed 106 pounds. On 04/06/2026, the resident weighed 86 lbs. This was an 18 percent weight loss in six (6) months. On 03/25/26, Resident #29 was ordered a house supplement one (1) time a day for weight loss. The amount of supplement the resident consumed was recorded on the medication administration record (MAR). On 04/02/26, the order for the house supplement changed to two (2) times a day. The resident's supplement consumption was no longer recorded on the MAR. A quarterly nutrition note written on 04/13/26 by the Registered Dietician (RD) stated, No new losses since house supplements BID [twice a day] in place. On 04/20/26 at 2:24 PM, the Director of Nursing confirmed Resident #29's supplement consumption had not been recorded since 04/02/26. On 04/20/26 at 3:16 PM, the Registered Dietician agreed it would be important to know how much supplement Resident #29 was consuming. No further information was provided through the completion of the survey process.

Based on observation, record review and staff interview, the facility failed to store and label medications within accepted standards of care. A multi-use vial of Purified protein derivative (PPD) was not dated when accessed. Multi-use insulin pens were not discarded when they expired and were not dated when they were first opened. These deficient practices were discovered during investigation for the medication storage and labeling facility task. Resident Identifiers: #59, #44, #32, and #6. Facility census: 88. Findings included:a) Policy reviews The facility's policy titled, Insulin Pens, with effective date 10/01/12 and review date 05/01/25, stated as follows:- Insulin pens would be clearly labeled with the date used- Manufacturer recommendations would be followed for product expiration The facility's policy titled, Medications and Medication Labels, dated January 2025, stated nursing staff should document the date opened on multi-dose vials.b) Medication RoomOn 04/20/2026 at 7:48 am, inspection was made of the medication room serving A, B, C, and D hallways. Registered Nurse (RN) #43 was in attendance. In the refrigerator, there was a multi-use vial of Tubersol purified protein derivative (PPD) that had not been dated when first opened. There was no label on the vial packaging showing when the vial had been delivered from the pharmacy to the facility. PPD is injected under the skin to determine if a person is infected with tuberculosis (TB).RN #43 confirmed the multi-use vial of Tubersol PPD had not been dated when first accessed and there would be no way to determine when the vial had been in use for 30 days. The package insert for Tubersol PPD, available on-line on the Food and Drug Administration Website stated, A vial of Tubersol which has been entered and in use for 30 days should be discarded.Also in the refrigerator was a Lispro insulin multi-dose pen for Resident #59 dated with an opening date of 03/15/26. The pen had a label stating to discard the pen 28 days after opening. RN #43 confirmed the Lispro insulin pen for Resident #59 had been in use for longer than 28 days. Review of Resident #59's physician's orders showed the resident was currently prescribed Lispro insulin as coverage for elevated fingerstick blood glucose checks. The package insert for Lispro insulin, available on-line on the Food and Drug Administration Website, stated the pen must be used within 28 days or be discarded.c) Medication Cart - D Hallway On 04/20/2026 at 8:41 AM, inspection was made of the D hallway medication cart with RN #43 in attendance. A Novolog insulin pen labeled for Resident #44 was labeled as being opened on 03/15/26. The pen had a label to discard within 28 days. Review of Resident #44's physician's orders showed the resident was currently prescribed Novolog insulin as coverage for elevated fingerstick blood glucose checks. The package insert for Novolog insulin pen, available on-line on the Food and Drug Administration Website, stated to dispose of the pen after 28 days of use. Also, the following insulin pens located in the D hallway medication cart were not dated to indicate when they were first opened: Lispro insulin pen for Resident #44 Lantus insulin pen for Resident #32Two (2) Humalog insulin pens for Resident #32Lantus insulin pen for Resident #6 All pens were labeled to be discarded within 28 days. The package inserts for these insulins, available on-line on the Food and Drug Administration Website, stated to discard the pens after 28 days of use. RN #43 confirmed these insulin pens had not been dated when first accessed and there would be no way to determine when the pens had been in use for 28 days. No further information was provided through the completion of the survey process.

Based on record review, resident interview, and staff interview. The facility failed to develop and implement a comprehensive care plan for activities. This was found during the Long Term Care Annual Survey process. (Facility census 88) (Resident indicators, #2, and #12.) c1) Resident #69 - AIMS The facility's policy titled, Behaviors: Management of Symptoms, with an effective date of 08/01/99 and a revision date of 09/15/25, stated the Abnormal Involuntary Movement Scale (AIMS) would be completed per nursing schedule for patients receiving antipsychotic medications. Review of Resident #69's comprehensive care plan showed the following focus, Resident is at risk for complications related to the use of psychotropic drugs for schizophrenia. Antipsychotic and antidepressant medications. The focus was initiated on 09/23/19 and revised on 01/11/24. Interventions included AIMS testing per protocol, initiated 12/05/25. Tardive dyskinesia, involuntary movements of the face and mouth, is a potential side effect of antipsychotic medications. Abnormal Involuntary Movement Scale (AIMS) assessments are used to assess the presence or progression of tardive dyskinesia. AIMS assessments were performed for Resident #69 on 01/04/24 and 07/03/24. Symptoms of tardive dyskinesia were not documented. On 04/09/25, the monthly consultant pharmacist's medication regimen review stated, Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 06/07/25, the monthly consultant pharmacist's medication regimen review stated, REPEAT RECOMMENDATION FROM APRIL 2025. Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 08/21/25, the monthly consultant pharmacist's medication regimen review stated, REPEAT RECOMMENDATION FROM APRIL 2025. Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 10/29/25, the monthly consultant pharmacist's medication regimen review stated, Risperidone 0.5 twice daily schizophrenia and Benztropine 1 mg two times daily drooling. Last AIMS in PCC from 07/03/24. Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. This resident is taking risperdal. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. On 02/19/26, a Note to Attending Physician/Prescriber from the consultant pharmacist stated, Antipsychotics have the capacity to cause tardive dyskinesia and other movement disorders. Recommend movement test, such as AIMS or DISCUS, be performed at least every six months while this resident continues on antipsychotic therapy. This resident continues on Risperdal. The last AIMS/DISCUS test located in the chart was dated 2024. An AIMS assessment was performed for Resident #69 on 03/02/26. Symptoms of tardive dyskinesia were not documented. Another AIMS assessment was performed for Resident #69 on 03/23/26. The following observations were made: The resident had minimal movements of muscles of facial expression The resident had minimal tongue movements On 04/21/2026 at 10:51 AM, the Director of Nursing (DON) confirmed Resident #69's care plan was not followed regarding AIMS testing. The DON stated she did not disagree with the pharmacist's statement that AIMS assessments should be performed at least every six (6) months for residents receiving antipsychotic medications. c2) Resident #69 - Behavior monitoring The facility's policy titled, Behaviors: Management of Symptoms, with effective date 08/01/99 and review date 09/15/25, stated as follows: - Staff will observe and monitor for behavioral symptoms and document these symptoms in the medical records.- Individualized, person-centered, non-pharmacologic interventions would be implemented. Review of Resident #69's comprehensive care plan showed the following focus, Resident is at risk for complications related to the use of psychotropic drugs for schizophrenia. Antipsychotic and antidepressant medications. The focus was initiated on 09/23/19 and revised on 01/11/24. Interventions included Complete behavior monitoring flow sheet, initiated 12/05/25. Resident #69's MAR showed no documentation regarding behavioral monitoring. Review of the resident's other electronic medical records showed no evidence of behavioral monitoring. On 04/22/2026 at 9:54 AM, the Director of Nursing (DON) confirmed Resident #69's medical records contained no documentation the resident's care plan was followed to monitor behaviors. She stated a performance improvement plan (PIP) regarding behavioral monitoring and non-pharmaceutical interventions had been started in February. The DON stated the plan was for the physician to write orders for specific behavioral monitoring. These orders would be placed on residents' MARs for nurses' documentation. No further information was provided through the completion of the survey process. Findings include -04/19/2026 2:30PM Interview with (Resident #2), she reports I don't go to activities much, I'd prefer to stay in my room, They only ask if I want to go play bingo nothing else -4/19/26 2:15PM Resident interview regarding activities, resident reports, I usually don't go to any they seem pointless. Usually someone comes in here every day or so to talk with me, I like that. -04/20/2026 4:00PM( Resident #2, Resident #12) record review, no care plan for activities was observed for the above stated residents. At around 4:15PM I held a staff interview with the Administrator. Questioned the Administrator regarding not being able to locate the care plan in the records. The Administrator reports These are not in the record, our activities director has been doing audits to ensure all aspects of care plans assessments etcetera(etc.) are in the system and she is now on leave and is not available. The assistant can do all questions of the assessments but not input anything, our MDS person does that.

Based on observation, resident interviews and staff interview. The facility failed to ensure meals were served in an appealing manner for residents to consume. This was found during the Annual Long Term Care survey. (Resident indicators # 2,16, 24,and47) (Facility census 88)Findings include A)On 04/19/2026 at around 12:30 PM. During a resident interview with (Resident #47). This resident reports the food is not real good most of the time, I usually ask for what is on the always available menu-On 04/19/2026 at around 1:30PM. During observation of meal service on the unit. In (room [ROOM NUMBER]B) meal that was served, chicken cacciatore, rice and capri vegetable blend, with a dinner roll. The dinner roll was placed on the plate and had become soggy from the tomato juices. (Resident #2,16 and 47) reports they do this all the time, I wish they would bag the bread. Dietary manager (#82) verified plating with dinner roll on the plate and was soggy, reports I will educate them to ensure the dinner roll is bagged. -On 04/19/2026 at around 2:50 PM. During resident interview,(Resident #24) reports the food is not good here, I usually have my daughter bring me something B) On 04/20/2026 at around 1:50 PM. During observation in the dining room (x4) residents did not receive desserts, they had left before nursing assistants offered. Residents affected,(#77,39,30,and18). -Nursing assistant (#5) verified these residents left before dessert was offered and reported We should have served the dessert with the meal. -Puree meal plate presentation: BBQ in firm round form, baked beans smooth however running on plate, puree bread firm stiff difficult to smash with fork. Nursing assistant (#5) verified the puree plate presentation reporting the vegetables and bread are always like this, Dietary manager (#82) verified the dessert was missed for the residents in the dining room and the puree plate presentation for the baked beans and bread were not appealing. Reporting I will work with the cook for puree diets and the aides to ensure all residents are offered a dessert while in the dining room.

Based on observation, record review, and staff interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to perform appropriate infection surveillance, which had the potential to affect more than a limited number of residents. Also, the facility failed to ensure enhanced barrier precautions were followed during one (1) of one (1) dressing change observations. Additionally, the facility failed to store bedpans appropriately. This was a random opportunity for discovery. Resident Identifiers: #42 and #30. Facility Census: 88. Findings included: a) Infection Control Surveillance The facility's policy titled, Infection Control Outcome and Process Surveillance and Reporting, with effective date 09/01/04 and revision date 03/20/26 stated as follows: The Infection Preventionist will conduct regular outcome surveillance which consists of collecting/documenting data on individual cases and comparing the collective data to standard, written definitions of infections. Review of the facility's Infection Surveillance Reports for May 2025 through April 2026 showed no infections documented in February, March, and April 2026. On 04/21/2026 at 1:36 PM, the Director of Nursing (DON) stated the facility's Infection Preventionist had resigned in February, and no one had been available to perform infection surveillance since that time. On 04/22/26 at 9:26 AM, the DON stated an Infection Preventionist had been hired and started yesterday. No further information was provided through the completion of the survey process. b) Resident #42 The facility's policy titled Enhanced Barrier Precautions, with an effective date of 01/06/20 and a review date of 11/14/25, stated that a gown and gloves would be used during high-contact patient activities demonstrated to result in the transfer of MDROs [multidrug-resistant organisms] to healthcare personnel's hands and clothing. Resident #42 had an order for Enhanced Barrier Precautions (EBP) dated 02/04/26. He had pressure ulcers on his left foot requiring dressings. On the door to Resident #42's room was a sign stating, Enhanced Barrier Precautions Staff: Wear . Gown and gloves when providing high-contact direct care for resident Change PPE [personal protective equipment] before caring for another patient Additional PPE as needed: Examples of high-contact direct care Changing linens Dressing Bathing/Showering Providing Hygiene Transferring/Repositioning Changing briefs or assisting with toileting Device care or use: urinary catheter, feeding tube, tracheostomy, etc. Wound Care: any chronic skin opening requiring a dressing On 04/21/26 at 12:04 PM, Registered Nurse (RN) #64 was observed changing the dressings on Resident #42's left foot. RN #64 was assisted by Nurse Aide (NA) #36 and visiting Administrator #100. RN #64 and visiting Administrator #100 wore gowns and gloves. NA #36 only wore gloves. NA #36 was standing on the right side of the bed. She leaned over the bed to assist the resident in elevating his left leg and foot so RN #64 could change the dressings. NA #36's scrub top and pants were observed to contact the resident's bed linens. NA #36's bare arms were observed to rest on the resident's bare legs. On 04/21/26 at 12:15 PM, the Director of Nursing (DON) confirmed NA #36 should have worn a gown to assist with positioning the resident during his dressing changes. No further information was provided through the completion of the survey process. c) Resident rooms C24 and C26 The initial observation on 04/19/26 at 12:02 PM, revealed (2) two bedpans in the bathroom between rooms C24 and C26. One bed pad was sitting on the commode and one was sitting on the handrail. Neither bedpan was in a bag. During an interview on 04/19/26 at 12:15 PM, the Regional Resource Registered Nurse (RRRN) confirmed that the bedpans were in the bathroom, unlabeled and not in a bag and stated, I will get someone to get it.

Based on observation, record review, and staff interview the facility failed to ensure that the administration of enteral nutrition is consistent with and follows physician orders. This failed practice was found true for (1) one of (2) residents reviewed for the care area of tube feeding during the Long-Term Care Survey Process. Resident identifier #59. Facility Census: 88. a) Resident #59A record review on 04/19/26 at 11:30 PM, revealed an order for Resident #59 that read as follows:One time a day Isosource 1.5 @60ml/hr X18 hrs. Volume 1080ml.Instructions for the 18-hour tube feeding were to start at 12:00 PM, and end at 6:00 AM.An observation on 04/19/26 at 12:10 PM, found Resident #59 asleep in bed. No tube feeding was being administered.Further observations at 12:30 PM, 1:00 PM, and 1:45 PM found no tube feeding being administeredDuring an interview on 04/19/26 at 1:55 PM, The Director of Nursing confirmed that the tube feeding for Resident #56 was not hanging and should have started at 12:00 PM.During an interview on 04/19/26 at 1:55 PM, Licensed Practical Nurse (LPN) #68 stated, I forgot, I missed my one hour window. LPN confirmed that she had already signed, as if she had administered the tube feeding.To deliver the correct nutrition over 18 hours, the tube feeding would now have to run until 8:00 AM on 04/20/26 rather than 6:00 AM.An observation on 04/20/26 at 7:45 AM, revealed no tube feed hanging for Resident #59. LPN #7 confirmed the tube feeding was not hanging and stated, I already stopped it for the day.During an interview on 04/20/26 at 10:30 AM, the Corporate Resource Registered Nurse (CRRN) confirmed that the tube feeding did not appear to have hung for the ordered 18 hours and stated, It would have to run for 18 hours for her to get the 1080 ml that are ordered.

Based on record review, and staff interviews the facility failed to document behavioral monitoring and the effectiveness of non-pharmacological interventions for Resident #69, who was receiving psychotropic medications. Additionally, the facility failed to ensure Resident #10 was not overly medicated, which caused drowsiness and restraint. This failed practice was found true for one (1) of five (5) residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifier: #69. Facility Census: 88. a) Resident #69 The facility's policy titled, Behaviors: Management of Symptoms, with effective date 08/01/99 and review date 09/15/25, stated as follows: - Staff will observe and monitor for behavioral symptoms and document these symptoms in the medical records. - Individualized, person-centered, non-pharmacologic interventions would be implemented. Review of Resident #69's physician's orders showed the resident had been receiving the antipsychotic medication Risperdal (risperidone) since 2023 for schizophrenia as evidenced by hallucinations and delusions. Resident #69's comprehensive care plan contained the following focus created and revised on 08/09/23: Resident/Patient exhibits or has the potential to demonstrate verbal behaviors related to: cognitive loss/dementia. Resident noted to have agitation, yelling, cursing, screaming, attempting to hit and kick staff. Increased hallucinations including seeing snakes and rats. The goal created on 08/09/23 and revised on 12/29/25 was as follows: Resident/Patient will have not more than 10 episodes of (type of behavior i.e. verbal aggression) by next review. The interventions were as follows: - Monitor medications, especially new/changed/discontinued, for side-effect and resident's/patient's response contributing to verbal behaviors. - Evaluate the nature and circumstances (i.e. triggers of the [verbal behavior] with resident/patient and/or resident representative. - Evaluate need/provide for Psych/Behavioral Health consultation. - Explain all care, including procedures (one step at a time), and the reason for performing the care before initiating. - Provide consistent, trusted caregiver and structured daily routine, when possible. - Remove resident/patient from environment, if needed. Gently guide the resident from the environment while speaking in a calm, reassuring voice. - Provide a calm, quiet, well-lit environment. Resident #69's Medication Administration Record (MAR) contained the following order written on 10/15/24, Is the resident free from side effects of psychotherapeutic medications? (If no, document side-effects in PN [progress note]) every day and night shift for monitoring. Resident #69's MAR showed no documentation regarding behavioral monitoring or non-pharmaceutical interventions for behaviors. Review of the resident's other electronic medical records showed no evidence of behavioral monitoring or non-pharmaceutical interventions for behaviors. On 04/22/2026 at 9:54 AM, the Director of Nursing (DON) confirmed Resident #69's medical records contained no documentation of behavioral monitoring or non-pharmaceutical interventions for behaviors. She stated a performance improvement plan (PIP) regarding behavioral monitoring and non-pharmaceutical interventions had started in February. The DON stated the plan was for the physician to write orders for specific behavioral monitoring and non-pharmaceutical interventions for behaviors. These orders would be placed on residents' MARs for nurses' documentation. No further information was provided through the completion of the survey process.

Based on record review, resident interviews, and staff interviews, the facility failed to ensure residents had a choice in room assignments and that they were notified of the room change in a timely manner. This failed practice was found true for (1) one of (4) four residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier #63. Facility Census: 88.Findings Include:a) Resident #63A review on 04/23/25 at 10:00 AM, of the facilities room moves for the last month, revealed that (8) eight residents had room changes indicated as clinical need.Further record review showed that Resident #63 who has a Brief Interview for Mental Status (BIMS) of 14, was moved from room A3 B to room D32 A.During an interview on 04/22/26 at 11:20 AM, Resident #63 stated, I was not told the reason my room was changed. If I had my choice, I would of stayed in my old room becasue I like that hallway better. I went to my room one day and another lady was on my bed. I told the staff that someone was in my bed and she informed me that I was in a different room now.During an interview on 04/22/26 at 1:15 PM, the admission Director (AD) said that room changes are part of his responsibility. The AD stated, I told her of her room change that morning. Sometimes we have to change rooms to make sure we are putting MDRO'S together and stuff like that. The State Agency (SA) asked, Was Resident #63 agreeable to the room change? The AD replied, I think so. The AD further confirmed that a little more notice would be a good idea.

Based on record review and staff interview, the facility failed to administer COVID-19 vaccinations in accordance with professional standards of care. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of COVID-19 vaccination. Resident Identifier: #1. Facility Census: 88. Findings included:a) Resident #1 The facility's policy titled, COVID-19 Vaccination, with an effective date of 12/14/20 and a revision date of 12/16/24, stated COVID-19 vaccination would be administered with patient or patient representative consent. Review of Resident #1's medical records showed the resident lacked capacity to make medical decisions. On 02/24/26, Resident #1's representative verbally declined the 2025-2026 COVID-19 vaccination for the resident. The form stated, I do not give consent for the person named at the top of this form to be vaccinated with the COVID-19 vaccine. Resident #1's medication administration record (MAR) documented that the resident received the 2025-2026 COVID-19 vaccination on 03/02/26. On 04/20/26 at 12:07 PM, the Director of Nursing confirmed Resident #1 received the 2025-2026 COVID-19 vaccination despite the representative declining it. No further information was provided upon completion of the survey process.

Based on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of resident assessment and one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #7 and #69. Facility census: 88. Findings included:a) Resident #7 Resident #7's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/18/26 coded the resident had a wound infection. However, the resident's medical records did not show the resident had a wound infection in the seven (7) day look-back period. On 04/20/26 at 11:00 AM Licensed Practical Nurse (LPN) Clinical Reimbursement #15 confirmed the MDS was incorrect and Resident #7 did not have a wound infection during the look-back period. She stated the diagnosis pulled from an old MDS that correctly coded a wound infection. LPN #15 stated she would modify and correct the MDS. b) Resident #69 Resident #69's quarterly MDS with ARD 03/02/26 indicated the resident had a hip fracture and other fracture. No evidence of hip fracture and other fracture was seen in the resident's medical records during the seven (7) day look-back period. On 04/21/26 at 10:10 AM, the Administrator confirmed Resident #69's MDS was incorrect and the resident did not have fractures within the look back period. She stated the diagnoses of fractures had pulled from a previous MDS that correctly coded hip fracture and other fracture. The Administrator stated the MDS had just been modified and corrected. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to ensure a resident received double entree portions as ordered by the facility. This was a random opportunity for discovery. Resident Identifier: #69. Facility Census: 88. Findings included:a) Resident #69 Review of Resident #69's physician's orders showed an order written on 12/15/24 for double entrees with meals. On 04/20/2026 at 1:02 PM, Resident #69 was observed eating in the dining room. Nurse Aide (NA) #5 was sitting with the resident and assisting him. The resident's tray ticket stated he was to receive double entree. However, the resident only received one (1) BBQ sandwich. NA #5 left the table to get a clean spoon for Resident #69's tablemate. Resident #69 picked up his BBQ sandwich and had eaten almost all of it by the time NA #5 returned to the table. There was some bun left. Resident #69 picked off some of the BBQ meat that had fallen onto his shirt and put that in his mouth. When NA #5 returned to the table, she began feeding Resident #59 some chopped marinated vegetable salad with a spoon. The surveyor pointed out that Resident #69's tray ticket stated he was to receive double entrees. NA #5 stated, I didn't know that. She stated she would get another BBQ sandwich for the resident. No further information was provided through the completion of the survey process.

Based on interviews conducted and observation, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This practice had the potential to affect more than an isolated number of residents. Facility census 89.Findings included:a) An anonymous interview was conducted during the complaint investigation process and during the interview, the interviewee identified areas in the facility where there would be evidence of mice droppings. A second anonymous interview was conducted and the interviewee verified that they had seen mouse droppings behind resident's furniture in 2 resident rooms which were identified during the first anonymous interview.During an observation on 01/30/26 at approximately 1:00 p.m., this surveyor observed mice droppings located on the floor near the outer wall to the left in the Activities Director's office located in B Hall. Interview with the Regional Administrator (RA) verified this finding on 01/30/26 at approximately 1:10 p.m. On 01/30/26 at approximately 5:00 p.m., an exit interview was conducted with the facility's Administrator, Clinical Lead, and Marker Resource Clinician. During this meeting the above findings were discussed and the CL, MRC and Administrator acknowledged the findings.

Based on observation and staff interviews, the facility failed to maintain a sanitary environment related to gnats and a damaged countertop located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: On 06/25/25 at approximately 11:05 a.m., this surveyor observed several gnats on the left hand side of the Rehab pantry room sink countertop . On 06/25/25 at approximately 11:05 a.m., this surveyor observed exposed damp wood on the left hand side of the countertop sink located in the Rehab Pantry room. Interview with the facility's Maintenance Director verified the findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately 12:45 p.m.

Based on observation, document review, and staff interviews, the facility failed to ensure they stored food in accordance with professional standards for food quality. The facility failed to maintain proper refrigerator temperatures of the refrigerator located in the Rehab pantry room. This deficiency has the potential to affect more than an isolated number of residents, staff and visitors within the Facility census: 84. Findings include: a) On 06/25/25 at approximately 10:30 a.m., the Rehab Pantry room refrigerator had temperatures documented greater than 41 degrees Fahrenheit on the PM temperature check on the following dates with no documentation of the corrective issue (06/09/25, 06/14/25, 06/17/25, 06/21/25, 06/22/25, and 06/24/25). On 06/25/25 at approximately 10:30 a.m., there was no documented temperature for the AM temperature check on 06/24/25. Interview with the facility's Director of Nursing verified these findings at the time of discovery. The finding was also acknowledged by the facility Administrator at the time of discovery and upon exit on 06/25/25 at approximately 12:45 p.m.

Based on observation, policy review and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect more than an isolated number of residents. Facility census: 88. Findings Include: a) Upon entry of the facility on 02/03/25 there was a sign in place on the main entrance door that indicated the facility was in a COVID outbreak. This was confirmed with the Administrator. On 02/03/25 at 12:20 PM Nurse Aides #40 and #51 were seen on C Hall with their N-95 mask off their face and down under their chin. According to the facility policy for Infection Control (IC405 COVID-19) revision date of 07/01/24 under General Standard Precautions: .follow Center for Disease Control and Prevention (CDC) published guidance related to the use of facemask, respirators, gowns, gloves and eye protection . The CDC recommends general standard precautions to prevent and control the spread of COVID-19. These precautions include: wearing well-fitting masks . During an interview with the Administrator on 02/03/25 at 12:22 PM the Administrator stated all staff members were to wear N-95 respirators when they have an active case of COVID in the building. It was confirmed with the Administrator that the two (2) staff members listed above did not have face masks in place on the residents' hall

Based on record review and staff interview, the facility failed to report two (2) changes in conditions for reasonable suspicion of a crime to the appropriate State agencies for Resident #84. This was true for one (1) of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility Census: 88. Findings include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found two (2) changes in conditions for the resident regarding behaviors; and the staff calling the local police to report a suspicion of a crime on 01/17/25 and 01/24/25. The incident on 01/17/25 was related to resident trashed his room, kicking heater, letting water run in his sink trying to flood room, cursing, throwing razors all over his room. (Typed as written.) The facility physician recommended sending the resident to an acute care facility for a psychiatric evaluation. The resident had the capacity to make medical decisions and refused to go out of the facility. The staff called the local police department due to the resident's behaviors. The incident on 01/24/25 was related to resident wanted to keep his door shut and residents being on 1:1 observation from previous behavior. When opening the door, the resident started screaming and cussing towards staff. Resident then proceeded to slam the door and then kicking it, causing harm to a coworker. (Typed as written.) An interview was held with Resident #84 on 02/03/25 at 12:30 PM. The resident was interviewed regarding the 1:1 monitoring. The resident stated, They will not let me shut my door any time .even when I'm using the bathroom or changing clothes .it's embarrassing knowing anyone can walk by and see me anytime. They (staff) accused me of having a temper tantrum .that's not what happened .I accidentally knocked over the tray table in the bathroom while trying to maneuver my wheelchair .which knocked everything off including razors. I was pushing them with my foot so I would not run over them .they are too expensive. When the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) comes in, they speak to me like I'm a child. It is like they want to make me mad just saying things over and over again. I have told them I don't want to talk, and they continue to keep hashing it over and won't leave me alone until I calm down. The resident was then asked about the incident on 01/24/24. The resident stated, I wanted my door closed. I was using the phone, and I couldn't hear because of the noise in the hallway. The ADON opened my door and yelled at me saying (Name of resident) you know you have to keep your door open. The resident stated, I did shut my door, and I was upset. I was talking on the phone. (Name of ADON) did not get hurt and I did not slam her hand in the door. On 02/03/25 at 2:20 PM, the Administrator was interviewed regarding the two (2) incidents when the local police were called. The Administrator stated, We called the police because of (Name of Resident)'s behaviors. The staff was upset and afraid. The second time was because he hurt a staff member . The Administrator was then asked, What injuries did the staff member receive from this incident? The Administrator stated, The staff member did not have any injuries from this encounter with the resident. The Administrator stated, The police department did make reports, but we haven't received anything yet. The Administrator stated, the Director of Nursing (DON) and I were going to discuss the 1:1 monitoring and if it could be discontinued. The Administrator stated, I didn't feel this was something to report . The Administrator was asked, Why did you call the police? Did you feel like a suspected crime had taken place? The Administrator stated, I guess I really didn't look at it that way.

Based on observation, record review, resident interview and staff interview the facility failed to provide a dignified and respectful existence for Resident #84. This was true for one (1) resident of one (1) residents reviewed during the survey process. Resident identifier: #84. Facility census: 88. Findings include: a) Resident #84 On 02/03/25 at 10:00 AM, a record review was completed for Resident #84. The review found the resident had been placed on one-on-one (1:1) monitoring on 01/17/25 at 6:00 PM. The reason for the 1:1 monitoring was noted in the change in condition dated 01/17/25. The reason noted was resident trashed his room, kicking heater, letting the water run in his sink trying to flood room, cursing, throwing razors all over his room. The 1:1 monitoring was for 24 hours daily since 01/17/25. The resident's door was always left open; including during toileting, bathing and changing clothes. On 02/03/25 at approximately 12:30 PM, the resident was interviewed regarding the 1:1 monitoring. The resident stated, They will not let me shut my door any time .even when I'm using the bathroom or changing clothes .it's embarrassing knowing anyone can walk by and see me anytime. They (staff) accused me of having a temper tantrum .that's not what happened .I accidentally knocked over the tray table in the bathroom while trying to maneuver my wheelchair .which knocked everything off including razors .I was pushing them with my feet so I would not run over them .they are too expensive .when the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) come in, they speak to me like I'm a child .it's like they want to make me mad .just saying things over and over again .I have told them I don't want to talk and they continue to keep hashing it over and won't leave me alone until I calm down. On 02/03/25 at 1:15 PM, an interview with the Administrator was held. The Administrator stated, (Name of resident) is always yelling and cursing at staff .the staff is afraid to be in the room with him by themselves. The Administrator was asked, Do you think he should have privacy while bathing, dressing and using the bathroom? The Administrator stated, We have offered a privacy curtain and he doesn't want it. The Administrator was then asked, Do you think a privacy curtain is sufficient for an alert and orient [AGE] year-old man who has capacity? The Administrator stated, I don't know what else to do when the staff are afraid of him because of his behaviors . The Administrator was then asked, How long will he remain on 1:1 monitoring? The Administrator stated, The DON and I were going to look at that today . A review of the behaviors from 01/17/25 through 02/03/25 was completed. The resident had three (3) documented behaviors during this time. The behaviors noted were yelling or cursing but within the next 15 minutes the resident had calmed down with no additional interventions needed. An additional interview was held with the DON on 02/03/25 at 3:30 PM. The DON stated, They can crack the door .and still see him. The Administrator stated, We will review the records and see if we can discontinue the 1:1 monitoring.

Based on record review and staff interview the facility failed to ensure one (1) of seven (7) residents did not receive doses of medications that had errors in the dose ordered by the physician assistant. Resident #201 received a larger dose of morphine sulfate than what the physician assistant intended to prescribe. This created an immediate jeopardy situation. Resident identifier: #82. Facility census: 82. Findings included: a) Resident #201 Record review revealed the resident was admitted to the facility on [DATE]. The resident expired at the facility on [DATE] at 9:05 PM. The resident had the following diagnoses: Sick Sinus Syndrome, History of Urinary Tract Infections, Erythematous, Diabetes Type 2, Dementia, Dysphagia, Atrial Fibrillation, Hypertension, Atherosclerotic Heart Disease, Hyperlipidemia, and Kidney Failure. A progress note on [DATE] at 9:02 PM revealed that the resident's power of attorney wished for him to have comfort measures and that they were unable to bring his oxygen level above 80%. He was also noted to not be eating or drinking. The recommendations at that time were for medications to be discontinued and new orders for Ativan and Morphine. A progress note on [DATE] at 9:02 PM revealed that the resident's power of attorney wished for him to have comfort measures and that they were unable to bring his oxygen level above 80%. He was also noted to not be eating or drinking. The recommendations at that time were for medications to be discontinued and new orders for Ativan and Morphine. The resident had an order dated [DATE] at 12:30 PM for Morphine Sulfate Oral Solution 20 MG (milligram)/5 ML (milliliter) (Morphine Sulfate) Give 2.5 ml by mouth every four (4) hours as needed for shortness of breath. The resident received two (2) doses of this medication. The first dose was administered on [DATE] at 9:00 PM and the second dose was given on [DATE] at 12:00 AM. A progress note by the physician assistant dated [DATE] reflected: Morphine dose was evaluated and adjustments made. Morphine 20 mg/5 ml 0.25 ml every 4 hour as needed for SOB. Nurse was advised and asked to give dose of Morphine at this time in addition to Ativan if he has not had it this morning. This note described the resident as being an elderly man in mild respiratory distress. The Medication Administration Record (MAR) showed this order was entered on [DATE] at 8:30 AM. During a confidential employee interview by phone on [DATE] at 10:00 AM the employee stated they felt the 2.5 ml dose was excessive but this resident was not on their assignment. The employee also stated the nurse administering the medication said this dose was justified because the resident was on comfort care. The licensed pratcial nurse who administered the medication was interviewed on [DATE] at 8:00 AM. This nurse said she did not question the order when administering the medication on [DATE] and [DATE]. She said she knew the resident was comfort care and was following the order as it was listed on the medication administration record (MAR). During an interview with the Physician Assistant and Director of Nursing on [DATE] at 1:15 PM the Director of Nursing (DON) stated she was unaware of this situation until the surveyor brought it to her attention. The physician assistant said she realized the order was in error on [DATE] and corrected the order at that time. The DON mentioned that the progress note written by the Physician Assistant on [DATE] revealed the order should have been for 2.5 mg not 2.5 ml. A progress note dated [DATE] at 12:12 PM reflected this to be accurate. The progress note stated, He was started on O 2 via NC at 2L and increased to 5L to maintain an O 2 of 90%. Representative was contacted and did not want him sent to the hospital. She requested that comfort care be carried out. Morphine 20 mg/5 ml 2.5 mg every 4 hours as needed for respiratory distress and Ativan 0.5 mg every 4 hours as needed. Medications were placed on hold. Discussed with nurse, continue to monitor. The Medication Administration Record (MAR) showed the corrected order was put in on [DATE] at 8:30 PM. The original order was put in on [DATE] at 12:30 PM. The facility was notified of the immediate jeopardy and the template was presented at [DATE] at 2:01 PM. A plan of correction was received at 2:35 PM. Modifications were made to the plan of correction and it was accepted at 2:50 PM on [DATE]. Resident #201 no longer resides in the facility. All residents of the facility havethe potential to be affected. The Director of Nursing (DON) designee conducted an audit on [DATE] for all residents with controlled substance/medications to ensure order is accurately entered in resident's medical record with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses and medical provideres regarding controlled substances/medication for a resident that is accurately entered in the resident's medical record. A Post test to validate understanding. Any licensed nurses and medical providers not available during this time frame will be provided re-education, including post test upon the begining of the next shift to work. New licensed nurses will be provided education including post-test during orientation by the DON/designee. The Unit Manager (UM)/designee will monitor starting on or before [DATE] new orders and medical provider progress notes to ensure residents ordered controlled substances/medications is accurately entered in resident's medical record daily across all shifts for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks then randomly therafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as deterimend by the QIC committee. The immediate jeopardy was abated on [DATE] at 4:45 PM.

Based on record review, staff interview, policy review, and resident interview, the facility failed to ensure seven (7) of thirty-one (31) residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Residents #79, #189, and #31 experienced a change in condition that was not assessed and monitored. The lack of assessment and monitoring, failure to notify the physician timely, and failure to implement interventions were determined to constitute actual harm to Resident #79. Residents #190, #73, and #64 did not received neurological (neuro)-checks after a fall. Resident #32's physician was not notified when the residents blood sugar was over 400. Resident identifiers: #79, #190, #73, #31, #189, #32, and #64. Facility census: 86. Findings include: a) Resident #79 Record review found this [AGE] year-old resident was admitted to the facility from the hospital, on 12/21/17. His admitting [DIAGNOSES REDACTED]. Review of the resident's nursing notes found a note dated 12/27/17 at 11:59 p.m. to, Obtain a chest x-ray 2 view AP/lateral (anterior-posterior/lateral), [MEDICATION NAME] (a breathing treatment to treat and prevent breathing problems) every 6 hours as needed for 2 days. Blood pressure checks every 2 hours until a.m. Resident notified. Review of the order found the chest x-ray was to be obtained STAT (immediately). The nursing note did not include any documentation as to why the above orders were given by the physician or why the nurse called the physician. Review of the resident's vital signs found the following blood pressure documentation on 12/27/17: - At 1:05 a.m., 132/79 - At 8:18 a.m., 133/77 - At 10:58 p.m., 78/45 - At 11:57 p.m., 68/45 There was no evidence the resident's blood pressure was ever obtained again on 12/28/17 before he was sent to the hospital at 11:55 a.m. on 12/28/17. Review of the resident's temperature log found the following entries on 12/27/17: - 12/27/17 at 1:05 a.m. 98.3 degrees - 12/27/17 at 8:18 a.m. 98.3 - 12/27/17 at 10:58 p.m. 99.9 - 12/27/17 at 11:57 p.m. 101.4 The resident's temperature was not obtained again on 12/27/17 or 12/28/17 before the resident was sent to the hospital at 11:55 a.m. on 12/28/17. The resident's oxygen saturations on 12/27/17 were recorded as: - 12/27/17 at 1:05 a.m., 98% - 12/27/17 at 8:18 a.m., 98% - 12/27/17 at 10:58 p.m., 93% - 12/27/17 at 11:58 p.m., 92% (Normal pulse oxygenation levels are usually 95 to 100%.) A nursing entry at 12:18 p.m. on 12/28/17 noted, Physician wrote new orders to send to ER (emergency room ) for shortness of breath and dyspnea (difficult or labored breathing). EMS (emergency medical services) called pt. (patient) transported out of facility at 11:55 a.m. to (name of hospital). Review of the nursing notes found no documentation regarding the condition of the resident on 12/27/17 or 12/28/17 when his temperature was 101.4, blood pressure was 68/45, oxygen saturation was 92%. There was no documentation the resident was being monitored throughout his change of condition. It was 12 hours after the change in condition was known by the nurse until the resident was sent to the hospital. The physician gave orders for nebulizer treatments at 11:59 p.m. on 12/27/17, but review of the Medication Administration Record [REDACTED]. The x-ray was obtained on 12/28/17 at 10:31 a.m. There was no evidence the results of the x-ray were discussed with the physician. The x-ray was signed by the physician as being reviewed on 01/02/18. The results of the x-ray, The heart size is normal. Medial right lung base opacity favored to be due to confluence of [MEDICATION NAME] markings. The lungs shows no confluent infiltrate, masses' or [MEDICAL CONDITION]. There is no evidence of pleural effusion. Conclusion: Medial right lung base opacity favored to be due to confluence of [MEDICATION NAME] markings. No confluent pneumonia. According to the documentation, the x-ray was read at 10:31 a.m. on 12/28/17. Review of the transfer summary sent with the resident at the time of his transfer to the hospital on [DATE] found he was sent for respiratory infection. Further documentation of the discharge summary: Blood pressure was 68/45, heart rate was 91, respiratory rate was 20, temperature was 101.4, oxygen saturation was 92%, and weight was 187 pounds. The resident was receiving oxygen at 2 liters. At 12:58 p.m. on 04/11/18, the director or nursing confirmed she could find no evidence the resident was being monitored when his vital signs were critical. It is unknown if the resident's vital signs improved or worsened during these 12 hours before he was sent to the hospital. She said she would have expected more documentation on the resident during the 12 hours after the vital signs were obtained until he was sent to the hospital. She confirmed the nebulizer treatment was in the emergency box should the nurse have wanted to provide a treatment. She also confirmed the resident received no Tylenol when his temperature spiked to 101.4. She said the nurse would have had to call the physician to give Tylenol. She said the facility had no standing policy as to when to provide Tylenol. The resident was currently ordered Tylenol, but the Tylenol was for pain, not fever. The resident was admitted to the hospital. He returned to the facility on [DATE]. Review of the discharge summary, completed by the hospital on [DATE], found the resident was admitted for acute kidney injury (AKI) and a cough. An AKI occurs when your kidneys stop working suddenly, over a very short period of time (usually two days or less). The resident's blood pressure was 95/58 at the time of his exam. He was given IV fluids. Discharge [DIAGNOSES REDACTED]. The resident was interviewed on the afternoon of 04/12/18. The resident was determined to have capacity to make medical decisions upon his 12/21/17 admission to the facility. The resident said he did not remember going to the hospital on [DATE]. He said he woke up at the hospital and realized he was there. After obtaining the resident's vital signs on 12/27/17, there was no evidence the facility made no attempt to monitor the resident's vital signs to determine if there was an improvement or a decline. There was no evidence of an assessment of the resident's mental status, level of consciousness, or respiratory efforts. Twelve hours later, the resident was sent to the hospital. There was no evidence the nurse informed the physician of the resident's vital signs when the resident's blood pressure dropped. No interventions were taken to address the high temperature, such as asking the physician if the resident could receive a Tylenol. These findings were determined to have resulted in actual harm to the resident. Had the physician been notified in a timely manner and interventions implemented, the resident's condition would not have deteriorated to where the resident was not even aware of being transferred to the hospital. b) Resident #190 Record review found the resident fell at the facility on 07/08/17. Further review of the risk management system found the following description of the event: - The resident was found sitting on the floor on buttocks in front of her wheelchair. Assessed resident for injury, range of motion, pain. Made comfortable in wheelchair. - The immediate action taken was: vital signs, body assessment for injury, neuro checks and assisted into wheelchair. At 12:48 p.m. on 04/12/18, the Director of Nursing (DON) confirmed there were no neuro-checks completed on the resident as directed by facility policy. The DON provided a copy of the policy, entitled Neurological Assessment, which indicated neurological assessments will be performed with an unwitnessed fall. The policy directed assessments be completed as follows: - Every 30 minutes for 2 hours, then - Every one hour for 4 hours, then - Every 4 hour hours for 24 hours. c) Resident #73 On 03/01/18 at 5:00 AM, Resident #73 was found on the floor of his room beside his bed. Neurological assessments for an unwitnessed fall were initiated. According to the Neurological Assessment Flow Sheet, neurological assessments were performed at the time of the fall at 5:00 AM, and again at 5:30 AM and 6:00 AM. Resident #73's neurological condition was within normal limits during these neurological checks. Neurological assessment was performed at 7:00 AM on 03/01/18. At that time, Resident #73 was noted to have increased confusion. He was transferred to the hospital for evaluation. At the hospital, Resident #73 was diagnosed with [REDACTED]. The facility's Neurological Assessment Policy and Procedure stated When a patient sustains an injury to the head and/or has an unwitnessed fall, the neurological assessment will be performed: - every 30 minutes x two hours, then - every one hour x four hours, then - every four hours x 24 hours. During an interview on 04/11/18 at 11:45 AM, the Director of Nursing (DoN) confirmed that according to the facility's Neurological Assessment Policy and Procedure, Resident #73 should have had a neurological assessment performed at 6:30 AM. She agreed the Neurological Assessment Flow Sheet indicated neurological assessment was not performed at 6:30 AM on 03/01/18. d) Resident #31 On 12/02/17 at 3:00 AM, Resident #31 was observed by facility staff to slide to the floor from a sitting position on her bed, landing on the floor mat. The incident was documented in a note in the Risk Management System. A nursing progress note was not written regarding Resident #31's fall on 12/02/17. Daily change in condition progress notes were not written following the fall. During an interview on 04/10/18 at 4:26 PM, the Director of Nursing confirmed a nursing note and daily change of condition progress notes were not completed following Resident #31's fall on 12/02/17. e) Resident #189 Resident #189, an [AGE] year-old man admitted on [DATE] with [DIAGNOSES REDACTED]. He received [MEDICAL TREATMENT] three (3) times a week. On 08/08/17 at 3:00 PM, skilled nursing documentation noted, Resident alert this am (morning). Resident picked up and transported to [MEDICAL TREATMENT] by (name of transportation service). No distress noted speech. No s/s (signs and symptoms) of acute distress. Resident has permacath to right [MEDICATION NAME]. Drsg (dressing) dry and intact. Changed at [MEDICAL TREATMENT] center. The progress notes contain subsequent notes on 08/08/17 of a skin assessment at 4:33 PM and a general note regarding Resident's #189 pressure ulcers at 6:59 PM. Resident #189's next progress note was written on 08/08/17 at 8:31 PM and stated, New order for O2 (oxygen) via nasal cannula at 2L (two liters) to keep O2 sats (oxygen saturations) above 90% d/t (due to) low O2 sats and decreased L[NAME] (level of consciousness). The next progress note, written on 08/09/17 at 6:56 AM, was a change in condition follow-up note for a fall the resident experienced on 08/06/17. The progress note stated, (Note transcribed as written) Status of condition: improved. DATA: Patient now WBAT (weight bearing as tolerated), however patient is an extensive transfer x 2, however, patient is so weak, he has difficulty transferring. Patient continues to sling legs out of bed and attempt to get up, staff too reposition. Staff to reposition as needed. Will continue to monitor. ACTION: Medications and treatments as needed, provide all care as needed, reorient and redirect as needed, monitor for acute distress, provide all care as needed, call light in reach and frequent monitoring. RESPONSE: Patient HOH (hard of hearing), but has been compliant for the most when able to understand staff, still seems a bit confused at times. A transfer note written in the progress notes on 08/09/17 at 9:49 AM, stated Resident #189 had an unplanned transfer. A progress note written on 08/09/17 at 11:53 AM stated Resident #189 was transferred to the hospital for two (2) units of blood for a low hemoglobin. A progress note written on 08/11/17 indicated that Resident #189 had been admitted to the hospital. An untimed physician order [REDACTED]. The written indication for the order was decreased oxygen saturation. Review of Resident #189's vital signs summary revealed the following measurements: - 08/08/17 at 8:40 AM: Blood pressure 109/59, oxygen saturation 96% on room air, pulse 77 - 08/08/17 at 11:36 PM: Blood pressure 70/42, oxygen saturation 91% on oxygen via nasal cannula, pulse 99 - 08/09/17 at 8:41 AM: Blood pressure 79/47, oxygen saturation 97% on room air, pulse 61 On 08/09/17 at 10:00 AM, Resident #189 was seen by his physician who noted resident was confused, not at his baseline, and not communicating. The physician note stated resident was to be transferred to the hospital for a hemoglobin of 6.7 and a blood pressure of 70/42. A Nursing Home to Hospital Transfer Form was completed on 08/09/17 at 9:49 AM. According to the transfer form, Resident #189 was transferred because the resident's nephrologist had called and gave a telephone order to transfuse two (2) liters of packed red blood cells due to a hemoglobin of 6.7. During an interview on 04/12/18 at 2:08 PM, the Director of Nursing (DoN) confirmed the nursing notes did not contain information regarding the decreased oxygen saturation and decreased level of consciousness Resident #189 experienced on the evening of 08/08/17 through 08/09/17. The DoN confirmed the nursing notes did not contain information regarding information given to the physician when he was contacted and gave an order for [REDACTED].#189's nephrologist monitored his hemoglobin and called the facility on 08/09/17 to report the resident's hemoglobin was low, requiring a transfusion. f) Resident #32 A review of Resident #32's medical record revealed a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]= 0 units if less than 70 or greater than 400 notify physician. Further review revealed the resident's blood sugar equaled 405 on 12/14/17, 409 on 12/19/17, 405 on 12/20/17, and 402 on 12/23/17 with no indication the facility had notified the physician. At 1:11 PM on 04/10/18 the Center Nurse Executive said she knew there were a lot adjustments in the resident's insulin recently. She agreed the facility lacked evidence to show they notified the physician when the blood sugars were over 400. g) Resident 64 A review of Resident #64's medical record revealed the resident experienced an unwitnessed fall on 03/03/18 at 9:00 PM. The risk management system report (accident/incident report) stated, resident took self to bathroom and was transferring her self from the toilet and was holding onto the door handle and slid into the floor onto her buttocks. resident found to have no noted injuries, neuro checks initiated and WNL (within normal limits) at this time. resident assisted onto her feet and back into her bed. The neurological assessment policy, revision date 10/01/12, stated Neurological assessments would be performed as indicated or ordered. The policy also stated, when a patient sustained and injury to the head and/or has an unwitnessed fall, neurological assessment would be performed: - Every 30 minutes x two hours, -Every one hour x four hours, -Every four hours x 24 hours The neurological assessment flow sheet for Resident #64, dated 03/03/18 at 9:00 PM, revealed the facility took vitals (blood pressure, temperature, pulse and respirations) on 03/03/18 at 9:00 PM, 9:30 PM, 10:00 PM, 10:30 PM, 11:30 PM, 12:30 AM, 1:30 AM, 2:30 AM, and 6:30 PM. They did not assess for level of consciousness, pupil response or motor functions and pain responses during these times. They also did not perform the assessments for duration of time specified in the policy. Assessments were done on 03/03/18 at 9:00 PM, 9:30 PM, 10:00 PM, 10:30 PM, 11:30 PM, 12:30 AM, 1:30 AM, 2:30 AM, 6:30 AM, 10:30 AM, 2:30 PM, 6:30 PM, 10:30 PM, and 2:30 AM. According to the policy for neurological assessment the facility should have completed assessments at the following times: 9:00 PM, 9:30 PM, 10:00 PM, 10:30 PM, 11:00 PM, 12:00 AM, 1:00 AM, 2:00 AM, 3:00 AM, 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, 11:00 PM, 3:00 AM, 7:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, 11:00 PM, 3:00 AM, 7:00 AM. As of 2:31 PM on 04/21/18 Registered Nurse #84 did not have any further information regarding the issues identified with the lack of neurological assessments for Resident #64. These findings were determined to have resulted in actual harm to the resident. Had the physician been notified in a timely manner and interventions implemented, the resident's condition would not have deteriorated to where the resident was not even aware of being transferred to the hospital. .

Based on medical record review, staff interview, facility policy review, observation and resident interview the facility failed to provide pharmaceutical services to meet the needs of each resident. --Resident #42 did not receive his physician ordered pain medication and experienced pain during the time the facility did not have the medication. The failure of the facility to provide effective pain management, especially when the medication was available in-house, resulted in the resident experiencing pain that interfered with his sleep and diversional activities and this was determine to constitute actual harm. --Resident #36 did not receive the medication Ranexa used to treat chronic angina. --Resident #2 did not receive natural tears. This occurred for one random observation and two (2) of five (5) residents observed as during medication administration observation. Resident identifiers: #42, #36, and #2. Facility census: 89. Based on resident interview, staff interview, observation and record review, the facility failed to ensure Resident #39, who had previous pressure ulcers present on admission and was a high risk of development of new pressure ulcers, received necessary care and treatment to prevent the development if a new pressure ulcer. The facility failed to adequately assess, monitor, evaluate, and provide timely treatment according to accepted standards of practice. The resident was not evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the resident in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent infection and promote prompt healing of moisture associated dermatitis (MASD) caused by a leaking Foley catheter and a delay in arranging a urology consult, resulted in actual harm to Resident #39. For Resident #90 the facility failed to assess, monitor, report and promote healing of a pressure ulcer present on admission. Findings include: a) Resident #42 During a resident interview on 02/17/17 at 10:00 a.m., Resident #42 said something happened over the weekend related to his pain medication. Upon further inquiry, he stated he had not received his as needed (prn) pain medication on Saturday (02/25/17). He said he received the last dose on Friday (02/24/17) and then again early Sunday (02/26/17) morning. He was asked if he was in pain and he said he was in pain Friday and on Saturday. He described this pain as a constant ache. Resident #42 said he had pain in his legs due to vascular ulcers. Resident #42 said the pain would run from his lower extremities up into this groin. He said when he normally received his scheduled and prn pain medicine, he could distract himself from the pain by reading papers, drawing or talking to others. He said during the time he did not get his prn pain medication he could not do these things and also could not sleep well. He commented that he normally slept for about one hour before waking up. During the time he did not receive his prn pain medication he said he would only be able to stay asleep for about 15 minutes before waking up. The medical record review revealed the resident had physician's orders [REDACTED]. The medical record review verified the resident had a [DIAGNOSES REDACTED]. During an interview with Licensed Practical Nurse (LPN) #68 at 10:30 a.m. on 02/27/17, she obtained the Medication Administration Record [REDACTED]. The instructions on the MAR for administration of the medication stated, Give 1 tablet by mouth every 4 hours as needed for pain. Resident #42 did not receive the medication at all on 02/25/17. The last dose was given on 02/24/17 at 11:00 a.m. The MAR indicated [REDACTED]. On 02/27/17 at 11:00 a.m., Unit Manager (UM) #9 provided copies of the fax transmittals sent to the pharmacy. The prescription renewal form was written for Percocet 10/325 one tablet by mouth, every four hour, as needed. This was faxed to the pharmacy and received by the pharmacy on 02/25/17 at 7:38 a.m. The fax transmittal from the facility identified the need for the refill as STAT please. UM #9 said she did not know why the resident's medications were not received on Friday. She said if they put STAT on the prescription, then they normally received it within four (4) hours. At 1:00 p.m., UM #9 was asked to provide a list of what the facility kept in its emergency medical supply, which was identified as a Pyxis (automated medication dispensing system that supports decentralized medication management with various features for safety and efficiency). The list revealed the Oxycodone-Acetaminophen 5/325 was available in a quantity of five pills. UM #9 was asked if the facility had considered accessing the medication from the Pyxis system when it had not been delivered from the pharmacy. UM #9 said they did not access this medication from the Pyxis. She said in order to use the Pyxis the facility had to fax the physician for the prescription. The physician faxes this prescription back to the facility. The facility then faxes this prescription to the pharmacy and request a code to gain access to the medication in the Pyxis. The facility did not access the Pyxis system to obtain the pain medication needed by Resident #42. The Center Nurse Executive (CNE) was interviewed on 02/28/17 at 1:44 p.m. He said the facility attempted to get the medication from the pharmacy, but the pharmacy did not send it. No further comments were given as to why the resident did not receive the as needed pain medication or why the facility did not access the Pyxis. The failure of the facility to provide effective pain management, especially when the medication was available in-house, resulted in the resident experiencing pain that interfered with his sleep and diversional activities and this was determine to constitute actual harm. b) Resident #36 During the medication pass observation, on 02/22/17 at 10:25 a.m., Registered Nurse (RN) #9, was observed administering medications to Resident #36. During the medication pass, Ranexa 500 milligrams (mg), one (1) tablet by mouth twice daily (a medication given for treatment of [REDACTED]. At 11:30 a.m. on 02/22/17, the Director of Nursing (DON) was made aware of the medications for Resident #36 was not available from pharmacy. The DON verified neither medication could be located on the medication cart. c) Resident #2 During the medication pass observation, on 02/22/17 at 10:05 a.m., Registered Nurse (RN) #35, was observed administering medications to Resident #2. Artificial tears solution 1.4%. Instill one (1) drop to both eyes two times a day for dry eyes, scheduled at 9:00 a.m. and 9:00p.m., was unavailable from pharmacy. At 11:30 a.m. on 02/22/17, the Director of Nursing (DON) was made aware of the medications for Resident #2 was not available from pharmacy. The DON verified neither medication could be located on the medication cart.

Based on resident interview, staff interview, observation and record review, the facility failed to ensure Resident #39, who had previous pressure ulcers present on admission and was a high risk of development of new pressure ulcers, received necessary care and treatment to prevent the development if a new pressure ulcer. The facility failed to adequately assess, monitor, evaluate, and provide timely treatment according to accepted standards of practice. The resident was not evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the resident in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent infection and promote prompt healing of moisture associated [MEDICAL CONDITION] (MASD) caused by a leaking Foley catheter and a delay in arranging a urology consult, resulted in actual harm to Resident #39. For Resident #90 the facility failed to assess, monitor, report and promote healing of a pressure ulcer present on admission. Resident identifiers: #39 and #90. Facility census: 89 Findings include: a) Resident #39 During Stage 1 of the Quality Indicator Survey (QIS), at 2:00 p.m. on 02/20/17, Resident #39 asked to speak with me again. She voiced concern she was to be discharged to home but since she had acquired a new pressure ulcer while in the facility. She said it was a new area on her sacrum and now it was large and she was probably going to have another [DEVICE] placed and then she would not be able to go home. Medical record review for Resident #39, at 10:05 a.m. on 02/22/17, found this forty-eight (48) year old resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #39's Skin Integrity Reports and Nursing Admission assessment dated [DATE] showed the resident to have the following eleven (11) pressure ulcers on admission: --Two (2) Stage 3 pressure ulcer on her right hip, both resolved on 07/17/16 --Unstageable pressure ulcer on her right buttocks, resolved on 07/17/16 --Three (3) pressure ulcers on her left hip, a Stage 2 resolved on 06/13/16, a Stage 3 resolved on 07/17/16, and an unstageable pressure ulcer resolved on 09/05/16 --One (1) Stage 4 pressure ulcer on her left thigh/hip, resolved on 09/19/16 --One (1) deep tissue injury on her left heel, resolved on 07/27/26 --One (1) Stage 2 pressure ulcer on her left distal calf/upper ankle, resolved on 06/20/16 --One (1) Stage 2 pressure ulcer on her right knee, resolved on 06/20/16 --One (1) Stage 2 pressure ulcer on her left great toe, resolved on 08/08/16 All pressure ulcers were resolved as of 09/19/16. Review of physician's progress notes found: --08/03/16 - Patient has a Foley catheter in; keeps coming out and has to be reinserted. Consult urologist for possible suprapubic catheter. --08/09/16 - Patient with [MEDICAL CONDITION] bladder, Foley keeps coming out frequently. Will refer to urologist. Referral forms reviewed and found the facility faxed the first referral on 08/12/16 for a consult due to, [MEDICAL CONDITION] has a catheter and comes out! Treatment nurse concern about damage to the resident; keeps putting it back in. The next referral was faxed on 08/18/16. The facility received the appointment with urologist for 09/14/16. Review of the significant change Minimum Date Set (MDS) with assessment reference date (ARD) of 09/26/16 indicates Resident #39 had no pressure ulcers at time of assessment, although remained at risk for developing pressure ulcers. Further review of Resident 39's Skin Integrity Reports showed she developed a deep tissue injury on her left heel/foot on 11/14/16 and a Stage 3 on her right inner heel, although in February the physicians at the wound care center diagnosed the areas as vascular/diabetic. Review of Resident #39's nurse's notes revealed the following skin injury/pressure ulcers: --09/19/16 - No skin issues noted. --09/27/16 - No skin issues noted --10/04/16 - No skin issues noted --10/11/16 - No skin issues noted --10/18/16 - No skin issues noted --10/25/16 - No skin issues noted --11/01/16 - No skin issues noted --11/08/16 - Resident has a new onset/change in skin integrity, severe incontinence associated [MEDICAL CONDITION] (IAD) to coccyx and buttocks, and resident has been staying in the bed more recently due to taking more as needed [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] (narcotic medication). Resident's catheter was out; reinserted, and medication may be contributing to change in condition. --11/14/16 - Resident's coccyx area is much macerated from urine, and resident is a very heavy wetter and Foley catheter has been out since Friday night. --11/22/16 - Resident's glucose labs came back with results being 730. Attending physician notified and glucometer blood glucose test ordered twice daily and sliding scale coverage with [MEDICATION NAME] insulin. --11/22/16 - Resident noted to with a Stage 2 pressure ulcer on her left and right buttocks and posterior right upper thigh. Foley catheter was out again and skin very macerated from urine. Foley catheter reinserted. --12/04/16 - New pressure ulcer noted to sacrum and back of right upper thigh/ischium. Wounds to left and right buttocks have resolved. Resident's Foley catheter was leaking and brief was saturated with urine. --12/12/16 - Resident's brief was saturated in the morning and skin macerated. Foley catheter reinserted. --12/14/16 - Resident has [MEDICAL CONDITION], which could slow wound healing. --01/09/16 - Resident out for placement of Suprapubic catheter. --01/11/16 - Resident has a surgical incision mid lower abdomen with thirteen (13) staples and the Suprapubic catheter noted to be in the middle of incision line sutured in place. Wounds continue to improve; right inner foot pressure ulcer is a healing Stage 2 measuring 3.8 centimeters (cm) in length and 5 cm in width, area on her posterior right upper thigh/ischium measures 0.5 cm in length and 2 cm in width and is a healing Stage 2 pressure ulcer, her coccyx/buttocks area has a healing Stage 3 pressure ulcer measuring 3.5 cm in length and 4 cm in width and 0.3 cm in depth, and a healing Stage 3 pressure ulcer on her left heel/foot measures 3 cm in length and 5cm in width and 0.2 in depth. Review of the significant change MDS with ARD of 12/05/16 indicates Resident #39 had one (1) Stage 3 pressure ulcer to her left heel and two (2) unstageable pressure ulcers to her sacrum and her right upper thigh/ischium. Resident #39's current care plan reviewed and found: --Focus - Resident has actual skin breakdown (multiple pressure ulcers related to impaired sensation, limited mobility secondary to [MEDICAL CONDITION] and bowel incontinence . Stage 4 to left hip and Stage 2 to left Achilles. Date initiated: 06/18/16. Revision date: 09/12/16. Goals initiated on 06/18/16 and revised on 06/21/16. All interventions initiated on 06/18/16 with no revisions since. Observation, at 11:45 a.m. on 02/27/17, of wound care completed by Registered Nurse (RN) #53, found a Stage 4 pressure ulcer noted on the sacrum, foul odor noted when old dressing was removed and a moderate amount of serosanguinous (blood and serous fluid resembling serum) drainage noted. The last measurements provided by RN #53, and obtained on 02/20/17 measured 6 cm in length, 7 cm in width and 4.5 cm in depth. Wound bed appeared to have 25% of slough and 25% necrotic tissue. No indication of pain during the treatment. Resident #39 told me she had pressure ulcers when she came in but they were on her hip and buttocks and not on her sacrum. Old pressure ulcers scars were noted on hips and buttocks. Interview with the Director of Nursing (DON), at 2:15 p.m. on 02/23/17, found Resident #39's pressure ulcers had all healed by 09/19/16. He confirmed on 11/22/16 the resident had developed new pressure ulcers. Review of the urologist referral forms and physician's progress notes and nurse's notes show there was a delay in obtaining the urology consult from 08/03/26 to 08/18/16. He acknowledged the resident's Foley catheter was coming out and leaking frequently. No documentation of special precautions during the time of her catheter leaking for extra incontinence care and turning. No documentation on care plan to suggest the resident had refused to be turned and or incontinence care. No further information provided. Resident #39, who had previous pressure ulcers present on admission and was a high risk of development of new pressure ulcers, did not received necessary care and treatment to prevent the development if a new pressure ulcer. The facility failed to adequately assess, monitor, evaluate, and provide timely treatment according to accepted standards of practice. The resident was not evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the resident in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent infection and promote prompt healing of moisture associated [MEDICAL CONDITION] (MASD) caused by a leaking Foley catheter and a delay in arranging a urology consult, resulted in actual harm to Resident #39. For Resident #90 the facility failed to assess, monitor, report and promote healing of a pressure ulcer present on admission. b) Resident #90 On 02/22/17 at 2:12 p.m., the wound care nurse, Registered Nurse (RN) #53, assisted by Licensed Practical Nurse (LPN) #5 was observed providing pressure ulcer wound care to Resident #90, without any breach in infection control practices. RN #53 stated the Stage 3 pressure ulcer, on the resident's coccyx was about the same since resident was admitted in November, and resident would be returning to the wound care center for treatment. Review of records, on 02/22/17 at 2:40 p.m., revealed the resident was admitted to facility on 11/04/16. A nursing progress note written on 02/08/17, by the wound care nurse, revealed the resident was admitted to center with Stage 3 decubitus ulcer/pressure ulcer to coccyx, area remains a Stage 3 but measurements have increased in size. Resident has been to the wound care center in the past, will refer back to wound care center and the son is in agreement. Resident has had decubitus for a long period of time, because when she used to visit her sister at Center she let the wound care nurse look at area. Review of records revealed Resident #90 was admitted to the facility with a Stage 3 pressure ulcer on her coccyx and also a history of having the Stage 3, and was not provided a pressure relieving mattress to help promote healing of the ulcer. On 02/28/17 at 12:00 p.m., review of weekly measurements records revealed on admission on 11/04/17, Stage 3 decubitus ulcer on coccyx measured 1.5 centimeters (cm) x 1.5 cm x .5 cm. On 11/07/16 Stage 3 decubitus ulcer on coccyx measured 1.9 cm x 1.5 cm x .7 cm. On 02/28/17 at 12:10 p.m., interview with LPN #44 revealed she just recently requested a special pressure relieving mattress for the resident. LPN #44 said, Last week I requested the mattress, I thought it might help.

Based on observation, resident interview, staff interview, policy review, medical record review, and review of facility grievance/concern log, the facility failed to provide necessary care and services to 12 of 27 Stage 2 sampled residents in order for the residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The failed practices included: --For Resident #42, the facility failed to ensure the resident received effective pain management, which resulted in the resident's sleep and activities being affected adversely. Although the needed medication was available in the facility's emergency supply, staff failed to obtain the medication when the pharmacy failed to deliver the resident's medication timely. This was determined to constitute actual harm to the resident as a result resident's experiencing pain without relief due to the lack of administration prescribed pain medication, and the negative, adverse impact on the resident's sleep and activities. --The facility failed to arrange for an Ear Nose and Throat (ENT) consultation for Resident #79. --Resident #86's care plan was not correlated with the [MEDICAL TREATMENT] center. --Resident #32's pain was not assessed. --Resident #39 did not have the effectiveness of a prn pain medication assessed, nor were non-pharmacological interventions attempted. --Resident #84 did not have medications administered as directed by the physician. --Resident #52 did not have their pain assessed. --Resident #3 did not have the effectiveness of an as needed (prn) pain medication assessed. --The facility also failed to accurately assess and treat Resident #2 after this resident expressed [MEDICAL CONDITION]. --Resident #82 did not receive an antibiotic as directed by the physician's orders [REDACTED]. --Resident #10 did not have the effectives of a prn pain medication assessed. --In addition, Resident #59 did not have an assessment to evaluate and treat pain. Resident identifiers: #42, #79, #86, #32, #39, #84, #52, #3, #2, #82, #10 and #59. Facility census: 89. Findings include: a) Resident #42 During a resident interview on [DATE] at 10:00 a.m., Resident #42 said something happened over the weekend related to his pain medication. Upon further inquiry, he stated he had not received his as needed (prn) pain medication on Saturday ([DATE]). He said he received the last dose on Friday ([DATE]) and then again early Sunday ([DATE]) morning. He was asked if he was in pain and he said he was in pain Friday and on Saturday. He described this pain as a constant ache. Resident #42 said he had pain in his legs due to vascular ulcers. Resident #42 said the pain would run from his lower extremities up into this groin. He said when he normally received his scheduled and prn pain medicine, he could distract himself from the pain by reading papers, drawing or talking to others. He said during the time he did not get his prn pain medication he could not do these things and also could not sleep well. He commented that he normally slept for about one hour before waking up. During the time he did not receive his prn pain medication he said he would only be able to stay asleep for about 15 minutes before waking up. The medical record review revealed the resident had physician's orders [REDACTED]. The medical record review verified the resident had a [DIAGNOSES REDACTED]. During an interview with Licensed Practical Nurse (LPN) #68 at 10:30 a.m. on [DATE], she obtained the medication administration record (MAR) for Resident #42. The MAR reflected Resident #42 received [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) tablet ,[DATE] mg (milligram). The instructions on the MAR for administration of the medication stated, Give 1 tablet by mouth every 4 hours as needed for pain. Resident #42 did not receive the medication at all on [DATE]. The last dose was given on [DATE] at 11:00 a.m. The MAR reflected the resident received two (2) doses of [MEDICATION NAME] 200 mg (3 tablets) on [DATE] at 6:00 a.m. and 12:00 p.m. He received his dose of [MEDICATION NAME] ,[DATE] mg on [DATE] at 3:30 a.m. The resident said the [MEDICATION NAME] he received on [DATE] did not do much to relieve his pain. On [DATE] at 11:00 a.m., Unit Manager (UM) #9 provided copies of the fax transmittals sent to the pharmacy. The prescription renewal form was written for [MEDICATION NAME] ,[DATE] one tablet by mouth, every four hour, as needed. This was faxed to the pharmacy and received by the pharmacy on [DATE] at 7:38 a.m. The fax transmittal from the facility identified the need for the refill as STAT please. UM #9 said she did not know why the resident's medications were not received on Friday. She said if they put STAT on the prescription, then they normally received it within four (4) hours. At 1:00 p.m., UM #9 was asked to provide a list of what the facility kept in its emergency medical supply, which was identified as a Pyxis (automated medication dispensing system that supports decentralized medication management with various features for safety and efficiency). The list revealed the [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] was available in a quantity of five pills. UM #9 was asked if the facility had considered accessing the medication from the Pyxis system when it had not been delivered from the pharmacy. UM #9 said they did not access this medication from the Pyxis. She said in order to use the Pyxis the facility had to fax the physician for the prescription. The physician faxes this prescription back to the facility. The facility then faxes this prescription to the pharmacy and request a code to gain access to the medication in the Pyxis. The facility did not take action to obtain the medication from the Pyxis system. The Center Nurse Executive (CNE) was interviewed on [DATE] at 1:44 p.m. He said the facility attempted to get the medication from the pharmacy, but the pharmacy did not send it. No further comments were given as to why the resident did not receive the prn pain medication or why the facility did not access the Pyxis. The failure of the facility to provide effective pain management, especially when the medication was available in-house, resulted in the resident experiencing pain that interfered with his sleep and diversional activities and this was determine to constitute actual harm. b) Resident #79 Resident #79 had a nursing facility subsequent visit form (physician visit) dated [DATE], which explained the Resident had complained of left ear pain and drainage. The physician documented the resident had intermittent ear infections and was previously scheduled for ear surgery three years ago but his physician had died . The note went on to say the resident was seen by (physician name) in the hospital but not in the physician's clinic. The note stated the resident's ear had been draining for one week and had yellow-brown malodorous (foul-smelling) discharge. The resident had pain in the left side of his face which was made worse by opening his mouth. The physician had recommended the resident be referred to an ear nose and throat (ENT) specialist. A review of the medical record did not reveal this resident had been referred to the ENT. Unit Clerk #72 reviewed the resident's record and facility's appointment log and confirmed this resident had not been to an ENT appointment since this referral was made. On [DATE] at 1:37 p.m. Unit Clerk #72 asked Center Nurse Executive (CNE) #15 if the resident should have an appointment made with an ENT, and the CNE said yes. c) Resident #86 Medical record review found the resident was receiving [MEDICAL TREATMENT] via a perma-catheter in the right [MEDICATION NAME] (relating to, being, or inserted into a part such as an artery, vein, or nerve located under the clavicle) three (3) days a week, on Mondays, Wednesday and Fridays, at an offsite [MEDICAL TREATMENT] center. The resident was admitted on [DATE] and had received [MEDICAL TREATMENT] on [DATE], [DATE], [DATE] and [DATE]; the medical record contained no copies of a [MEDICAL TREATMENT] communication record, shared by the facility and the [MEDICAL TREATMENT] center hospital. The resident was in the hospital from [DATE] to [DATE]. The resident received [MEDICAL TREATMENT] on [DATE], [DATE], [DATE] and [DATE]; the medical records contained no [MEDICAL TREATMENT] communication record. Again, the resident was in the hospital from [DATE] to [DATE] and returned to the facility on [DATE] and received [MEDICAL TREATMENT] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The medical record contained no [MEDICAL TREATMENT] communication record for these treatment days. The facility was to complete the top half of the communication form, which included the resident's vital signs before the resident left the facility for [MEDICAL TREATMENT], an examination of the access site and any significant changes since last [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] center was to complete the middle section of the form which also included obtained vital signs, completed lab work, medications given, intake and output, monitoring the access site for location, the condition of the dressing, ports, pain and any other pertinent information. Upon return to the facility, the facility was to complete the bottom of the form which included a narrative note upon arrival to the facility. Neither the facility, nor the [MEDICAL TREATMENT] center consistently recorded the resident's information pre and post [MEDICAL TREATMENT] treatments. The medical record / [MEDICAL TREATMENT] communication form contained no information regarding laboratory values obtained by the [MEDICAL TREATMENT] center Review of the resident's current care plan, on [DATE] at 11:50 a.m., found a care plan initiated on [DATE], found it contained no goals or interventions concerning [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. Review of the facility's policy for [MEDICAL TREATMENT] services found the purpose of the policy was, To provide continuation of necessary care and services to those residents receiving [MEDICAL TREATMENT] from a community based [MEDICAL TREATMENT] center. It is the facility responsibility to develop a plan of care for the resident that includes a means of communication between the resident, the center and the facility staff. The policy also contained the following procedures: --The facility staff will complete the [MEDICAL TREATMENT] Resident Communication Report to include the information required by the [MEDICAL TREATMENT] center prior to the resident leaving for treatment. The communication form will provide a means of useful communication between the facility and [MEDICAL TREATMENT] center. The resident care plan includes care of the shunt/fistula, including complications, i.e. bleeding infections, etc., nutritional needs, emotional and social well -being, management of [MEDICAL CONDITION] and monitoring aspects will be reviewed per the facility policy for care plan review and on as needed basis. The [MEDICAL TREATMENT] Resident Communication Report will be completed by the licensed nurse prior to the resident transfer. Upon return from the [MEDICAL TREATMENT] center, the resident will be evaluated by the licensed nurse including vital signs, shunt/fistula observation and the results of the evaluation will be documented in the medical record . There needs to be staff education on [MEDICAL CONDITION] and [MEDICAL TREATMENT] complications, documentation, care planning and management. Licensed staff needs to know what to do in case of an emergency. On [DATE] at 10:30 a.m., during an interview with the director of nursing (DON), he agreed the [MEDICAL TREATMENT] center should supply the facility with pre and post weights. He said he did not know what laboratory values the [MEDICAL TREATMENT] center should obtain. He also agreed there should be better communication between the facility and the [MEDICAL TREATMENT] center. The DON also agreed the resident's care plan did not include goals or interventions concerning [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. d) Resident #32 A review of Resident #32's medical record at 1:34 p.m. on [DATE], found a physician's orders [REDACTED]. Review of the MAR for the dates of [DATE] through present found Resident #32 received this medication on the following dates and times: -- [DATE] at 10:00 p.m. -- [DATE] at 10:30 p.m. -- [DATE] at 5:00 p.m. -- [DATE] at 9:00 a.m. -- [DATE] at 8:30 a.m. -- [DATE] at 10:00 p.m. -- [DATE] at 8:00 p.m. -- [DATE] at 12:00 p.m. -- [DATE] at 1:00 p.m. -- [DATE] at 11:00 a.m. -- [DATE] at 10:00 a.m. -- [DATE] at 10:00 p.m. -- [DATE] at 10:00 p.m. Further review of the record found no evidence prior to the administration of this as needed pain medication that nonpharmacological interventions were attempted to relieve the pain. Also there was no assessment of Resident #32's pain as to the location of the pain and the intensity of the pain prior to the administration of the PRN pain medication. Furthermore there was no assessment of Resident #32's pain intensity after the administration of the PRN pain medication to determine if the medication was effective in alleviating the resident's pain. e) Resident #39 A review of Resident #39's medical record, at 11:34 a.m. on [DATE], found a physician's orders [REDACTED]. Review of the MAR for the dates of [DATE] through [DATE] found Resident #39 received this medication on the following dates and times: --[DATE] at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. --[DATE] at 6:00 a.m. and 10:00 p.m. --[DATE] at 1:00 p.m., 5:40 p.m. and 9:00 p.m. --[DATE] at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. --[DATE] at 12:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 8:30 a.m., 2:30 p.m., and 10:00 p.m. --[DATE] at 2:00 a.m., 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m. and 6:30 p.m. --[DATE] at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:45 p.m. --[DATE] at 7:00 a.m., 11:00 a.m., and 10:00 p.m. --[DATE] at 7:00 a.m., 11:00 a.m., and 2:00 p.m. --[DATE] at 10:00 a.m., 3:00 p.m., and 10:00 p.m. --[DATE] at 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. --[DATE] at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. --[DATE] at 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., and 9:00 p.m. --[DATE] at 6:00 a.m. and 6:30 p.m. --[DATE] at 3:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 12:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 10:00 a.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 10:00 a.m., 4:00 p.m. and 9:00 p.m. --[DATE] at 10:00 a.m., 2:00 p.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 9:00 a.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 3:00 p.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 6:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m., and 10:00 p.m. --[DATE] at 2:00 a.m., 6:00 a.m., 1:00 p.m. and 10:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m. and 6:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 3:30 p.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m. and 7:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 a.m., 2:00 p.m. and 10:00 p.m. --[DATE] at 10:00 a.m. --[DATE] at 5:00 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m. and 9:30 p.m. --[DATE] at 8:30 a.m. and 8:00 p.m. Further review of the record found no evidence that prior to the administration of this as needed pain medication nonpharmacological interventions were attempted to relieve the pain. Also there was no assessment of Resident #39's pain as to the location of the pain and the intensity of the pain prior to the administration of the PRN pain medication. Furthermore, there was no assessment of Resident #39's pain intensity after the administration of the PRN pain medication to determine if the medication was effective in alleviating the resident's pain. An interview with the DON at 2:00 p.m. on [DATE], confirmed there was no nonpharmacological interventions attempted nor were any pre or post pain assessments completed on the above dates and times when Resident #32 was administered a PRN pain medication. He indicated that the PRN pain management flow sheet was what the facility used to evaluate a residents pain, and if it had been completed for each of the above occasions then the nonpharmacological interventions would have been completed as well as the pre and post pain assessments. f) Resident #84 Record review found the resident was admitted to the facility on [DATE] at 4:20 p.m. Review of the medication administration record (MAR) directed the resident was to receive the following medications upon admission: --[MEDICATION NAME] 0.5 milligrams (mg) twice a day, at 9:00 a.m. and 9:00 p.m., Diagnosis: [REDACTED].>--Aspirin 81 mg daily at 9:00 a.m., Diagnosis: [REDACTED]. --Atorvastatin 80 mg daily with dinner for [MEDICAL CONDITION] --[MEDICATION NAME] 75 mg daily at 9:00 a.m. for [MEDICAL CONDITION] Fibrillation --Vitamin D2 - 50,000 units weekly for vitamin deficiency --Folic Acid 1 mg daily at 9:00 a.m. --[MEDICATION NAME] 20 mg daily at 9:00 a.m., every Monday, Wednesday and Friday According to documentation on the MAR the resident did not receive the following medications upon admission: --The 9:00 p.m. dose of [MEDICATION NAME] on [DATE], and --The 9:00 a.m. and 9:00 p.m. dose of the medication on [DATE]. --Aspirin was not provided on [DATE]. --Atorvastatin was not provided with dinner on [DATE] or [DATE]. --The 9:00 a.m. dose of [MEDICATION NAME] was not provided on [DATE]. --Folic Acid was not provided at 9:00 a.m. on [DATE]. An interview with the director of nursing (DON), at 4:18 p.m. on [DATE], confirmed the MAR indicated the resident did not receive his medications upon admission as ordered by the physician. The DON said he could find no explanation as to why the medications were not given as ordered. The DON said the medication, [MEDICATION NAME] is currently available in the emergency medication system but he did not know if the medication was available at the time of the resident's admission. The DON said the Aspirin is available as a stock medication so he did not know why it was not given. Review of a grievance/concern log, dated [DATE] found the resident had complained about the medications not being available. The resolution to the problem was, Medications were ordered upon admission. He was explained they are not here before he arrives. He has not had any other concerns regarding medications. This was addressed upon admission. There was no follow up as to why it would have taken 2 days to have all the resident's medications available at the facility. g) Resident #52 An interview with the resident at 2:06 p.m. on [DATE], found the resident said she was having pain with no relief. She said her shoulder hurt. She said she thinks she gets Tylenol but, It doesn't make the pain go away. Review of the resident's MAR found the resident is receiving [MEDICATION NAME] 200 mg, 2 tablets daily for unspecified [MEDICAL CONDITION]. The resident does not receive a controlled pain medication. The resident was admitted to the facility on [DATE]. Review of the current care plan found the problem: --Resident exhibits or is at risk for alterations in comfort r/t chronic pain. The goal associated with the problem is: --Resident will achieve acceptable level of pain control through next review. Approaches included: --Evaluate pain characteristics, utilize pain scale, complete pain assessment, assist resident to position of comfort utilizing pillows as appropriate, etc. Review of the facility form, entitled Pain Presence Monitor, instructed nursing staff to ask the resident daily, Do you have any pain or hurting? (Code Y/N) Review of these forms for August, September, October, November, and December of 2016, and the January and February of 2017 found the form was rarely used. For example, there was no evidence the resident was asked about pain on any days in October, November and December, 2016. The resident pain level Pain was recorded for only 3 days in September and two (2) days in August. At 10:12 a.m. on [DATE], the DON was interviewed regarding the pain monitoring tool. At first the DON said, pain documentation is by exception only, so if she had no pain the form wouldn't be used. After review of the instruction on the form, the DON concluded he was incorrect as the form requires staff to ask the resident each day if they are having any pain. Review of the pain monitoring tool found staff had documented with an N, on some days, indicating no pain, so obviously staff did not think the tool was only used if the resident expressed pain. The facility's pain management policy, revised on [DATE] directs staff to, . At a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain . At 11:50 a.m. [DATE], the resident was interviewed with the DON present. When the DON asked the resident about her pain, she rated it as an 8 on a scale of ,[DATE] with 10 being the worst. She said her left shoulder was hurting. She demonstrated this by taking her right hand and raising her left arm. When she raised the left arm up and down, a crepitus (medical term to describe the grating, crackling or popping sounds and sensations experienced under the skin and joints or a crackling sensation due to the presence of air in the subcutaneous tissue) sound could be heard. The DON said he would talk to the physician about her pain. Review of the physician's orders [REDACTED]. h) Resident #3 Record review found Resident #3 began receiving Hospice services on [DATE]. Review of the resident's MAR found she was receiving the following medications for treatment of [REDACTED].>--[MEDICATION NAME] ,[DATE] mg every 4 hours as needed (PRN) for moderate pain --[MEDICATION NAME] Patch 72 hour, 12 micrograms per hour (mcg/hr), apply patch [MEDICATION NAME] daily, every 3 days, apply with [MEDICATION NAME] 75 mcg/hr to equal 87 mcg/hr. --[MEDICATION NAME] sulfate 20 mg/milliliter (ml), give 0.75, 1 tablet by mouth every 2 hours as needed (PRN) for pain. Review of the resident's care plan found the following problem: --The resident exhibits alterations in comfort related to muscle spasms, chronic pain present. The goal associated with this problem was: --Resident will relate improvement of pain after initiation of pain medication/relief measures as evidence by verbalization through next evaluation. Approaches included: --Evaluate pain characteristic: quality, severity, location, precipitating/relieving factions. Medicate as ordered for pain/muscle spasms and monitor for effectiveness. Monitor frequency of episodes of breakthrough pain to determine the need for pain medication adjustment. Review of the PRN pain monitoring management flow sheet for [DATE] found the facility administered the [MEDICATION NAME] medication on at least 39 occasions in January but only on 14 occasions did the facility follow up with the resident, after providing the medication, to determine if the treatment was effective. Pain medication was provided on the following dates and times in [DATE]: --[DATE] at 9:00 p.m. --[DATE] at 9:00 p.m. --[DATE] at 10:00 p.m. --On [DATE] the resident received the medication at 2 different times, only 1 time is legible -9:00 p.m. --[DATE] at 8:00 a.m. and 1:00 p.m. --[DATE] at 8:00 a.m. --[DATE] at 9:00 a.m. and 10:00 p.m. --[DATE] at 9:00 a.m. --[DATE] at 5:30 a.m. and 10:15 p.m. --[DATE] at 8:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE] at 9:00 a.m. --[DATE] at 8:00 a.m. --[DATE] at 8:00 a.m. and 9:00 p.m. --[DATE] at 6:00 a.m., 10:00 p.m. --[DATE] at 11:00 p.m. --[DATE] at 8:00 a.m. and 1:00 p.m. --[DATE] at 9:00 a.m., 2:00 p.m., and 9:00 p.m. --[DATE] at 8:00 a.m. --[DATE] at 8:00 a.m. --[DATE] at 8:00 a.m., 12:00 p.m., and 9:00 p.m. --[DATE] time is illegible --[DATE] at 9:00 a.m. --[DATE] time is illegible The PRN pain management flow sheet followed up on the effectiveness of the resident's [MEDICATION NAME] on the following days in [DATE]: --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE], two (2) occasions 9:00 a.m. and 2:00 p.m. --[DATE], two occasions time --[DATE] --[DATE] --[DATE] Review of the MAR for February 2017 found the [MEDICATION NAME] was administered on 25 occasions and the effectiveness of the medication was only rated on 10 occasions. The medication was administered on the following dates and times for February 2017 to date; --[DATE], at 10:00 a.m. --[DATE], at 12:00 midnight and 9:00 a.m. --[DATE], at 12:00 midnight and 1:00 p.m. --[DATE], at 12:00 p.m. --[DATE] at 12:00 p.m. --[DATE] at 9:00 a.m. and 9:00 p.m. --[DATE], time illegible --[DATE] at 9:00 a.m. --[DATE] at 2:00 p.m. and 8:00 p.m. --[DATE], time illegible --[DATE], time appears to be 12:00 midnight --[DATE] at 9:00 a.m. --[DATE], at 9:00 p.m. --[DATE] at 1:00 p.m. and 5:00 a.m. --[DATE], time appears to be 12:00 midnight --[DATE] at 8:00 a.m. --[DATE] at 1:00 p.m. --[DATE] at 8:00 a.m. --[DATE] at 8:00 a.m. and 9:00 p.m. Review of the PRN Pain Management Flow sheet found documentation of the effectiveness of the medication on the following dates and times in February 2017: --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] --[DATE] At 2:19 p.m. on [DATE], the DON agreed the facility's documentation for rating the resident's pain after providing PRN medications was not consistent. He said pain documentation and monitoring had been an issue and he was working with staff to correct the problem. i) Resident #2 During Stage one (1) of the Quality Indicator Survey, at 8:29 a.m. on [DATE], Resident #2 asked to speak with the surveyor. During the conversation Resident #2 voiced his concerns with his care and how depressed he was to be at the facility and not able to return home. He stated, I don't know what else to do. I guess commit suicide is all that's left to do. The resident then stated, I shouldn't have said that I am a Christian and I would never do that, but I wish I could go home. At approximately 10:00 a.m. on [DATE], the social service director (SSD) was made aware of Resident #2's statements pertaining to suicide. She indicated, Resident #2 has been more depressed lately because he wants to go home but his wife will not allow him to because she is not able to care for him. She stated she would speak to him about his statements and follow-up as necessary. A review of Resident #2's medical record at 12:16 p.m. on [DATE] found Resident #2 was seen by the physician on [DATE] for an acute visit related to suicidal ideation. The following was recorded by the physician under the heading, Assessment Plan (typed as written): 1. Suicidal ideation - looks as though patient regrets saying this. He states that he gets upset with his current situation and said something he did not mean. He commits to safety. Will increase his [MEDICATION NAME] ([MEDICATION NAME]). Further review of Resident #2's medical record found the following physician orders [REDACTED].>-- admission orders [REDACTED]. -- A physician written order also dated [DATE] to increase [MEDICATION NAME] to 50 mg one time a day related to depression and anxiety. (This order was entered into the resident's record after the admission orders [REDACTED]. This was the current order as of [DATE] when the physician examined the resident.) -- A physician written order dated [DATE] to increase [MEDICATION NAME] to 50 mg one time a day. A review of Resident #2's MAR for February 2017 found the resident began receiving [MEDICATION NAME] 50 mg on [DATE]. On [DATE] a nurse discontinued the [MEDICATION NAME] 50 mg which started on [DATE] from the MAR and re-wrote the new order for [MEDICATION NAME] 50 mg on the front page of the MAR the nurses began initialing this as administered on [DATE]. The physician failed to accurately assess what milligrams of [MEDICATION NAME] Resident #2 was on when they wrote the order to increase it to 50 mg. The nursing staff failed to identify the error made by the physician and failed call the physician to clarify the order when the medication was added to the MAR. An interview with the director of nursing (DON), at 12:30 p.m. on [DATE], confirmed the physician noted they were going to increase Resident #2's [MEDICATION NAME] as a result of his suicidal ideation, but in fact when the order was written the dosage remained unchanged. He agreed nursing should have called the physician and clarified the order since it was conflicting in the fact it said to increase the dosage but the dosage remained the same. An additional review of Resident #2's medical record at 10:30 a.m. on [DATE], found the following physicians order dated [DATE], [MEDICATION NAME] ([MEDICATION NAME]) 75 mg one time daily. Discontinue [MEDICATION NAME] 50 mg daily. After surveyor intervention nursing called the physician to clarify the order and the medication was increased. j) Resident #82 A review of Resident #82's medical record, at 9:52 a.m. on [DATE], found a physician's orders [REDACTED]. Review of the MAR for the month of [DATE] found Resident #82 received this medication at 9:00 p.m. on [DATE], at 9:00 a.m. and 9:00 p.m. on [DATE] an

Based on medical record review, policy review, and staff interview, the facility failed to follow its established bowel protocol which would have provided interventions when a resident had no bowel elimination for three (3) consecutive days. Standing orders were in place to address constipation, but the facility failed to implement these orders. This failure resulted in the resident's failure to experience bowel elimination for eleven (11) days. The resident was admitted to the hospital where she was given magnesium [MEDICATION NAME] and an enema and had multiple bowel movements. When the resident returned to the facility, an abdominal x-ray report, completed at the hospital, noted, "Question early fecal impaction." Upon her return, the facility continued to fail to address the resident's constipation allowing the resident to go for more than three (3) days without a bowel movement. On four (4) separate occasions, the resident went for nine (9) days, six (6) days, nine (9) days, and eight (8) days without a bowel movement in a five (5) month period. This was true for one (1) of forty (40) sampled residents. Resident identifier: #58. Facility census: 88. Findings include: a) Resident #58 Review of the medical record for Resident #58 revealed the following entries in nurse's notes: -- 06/20/11 at 4:28, "Constantly attempting to get up out of w/c (wheelchair) attempting to walk. Resident is unable to walk. Requires 2 person max assist with toileting and transfers. Appetite poor for dinner. Low grade temp reported by CNA. Medications administered accordingly. Resting quietly at this time." -- 6/20/11 at 9:51, "Staff reports that resident has swollen belly. Upon initial assessment of resident, she has distended abdomen, soft to palpation, nontender at this time. Bowel sounds are not present. Resident has not urinated since approximately 10:30 pm last night, Have contacted (name of physician). T/O (treatment orders) obtained for FUB and flat abdominal x-ray, may straight cath resident if she does not void. Notified contact (name of responsible party) of n/o (new order)." -- 6/20/11 at 11:40, "Resident has voided a large amount of urine. Her abdomen remains swollen. V/S (vital signs) now are 189/96, 94, 22, 98.9 ax 02 sat is 91-92% on RA. Resident placed on O2 (oxygen) @ (at) this time @ 2l (litters) pm via n/c. Resident has eaten and drank today without difficulty noted. (name of mobile x-ray company) in to obtain x-ray at this time " -- 06/20/11 at 13:24, "Resident is now c/o (complaining of) chest pain. Contacted (name of physician) and family to notify of change in condition. N/O (new order) obtained to send to (name of hospital). Awaiting results of earlier x-rays." -- 06/20/11 at 13:41 "(name of resident) transferred to hospital unplanned for evaluation and treatment....Resident presenting with new onset chest pain, increased blood pressure, pulse, decrease oxygen saturation. No history of cardiac illness. Family requests sent to the ER (emergency room ). See transfer form for additional clinical findings." -- The next entry in the nurses' notes was made by the director of nursing on 06/20/11 at 14:00. "At 1:30 pm assessed resident condition. Resident abdomen distended, bowel sounds heard, tender to palpation. Resident also complained of chest pain and headache. Bp (blood pressure) had been elevated. P (pulse) 92 and bounding/regular, R (respirations) 20. Periorbital [MEDICAL CONDITION]. [MEDICAL CONDITION], resolved at this time. Lung sounds clear bilaterally. (name of physician) notified at 1:43 pm and order obtained to send resident to ER (emergency room ) for evaluation. LPN spoke with family earlier who agreed to transfer if deemed necessary." Review of the discharge summary from the hospitalization revealed the resident was discharged from the hospital, and returned to the facility on [DATE]. The report of an x-ray of the abdomen, dated 06/20/11 (while hospitalized ), ". . . Mild gas distention of bowel loop in the central abdomen presumably enlarged bowel. Large amount of fecal debris in the rectosigmoid region. A lot of stool is noted within the right colon. Findings are suggestive of early fecal impaction." Documentation from the hospital discharge summary found, ". . . Brief hospital course: The patient was admitted to the floor. She was given magnesium [MEDICATION NAME] and an enema and had multiple bowel movements. She was started on [MEDICATION NAME]. Urine culture was not sent and it was sent later from the floor, but she was started on antibiotics. She continued to improve. She had some mild nausea, but was able to tolerate p. o. She had multiple bowel movements and was started on [MEDICATION NAME], started on a bowel regimen back at the nursing home. She was switched on oral [MEDICATION NAME] to complete her 7-day course and she is at her baseline mental status and her abdomen is much softer." The hospital discharge summary listed the resident's principal [DIAGNOSES REDACTED]." Under "Other Diagnosis: [REDACTED]. Further review of the activities of daily living (ADL) flow record, completed by the nursing assistants (NAs) for June 2011 found the following recorded information regarding the resident's bowel movements: -- On 06/04/11 the resident had two (2) bowel movements. -- The next record bowel movement was not until 06/15/11 when a medium bowel movement was recorded. The resident did not have a bowel movement for eleven (11) days. No interventions were provided by staff during this eleven (11) day period from 06/04/11 until 06/15/11. -- Two (2) small bowel movements were record as having occurred on 06/18/11 and 06/19/11. Review of the facility's standing orders for treatment of [REDACTED]. * If no bowel movement in three days, give milk of magnesia 30 cc PO X one dose. * If no bowel movement on day four, give [MEDICATION NAME] suppository rectally x one dose. * If no bowel movement on day five give fleets enema. * If no results from the Fleets enema, call physician for further orders. The ADL flow sheets were reviewed for July, August, September and November 2011 and the following issues were discovered: -- July 2011: The resident had a medium bowel movement on 07/19/11. The next documented BM was not until 07/28/11. The resident did not have a documented bowel movement for nine (9) days. -- On 07/26/11 the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation as to whether the intervention was effective. August, 2011: -- The resident had a bowel movement on 08/02/11 and the next bowel movement did not occur until 08/08/11 - six (6) days later. No interventions were provided during this six (6) day time frame and there was no indication the facility was following their protocol for constipation. September, 2011: -- The resident had a bowel movement on 09/13/11 and the next bowel movement occurred nine (9) days later on 09/22/11. Again no interventions were provided during this nine day time frame and there was no indication the facility was following their protocol for constipation. November, 2011: -- Documentation revealed the resident had a bowel movement on 11/01/11 with the next bowel movement occurring eight (8) days later on 11/09/11. Again no interventions were provided during this eight (8) day time frame and there was no indication the facility was following their protocol for constipation. ============ During an interview, at 11:45 a.m. on 11/14/11, with Employee #54, a licensed practical nurse on the resident's unit, verified the standing orders for constipation were not initiated for the resident. She verified the facility did not follow the standing orders for constipation. The facility physician completed a history and physical examination [REDACTED]. The physician noted the resident was admitted to the hospital with [REDACTED]." The resident's physician prescribed [MEDICATION NAME] 100 milligrams twice a day for unspecified constipation on 06/22/11. an order for [REDACTED]. The director of nursing was interviewed on the afternoon of 11/14/11. She stated the resident was not sent to the hospital on [DATE] for any issues pertaining to her constipation. She stated the resident was sent to the hospital for chest pains. She presented the results of an abdominal x-ray report completed at the facility on 06/20/11 prior to discharge to the hospital. The finding of this x-ray report found, "scattered collections of air in small and large bowel distribution. Slight motion artifact is present. Small amount of fecal material in the distribution of the colon except for the sigmoid and rectal vault where there is a moderate amount . . . ." The facility failed to monitor the bowel movements of Resident #58 and allowed the resident to go for eleven (11) days in June, without a bowel movement. After the resident's return from the hospital, on 06/22/2011, the facility was aware or should have been aware by reviewing hospital documentation, the resident was experiencing complications with bowel elimination. This was evidenced by the discharge summary that included, ". . . The patient was admitted to the floor. She was given magnesium [MEDICATION NAME] and an enema and had multiple bowel movements." The physician addressed the constipation by prescribing medication, but the facility continued to document the resident did not have a bowel movement within three (3) days and continued to fail to implement their standing orders for constipation which should have been implemented after three days of no bowel movement.

Based on review of medical records (both electronic and paper), staff interviews, review of in-service records, review of disciplinary action documents, review of controlled substances records, review of the facility's documentation regarding falls, review of the facility's investigations of falls and reportable events, and observations, the facility had failed to ensure a resident received appropriate and timely interventions for management of the onset of pain. The lack of pain management constituted actual harm to the resident. Review of documentation found a resident had sustained falls in December 2010. The last fall was noted to have occurred on 12/25/10. She later began to demonstrate both verbal and non-verbal indicators of pain. During this time, she also began to exhibit a limp and a decreased effort to ambulate. The onset of pain symptoms was evident beginning on the late morning of 12/31/10. A total of six (6) doses of Tylenol 650 mg were documented as given. The effectiveness of those doses was not documented (or documented in the negative), and documentation indicated the resident's pain symptoms persisted. The physician saw the resident in the afternoon on 12/31/10. He noted the resident was crying but did not order any additional pain medication. There was no evidence further treatment of [REDACTED]. On 01/02/11 at 23:39 (11:39 p.m.), the resident was sent to the hospital where it was found she had a [MEDICAL CONDITION]. Through review of medical records, review of the controlled substances sign-out book for Mary's Garden, staff interviews, observations, and review of documentation of in-services and disciplinary actions, it was determined the facility had identified and addressed the deficits in the provision of care related to pain management for Resident #50. This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/25/09) and before the start of this on-site revisit to a complaint investigation on 01/24/11. Resident identifier: #50. Facility census: 84. Findings include: a) Resident #50 During review of occurrences reported to the State in accordance with the ?483.13(c)(1)(ii), it was noted a report had been completed for Resident #50 on 01/03/11. The report indicated the resident had an injury of unknown source. She had been sent to the emergency room for complaints of pain, where she was found to have a displaced [MEDICAL CONDITION] hip. Record review revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]., and dementia with behavioral disturbances. -- 1. Review of the nursing entries and assessments found she had fallen on 12/09/10. A nursing entry for 12/09/10 at 18:09 (6:09 p.m.), by Employee #111 (a licensed practical nurse (LPN)) noted the resident had fallen in the last 72-hours. She had experienced a witnessed fall at the nurses' station. At that time, the resident was not exhibiting signs and symptoms of pain according to the nurse. A late entry on 12/10/10 at 2:09 (the author did not indicate the date or time of the original event for which this late entry was made), made by an LPN, noted the resident was ambulatory for short distances that morning. She was also noted to be unsteady of gait at times. On 12/12/10 at 13:14 (1:14 p.m.), Employee #29 (an LPN) noted the resident had fallen. The resident had been ambulating in the common area of the unit. The nurse wrote (excerpts typed as written), "... (Resident's name) is experiencing pain. right hip sore-per resident. ..." On 12/12/10 at 21:14 (9:14 p.m.), Employee #29 wrote the resident was resting in bed at that time. The note included (excerpts typed as written), "Cont(inue) to monitor for bruising/ c/o's (complaints of) pain." On 12/13/10 at 10:29 (8:29 p.m.), Employee #29 noted the resident was sitting in the common area with other residents. It was also noted, "Ambulating slow-gait steady at this time." The next nursing entry was at 19:57 (7:57 p.m.) on 12/19/10 by Employee #29. The resident was note to be ambulating in the common area. She refused to sit down or use a wheelchair. Her gait was noted to be unsteady. On 12/22/10 at 4:38 (4:38 a.m.), Employee #64 (an LPN) noted by that a body audit had been completed with no new areas found. On 12/27/10 at 16:12 (4:12 p.m.), Employee #29 noted the resident was ambulating with an unsteady gait. It was also noted staff had assisted the resident with ambulating several times that day. The nurse wrote (excerpts typed as written), "Res(ident) will sit for a few min's (minutes) then gets up and ambulates." On 12/29/10 at 10:17 (10:17 a.m.), Employee #49 (the director of nursing (DON)), spoke with the resident's son about the resident's lethargy and falls risk. The son stated he would rather not have a lap buddy or seat belt used at that time. Her medications were also discussed with the son - that [MEDICATION NAME] had been discontinued due to the possible side effect of muscle spasms. The psychologist had changed the resident's medication to [MEDICATION NAME], and she appeared to be a little more lethargic. Dosage reduction was to be discussed with a psychiatrist. The next entry was at 15:33 (3:33 p.m.) on 12/31/10 by Employee #113 (an LPN), who wrote (excerpts typed as written), "Res c\o severe pain to R(ight) leg\knee. Visible signs of pain present: teary eyes, moaning\guarding area with movement. This nurse administered Tylenol per standing order. RN supervisor notified and assessed area. Dr. (name) present new orders received for X-ray to R knee and R femur. (X-ray supplier) notified and X-rays ordered STAT (immediately)." On 12/31/10 at 16:33 (4:33 p.m.), it was noted the x-rays had been completed. On 12/31/10 at 22:24 (10:24 p.m.), Employee #64 (an LPN), wrote (excerpts typed as written), "Res c\o severe pain to R leg\knee. Visible signs of pain present: teary eyes, moaning \ guarding area with movement. This nurse administered Tylenol per standing order. X-ray result from (x-ray supplier) are unremarkable. Dr. (name) notified." On 01/01/11 at 04:54 (4:54 a.m.), Employee #113 (an LPN) wrote (excerpts typed as written), " Resident continues to complain of severe R knee and leg pain. Tylenol given per standing order. Will continue to monitor." On 01/01/11 at 09:33 (9:30 a.m.), Employee #113 noted (excerpts typed as written), "Res cont to c\o pain to R knee \ leg. Tylenol per standing order administered at this time." On 01/02/11 at 06:32 (6:32 a.m.), Employee #114 wrote (excerpts typed as written), "Res had c/o pain upon waking this am. Tylenol gave at 6am. Will cont to monitor." In the next entry, at 18:54 (6:54 p.m.) on 01/02/11, Employee #111 (an LPN) wrote (excerpts typed as written), "Resident had continued throughout the day to exhibit s/sx (signs/symptoms) of pain ( facial grimace, moaning, tears) and grabs at right hip when staff attempt to help reposition her. Resident denies pain and states she doesn't know what to do, as explaination as to why she was crying. Spoke with Dr. (name) who ordered STAT xrays of her right pelvis and right hip. [MEDICATION NAME] 5/500mg one by mouth every four hours as needed. Dr. (name) to call in the medication to the pharmacy, have contacted (x-ray supplier) for STAT x-rays. Son, (son's name) notified of n/o's (new orders). ..." The x-rays were noted to have been completed at 21:17 (9:17 p.m.) on 01/02/11. At 23:39 (11:39 p.m.) on 01/02/11, Employee #111 noted the x-ray had shown a "right displace [MEDICAL CONDITION]." She wrote the resident was transferred to the hospital for evaluation and treatment. -- 2. Review of the statements taken during the facility's investigation of the resident's fracture (written as faithfully to the original as possible, with the statements of some individuals having been broken into segments in order to place them in chronological order) found the following: 12/25/10 - Employee #99 (a nursing assistant - NA) - "... Resident was lethargic mood, resident when gotten up in wheel chair, attempted getting up and walking. When she did attempt to walk had a limp on right side, didn't seem to be in pain. Resident wasn't on feet for any length of time because of possible falling on X-mas day. Resident seemed very lethargic for several days, wouldn't hardly eat or drink. Resident seemed to want to sleep a lot... I worked on 12/25/26/28/29/30/31/1 On these days (Resident's name) got out of bed most days between 9 A and 11 A then on Fri, 31st she slept later than usual when resident finally got out of bed she states she was hurting on right side & started crying." 12/31/10, night shift - Employee #105 (NA) - "(Resident's name) was lying in bed awake all night. My self and nurse kept going in there to check on her. When straightened up in bed, resident would turn back to her one side facing the door. The nurse asked her if she was in pain, resident stated that it was never ending. ..." 12/31/10, days / evenings - Employee #113 (LPN) - This nurse noted the resident had slept later than usual. "... the CNA's reported to me the pt was in pain when they brought her into the common's area. Upon assessment, pt had visible s/s of pain. She was holding her right knee, had tears in her eyes and was shaking. I administered Tylenol per physician's standing order. I then call Rehab unit for an RN to come over and assess pt. (Employee #60), RN assess pt. right leg and knee. She stated she would ask Dr. (name) to come over since he was in the building. Dr. (name) came over about 20-30 mins later and examined pt. He ordered a STAT x-ray of right knee and femur. ... completed x-ray around 4:30 p.m. ..." 12/31/10, day shift - Employee #26 (NA) - "On Friday 12-31-10 on 2:00 p rounds (Resident's name) was still in bed. Another aid & I got her up. She would not put any weight on her (R) side. She was tearful and complained of pain while holding her (R) knee. I asked her where she was hurting & she said everywhere. ..." 01/01/11, night shift - Employee #20 (LPN) - This nurse noted the evening shift nurse had told her the resident had been complaining of pain and she had been given Tylenol. "...was in the bed, she was restless during the night but did not attempt to get out of bed. Around 6am this nurse and CNA (Employee 37) went in to do last round on resident. After she woke up she had a grimace on her face. I asked resident if she was in pain and she said 'yes.' We asked her to show us where she was hurting and resident stated 'All over.' I lifted residents R Leg to put on a sock and resident grabed her R side. I went and got resident some Tynenol per standing order . . . I asked the oncoming nurse if she could try to get (Resident's name) something stronger for pain and I told her how she had grabed at her R side when I lifted her leg." 01/01/11, day shift - Employee #26 (NA) - "On Saturday 1-1-11 she complained of being in pain all day & refused to eat. . . ." 01/01/11, days / evenings - Employee #113 (LPN) - "... Tylenol administered at 9:30am with am meds. Pt was holding her right knee and had tears in her eyes. ..." 01/01/11, evenings / nights - Employee #37 (NA) - "... At around 4 pm I helped take her to the bathroom, it took two of us because She was telling us the She couldn't stand because She was hurting. I asked what was hurting her and She said 'I'm hurting all over' . She was like that for most of the rest of the shift, tearful and had a pained look on her face... She was up most of the night on the 11-7 shift. She never tried to get out of bed, but She was restless and saying she was hurting. At around six Sunday morning, (Employee #20), LPN & I went in to do our last round and She had finally went to sleep, upon checking her for incontinence she woke up and I asked her if she was still hurting and she said she was. When (Employee #20) picked up her right foot to put her sock on, she grabbed her right leg and grimaced. We asked her where she was hurting and again She said 'All over'. We checked her all over real good while dressing her and found no abrasions or bruised other than two small faint ones on her right buttocks... (Employee #20) gave her some Tylenol. While sitting there, she fell back asleep but still had a pained look on her face. ... " 01/01/11 - Employee #32 - "On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. (Resident's name) did not stand and was watched closely watched in her wheelchair. On December 30, (Resident's name) was up in her wheelchair & made no attempts to get up that day." 01/01/11 - Employee #104 (NA) - "... was in bed complaining of leg pain, after, getting up she complained more to the point of not eating and crying. ..." Employee #104 also noted the resident could not stand on her leg. 01/02/11 - Employee #32 - "On Jan. 1 & 2, I noticed that (Resident's name) was in intense pain. She was crying about her hip. Staff was aware of this. ..." 01/02/11, day shift, Employee #26 (NA) - "... On Sunday 1-2-11 she still complained of being in pain all day long." 01/02/11 - Employee #104 (NA) - "... Cryed in bed and after getting in wheelchair. She was so miserable and crying in pain we put her in the recliner in the common area. She could not stand on her leg either day." 01/02/11 - days / evenings, Employee #111 (LPN) - "... Resident slept until right before lunch in the recliner chair. When (Resident's name) woke up, she was tearful, but when I asked her if she was hurting, she said 'no'. I asked her in several different ways if she was hurting, but she kept denying pain and stated, 'I just don't know where I am or what I'm supposed to do.' ... Throughout the shift, I administered Tylenol to (Resident) as ordered just to be sure that she wasn't experiencing pain. The Tylenol did not affect her tearfulness." She also noted she had tried to contact Dr. (name) at 1400 (2:00 p.m.), but contact was not made until 1830 (6:30 p.m.) She told him about the resident's "persistent tearfulness and guarding when awake. ..." An x-ray was ordered and at approximately 2330 (11:30 p.m.) received x-ray reports that the resident had a displaced [MEDICAL CONDITION] hip, and she was transferred to the hospital. 01/02/11, evenings / nights - Employee #37 - "I came back on at 3pm, (Resident's name) was asleep in beige recliner. She slept most of the evening but kept her hand on her right leg. She was gotten up and toileted before dinner, took 2 of us just like the night before. She ate (was fed) very little dinner saying she was tired of hurting and had tears in her eyes. This aide did not put her to bed but as I was putting her roommate to bed, she was lying in bed and crying, saying, 'I can't take this pain anymore'. After finishing with her roommate, I checked on her, tried to reposition her to make her a little more comfortable but nothing really helped. After that we kept making 15 min - ? hr checks on her until she was sent out." 01/02/11, night shift - Employee #20 (LPN) - "I came back in Sun night (1-2-11) for 11-7 shift. The nurse (nurse's name) that worked that day + evening gave report on (Resident's name). She said that she had got a order for [MEDICATION NAME]. I received a phone call about the x-rays and that (Resident's name) (R) hip was broken. ..." The resident was sent out to the hospital. -- 3. The physician's progress note for 12/31/10 included, "C/O pain (R) thigh & knee area. (Symbol of 'no') knee swelling. Able to extend knee. No perceptible tenderness but the pain is really hurting her/c crying, etc." -- 4. Review of the medication administration records found she had been given Tylenol, according to the front sheet of the medication administration records (MAR) as follows: on 12/31/10 at 2:00 p.m. and 9:00 p.m.; on 01/01/11 at 3:30 a.m., 9:30 a.m., and 5:00 p.m.; and on 01/02/11 at 6:00 a.m., 9:00 a.m., and 3:00 p.m. This was a total of eight (8) doses. - The back of the MARs indicated the resident received Tylenol for pain as follows: On 12/31/10: - At 2:00 p.m. for "C/O pain (R) knee/leg", with no results documented - At 9:00 p.m. for "C/O pain (R) knee/leg", with the results charted as "(-)" (a minus sign that was circled) On 01/01/11: - At 3:30 a.m. for "C/O (R) knee & leg pain, with the results charted as "(-)" - At 9:30 a.m. for "C/O (R) leg/knee pain", with no results charted - At 5:00 p.m. for "C/O (R) leg/knee pain", with no results charted On 01/02/11: - At 6:00 a.m. for "C/O (R) leg pain", with the results charted as "(-)" This was a total of six (6) doses. - On 01/24/11 at 6:05 p.m., Employee #29 (LPN) was asked about the minus signs. She said, "If you don't get a plus you need to do something else." Review of the nursing entries and MARs, regarding the administration of Tylenol, found it was given regardless of the severity of the pain. The pain was not rated consistently, and there were only three (3) of eight (8) doses that had been evaluated for effectiveness. The physician's orders [REDACTED]." However, it was not noted the resident complained of a headache during this time. Tylenol is for mild to moderate pain. Although the resident was noted to have severe pain at times, there was no evidence staff contacted the physician for an [MEDICATION NAME] that would control the resident's pain. According to the controlled medication book, the [MEDICATION NAME] had arrived at 11:00 p.m. on 01/02/11. No doses were signed out in the book, nor charted on the Medication Administration Record, [REDACTED] -- b) Evidence of the facility's identification and correction of the deficient practice related to pain management 1. On 01/24/11 at approximately 6:15 p.m., the director of nursing (DON) provided copies of two (2) "One on One Education" forms. One (1), date 01/07/11, was for Employee #56 (an RN). The concern was "not adequately assessing resident for pain or pain relief. Pain assessment and change of condition not initiated /c (with) new onset of pain." The corrective action needed to remedy concerns: "Must ensure that all resident are as free of pain as possible. Must complete pain assessment & change of condition /c any new onset of pain. Must notify physician of resident need and obtain adequate medication." Another education form was completed on 01/07/11 for Employee #113 (an LPN). It had essentially the same information as the other. As the DON pointed out, the RN was responsible for assessing resident and the LPN was responsible for evaluation of the resident. The DON said another form had been completed for another nurse, but she was unable to locate that document prior to exit. -- 2. The DON also provided a copy of an in-service on "Pain Management" that had been provided to staff. This addressed evaluation of pain, notification of the physician, continued assessment of the resident for the presence of pain - either verbal or observation of non-verbal indicators, documentation of evaluations, care planning, assessment and documentation of the effectiveness of pain interventions, notification of the physician when pain medications were ineffective, and so on. -- 3. The administration of pain medications to Resident #50 after her return from the hospital was reviewed. Page 204 of the "Controlled Substances Book" indicated she received [MEDICATION NAME] 5/500 at 9:00 p.m. on 01/13/11. She received a total of three (3) doses of [MEDICATION NAME] at this dosage. Page 206 indicated she received [MEDICATION NAME] 10/500 for two (2) doses on 01/19/11 and five (5) doses on 01/20/11, then it was discontinued. Page 211 of the book indicated she had been started on [MEDICATION NAME] 12 mcg patches. These had been applied on 01/21/11 and 01/24/11. Page 212 indicated the resident had been started on [MEDICATION NAME] 5/325. She received four (4) doses on 01/21/11, four (4) doses on 01/22/11, two (2) doses on 01/23/11, and two (2) on 01/24/11. -- 4. The controlled substances book was randomly reviewed with regard to the administration of [MEDICATION NAME]. No issues related to usage were noted. -- 5. The resident was observed in the common area of Mary's Garden on 01/25/11, after lunch. She did not appear to be in pain or exhibit non-verbal indicators of pain. Other residents in the common area were randomly observed and none demonstrated any indicators of pain. General observational tours of the other units did not find any visual or auditory indicators of residents experiencing pain or discomfort. -- 6. The records of Residents #41 and #53, both had sustained falls, were reviewed. No issues related to pain management were found. -- 7. On 01/25/11 at 12:42 p.m., the DON said they had done pain assessments on everyone in the building after the occurrence with Resident #50. -- 8. Based on the staff interviews, observations, review of medical records, and review of other facility documents, it was determined the had identified the deficits in care provided to Resident #50 with respect to assessment of her pain, relevant documentation, administration of [MEDICATION NAME], evaluation of the efficacy of [MEDICATION NAME], notification of the physician, and other related aspects of pain management. Staff had been provided with needed training and those involved had been given one-on-one educational counseling. It was therefore determined the facility had identified the deficient practice and implemented corrective actions to prevent recurrence. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at ?483.25 - Quality of Care.

Based on record review and staff interview, the facility failed to provide adequate supervision and/or assistive devices for one (1) of five (5) residents reviewed to prevent avoidable accidents. Resident #89, who had experienced a decline in physical condition and was diagnosed with [REDACTED]. There was no evidence the facility evaluated the resident's ability to be unsupervised in the wheelchair due to her condition at 9:00 a.m., her weakened condition due to pneumonia, and her potential weakness as the result of refusing both meals prior to the fall. The resident was not assessed to determine whether supervision to avoid an accident was necessary. The facility had not evaluated the risk of this resident having an avoidable accident or implemented any interventions to reduce the risk of a fall. Later that day, the resident was gotten out of bed and placed in a wheelchair so an air mattress could be placed on the bed. She was unsupervised in the wheelchair and was found on the floor at 4:23 p.m. on 10/13/10. She sustained injuries and required hospitalization . There was no evidence that staff, who placed her in the wheelchair, had been made aware the resident was put to bed earlier in the day because she was leaning forward in her wheelchair. Subsequently, the resident experienced a fall from the wheelchair with injuries. Resident identifier: #89. Facility census: 88. Findings include: a) Resident #89 When reviewed on 11/17/10 and 11/18/10, the medical record of Resident #89 disclosed this [AGE] year old female had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - On 10/13/10 at 9:00 a.m., a nursing note stated, "Resident up in w/c (wheelchair) with 1 person assist leaning (sic) forward in w/c assisted resident back to bed." A nursing note, dated 10/13/10 at 9:31 a.m., stated, "Resident's daughter was upset over finding her mother slumped in her bed ...Resident has shown a steady decline over last several months. Oral intake is poor. Resident refuses to be fed." A nursing note entry dated 10/13/2010 at 15:57 (3:57 p.m.) described that the resident was propelling herself in the wheelchair, and was found in the floor. Further review of the medical record revealed no interventions relative to safety and/or to prevent further falls. An additional nursing note, on 10/13/10 at 16:23 (4:23 p.m.), stated, "Notified by staff that resident was found in the floor. Resident had been gotten out of bed to place air mattress on bed. Resident had been wheeling self about facility and then was found in the floor on A hall. Resident was found face down with a laceration to the R (right) eyebrow and cheek. Complained of pain to R hip." The resident was transported to an area hospital. The medical record described the residents weakened Physical condition and continued decline. Documentation in the resident's medical record described a slow decline in her physical condition from the time of admission. The resident had acquired Clostridium difficile (C. diff - a condition that results in frequent diarrhea) after admission to the facility on [DATE] and, following treatment, had a negative stool culture on 10/05/10. The resident was diagnosed with [REDACTED]. The resident's oral intake was minimal from the time of admission. The resident's weight record stated an admission weight of 139.5# on 07/28/10 and a weight of 131# on 10/06/10. On 08/06/10, the resident was placed on the medication Megace to increase her appetite, and it was discontinued on 10/01/10. Meal intake reviews showed that, shortly before her hospitalization on [DATE], the resident's meal intake ranged from 0% (refusal) to 50%. The resident refused both meals prior to her fall and hospitalization on [DATE]. - A facility's occupational therapist (OT - Employee #3), who had worked with Resident #89 until shortly before her fall with injury, was interviewed at 10:30 a.m. on 10/18/10. When asked about her experiences with the resident and the resident's condition, the OT stated the resident had had a slow decline in her condition almost from the time of admission and, in the last few days prior to discontinuation of services, the resident had been less responsive and unable to follow direction. A nursing note, dated 10/06/10, stated, "Resident to be discharged from therapy services today." - The facility's director of nurses (DON), when interviewed on 11/18/10 concerning the resident's fall, stated she was fully aware of the resident's decline in several areas, to include her bout of [DIAGNOSES REDACTED], poor appetite and meal refusals, weight loss, and pneumonia, but that the resident had remained able to sit upright in her wheelchair. The DON did not know if facility staff who placed her in the wheelchair were aware the resident had been unable to sit up earlier in the day. The DON further confirmed the resident had not been re-evaluated for her ability to be independent in her wheelchair as her condition declined.