Every finding on record at Maverick Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the resident had a right to be treated with respect and dignity including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 1 of 4 residents (Resident #1) reviewed for restraints.The facility failed to protect Resident #1 from a physical restraint with a wheelchair.This failure could place residents at risk of abuse with emotional injury, isolation and a decreased quality of life. The findings included: Record review of Resident #1's face sheet dated 8/18/2026 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that slowly destroys memory, thinking, skills, and the ability to carry out simple tasks), hypertension (elevated blood pressure), diabetes type 2 (body's inability to produce enough insulin), severe dementia (a decline in mental ability severe enough to interfere with daily life) with anxiety (natural response to stress) and other behavioral disturbances (sudden or ongoing change in how a person acts that disrupts daily life, causes safety risk).Record review of Resident #1's CP dated 5/5/2026 revealed the resident was care planned for behavior with sexual comments, potential to be physically aggressive, communication problems, and falls. Resident #1 was not care planned for the use of restraints to prevent falls. However, interventions care planned for falls were increased monitoring, soft helmet to be placed on resident's head, and monitor close to nurses' station while awake.Record review of Resident #1's QMDS dated [DATE] revealed the resident could not have a BIMS score obtained due to severe cognitive deficits. Further review revealed the resident required total assistance with all ADLs. The resident's QMDS was not coded for restraints.Record review of Resident #1's physician orders dated 8/18/2026 revealed no physician orders for restraints.During an observation and interview on 8/18/2026 at 2:10PM, Resident #1 sat in the dining room in a wheelchair with the back of the wheelchair against the wall, chair locked, and a dining table was in front of her. When LVN A was asked about the position of Resident #1, LVN A stated, she's like that because she was being watched and because she falls. The wheelchair is locked. RN B saw the resident sitting against the wall with the table in front of her. RN B was asked if that was appropriate to do and RN B stated it was not because it was a restraint. RN B said a restraint should not be used because Resident #1 had the right to stand, walk, and be free to move.During an interview on 8/19/2026 at 1:00PM, the DON said the facility was restraint free and it was important for residents' rights to be respected and ensure they had free mobility without restraints to maintain a good quality of life. The DON said LVN A was a new nurse and thought that when she placed the resident in that position, she would be safe from falling. During an interview on 8/20/2026 at 10:08AM CNA C said she had not seen anyone restrained on the secured unit with their wheelchair against the wall and blocked with a table. She said usually, when Resident #1 would walk, they would try to catch Resident #1 and walk with her to ensure the resident did not fall. CNA C said she had training for Abuse and Neglect, and she knew restraints were a part of the training. During an interview on 8/20/2026 at 12:28PM CNA D said she had never seen Resident #1 or anybody else locked behind a table in a wheelchair. CNA D said no one on the unit did that because it was a restraint and the residents had the right to be free. CNA D said it was their responsibility to make sure the residents were safe, although it could be difficult to catch them before they had a fall. CNA D said she did not know why LVN A did that to Resident #1. CNA D said, when residents that had falls but could still walk, we would try to walk with them around the unit with a gait belt if the residents would allow them to use it with them walking. During an interview on 8/21/2026 at 4:05PM, LVN A said it was not appropriate for Resident #1 to be restrained because Resident #1 had the right to stand and walk. LVN A said she thought since Resident #1 had a fall previously, that it would keep her safe from falling again. She said she had not seen anyone else doing that with Resident #1. Record review of the facility's policy titled, Restraints, dated 8/15/2022 stated in part, each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience; as a definition, Physical Restraints refers to any manual method attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Under the definition of restraints: Using devices in conjunction with a chair such as tables; Placing a chair close enough to a wall that the resident is prevented from rising out of the chair.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 2 Residents (Resident #1 and Resident #2) reviewed for resident rights. CNA E failed to sit down while feeding Resident #1 and Resident #2 during the dinner meal on 6/25/26. This deficient practice could place residents at risk to feelings of poor self-esteem. The findings were:1.Record review of Resident #1's face sheet, dated 6/27/26, revealed he was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia, severe, with other behavioral disturbance (severe cognitive decline where the exact type of dementia is not specifically identified, but the severity and behavioral disturbances are clearly documented), unspecified protein-calorie malnutrition (caused by insufficient intake of protein and calories, leading to impaired body function and tissue loss) and adult failure to thrive (is a syndrome of progressive decline in weight, nutrition, physical function, and cognitive or emotional health). Record review of Resident #1's Care Plan, revised on 9/9/25, revealed The resident has an ADL self-care performance deficit r/t arthritis (range of conditions involving joint inflammation) and SOB and one of the interventions included the resident requires supervision with set up by staff to eat. Record review of Resident #1's 5-day MDS assessment, dated 6/10/26, revealed his BIMS score was 3 of 15 reflective of severe cognitive impairment and he was on a mechanically altered diet. 2. Record review of Resident #2's face sheet, dated 6/27/26, revealed she was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia, severe, with other behavioral disturbance (severe cognitive decline where the exact type of dementia is not specifically identified, but the severity and behavioral disturbances are clearly documented), unspecified Dementia, severe, with anxiety and other specified persistent mood disorders (chronic mood disturbances that do not meet full criteria for major depressive disorder or bipolar disorder). Record review of Resident #2's Care Plan, dated 3/27/26, revealed Resident receives regular, pureed texture, regular liquids diet. has an ADL self-care performance deficit r/t dementia and the resident requires limited assist by staff to eat. Record review of Resident #2's quarterly MDS assessment, dated 5/8/26, revealed her BIMS score was 3 of 15, reflective of severe cognitive impairment, she required substantial/maximal assistance with eating, and she was on a mechanically altered diet. Observation and interview on 6/25/26 at 5:55 PM in the secured unit revealed CNA E fed Resident #1 and Resident #2 at one of the dining room tables. CNA E was standing while feeding the residents. Resident #1 and Resident #2 looked up at CNA E as she fed them. Interview with CNA E revealed she should be sitting but when she started feeding the residents there were no chairs. She stated she gave her chair to one of the residents. Observation revealed there was an empty chair at one of the other dining room tables along the back wall. CNA E stated she had not seen it. She stated she should be sitting while feeding Resident #1 and Resident #2 so she could be at the resident's eye level. CNA E stated standing might cause the residents to feel overwhelmed and uncomfortable. Interview on 6/25/26 at 6:10 PM with ADON D revealed he was in charge of the secured unit. He stated he saw CNA E standing while feeding Resident #1 and Resident #2 and commented she knew better and should sit while feeding the residents. ADON D stated standing over residents while they ate might make them feel inferior and uncomfortable while eating. Interview on 6/26/26 at 3:46 PM with LVN A revealed she worked in the secured unit on 6/25/26. She stated she did not notice CNA D was standing while feeding Resident #1 and Resident #2. She stated staff would want to be at the resident's level to ensure they could see if the resident was choking. LVN A stated it could also affect the resident's dignity, maybe make the resident feel uncomfortable or maybe even vulnerable. Record review of the facility's, undated, policy, Statement of Resident Rights, read You have the right to: (4) be treated with courtesy, consideration and respect.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status (that was, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 Residents (Resident #5) reviewed for notification of changes. RN F failed to consult with Resident #5's physician when she administered two 100 mg tablets instead of two 50 mg tablets of Senna-Docusate.RN F failed to consult with Resident #5's physician when she was unable to successfully re-inject an IV into Resident #5's hand for the administration of Vancomycin (anti-biotic therapy) for the diagnosis of MRSA (Methicillin-resistant Staphylococcus aureus). These deficient practices could affect any resident and could result in a decline of the resident's health status. The findings were: Record review of Resident #5's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare (involves the diagnosis, treatment, and management of conditions related to the bones, joints, and muscles) and Driver injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter. Resident #5 was her own responsible party, and she had been discharged from the facility on 2/14/26. Record review of Resident #5's quarterly MDS assessment, dated 1/19/26, revealed her BIMS score was 15 of 15 reflective of no cognitive impairment. Record review of Resident #5's Care Plan, dated 2/18/26, revealed The resident has constipation r/t decreased mobility, pain and one of the interventions was to monitor/document/report PRN s/sx of complications related to constipation. Record review of Resident #5's order summary report with active orders as of 10/15/25 revealed an order for Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablets by mouth two times a day for constipation; Vancomycin HCl Intravenous Solution Reconstituted 1 GM (Vancomycin HCl) Use 1 application intravenously at bedtime for MRSA to surgical wound right rear malleolus (refers to the bony prominences on the right ankle) and right medial ankle (inner ankle), start date 11/14/25 until 11/24/25. Record review of Resident #5's MAR for October 2025 revealed she received Senna-Docusate on 10/20/25 but it did not reflect any discrepancies. Record review of Resident #5's MAR for November 2025 revealed on 11/17/26 it was coded 5 for the administration of Vancomycin which was defined as hold/see progress note and on 11/19/25 revealed it was coded 9 for the administration of Vancomycin which was defined as other/see progress note. Record review of Resident #5's progress notes for 11/17/26 and 11/19/26 did not reveal documentation to reflect why Resident #5 did not receive the dose of Vancomycin ABT on these dates or Resident #5's physician was contacted. Telephone interview on 6/25/26 at 11:35 AM with former Resident#5 revealed she had multiple problems during her stay at the facility. She stated she was a nurse as well and she addressed her concerns with nursing staff. Resident #5 stated one evening she received two white pills, a generic brand for stool softener. Resident #5 stated she did not recognize the pills but took them anyway. She stated the more she thought about it the more it bothered her, so she asked RN F to bring her the bottle of pills. She stated RN F returned with another staff member and handed her the bottle of pills. Resident #5 stated she noted the Docusate in the bottle were 100 mg tablets. She stated she told the nurse she was taking 50 mg tablets and not 100 mg tablets. Resident #5 stated she was upset because RN F gave her double the amount of the medication and expressed her frustration to RN F. Resident #5 stated RN F commented it's just a laxative. Resident #5 stated she did not experience any adverse reaction as a result. Further interview with Resident #5 revealed she developed MRSA on her surgical incision and was ordered Vancomycin ABT. She stated on the same night (date unknown) when the medication error occurred, she noticed the drip on the IV was very slow. She alerted RN F who stated there was nothing wrong with the IV. Resident #5 stated she kept asking RN F to check the access point and then after looking at it again, RN F stated it was clogged. Resident #5 stated RN F made two attempts to re-insert the IV on the back of her right hand with no success. Resident #5 stated RN F did not want to try again and left the room without further explanation. She stated RN F did not tell her if she was going to get another nurse or if she was going to call anyone else to assist. Resident #5 stated she did not receive the dose of Vancomycin 1 gram that night. Resident #5 stated she was upset about the lack of communication and what appeared to RN Fs lack of clinical knowledge. Interview on 6/25/26 at 6:25 PM with RN F revealed she remembered Resident #5 getting upset because she administered two 100 mg tablets instead of two 50 mg. tablets of Docusate. RN F stated she did not look at the orders and instead grabbed the OTC bottle of Docusate. She stated she thought Resident #5 was asking for a PRN dose and did not know it was scheduled. RN F stated administering the wrong milligrams could give Resident #5 diarrhea and it would be considered a medication error. She stated she reported the incident to ADON G but did not call the doctor to report the error. Further interview revealed RN F stated she also remembered Resident #5 developed MRSA and was ordered Vancomycin ABT. She stated one night Resident #5 reported the IV was not dripping at a normal rate. She stated she checked and the IVs access point was clogged. RN F stated she attempted to re-inject the IV with two failed attempts which was the maximum amount of times she could try. RN F stated she called ADON G for assistance, and he told her he was not available. RN F stated she did not administer the dose of Vancomycin that night; she stated she could not remember the date. RN F stated she did not call the doctor per facility policy and to get implement any changes per physician orders. She stated she should have followed facility policy. RN F stated Resident #5's infection could have become worse, or they would have had to prolong the ABT because of the missed dose. Resident #5 stated the wound improved but she was concerned the Vancomycin labs would not accurately reflect whether or not it was being effective. Interview on 6/27/26 at 10:13 AM with ADON G revealed he was in charge of the hall where Resident #5 was previously placed. He stated he remembered talking with Resident #5 about RN F giving her two 100 mg tablets of Docusate instead of two 50 mg. tablets. ADON G stated he did not remember the exact conversation he had with Resident #5 and did not remember if RN F called him about it. ADON G stated the incident would be considered a medication error which would require RN F to notify the doctor. ADON G stated after reviewing Resident #5's EHR, there was no documentation that RN F called Resident #5's doctor. ADON G stated as a result of Resident #5 receiving the wrong dose of Docusate, she could have developed diarrhea which could have led to dehydration, or it could have resulted in a negative interaction with other prescribed medications. In addition, ADON G stated he did not remember anyone calling him about not being able to re-inject Resident #5's IV. He stated Resident #5 was receiving Vancomycin, ABT, for MRSA. He stated per policy a nurse could attempt 3 times if the resident allowed and then another nurse could also attempt. If unsuccessful, the charge nurse should call the physician and get a new order to send the resident to the ER for midline or PICC line placement if the resident agreed. ADON G stated not administering Vancomycin per physician orders could affect the Vancomycin lab values; they would read low. He stated the Vancomycin levels had to fall within a therapeutic range to determine the medication was being effective to rid of the infection. ADON G stated such an incident would warrant a call to the physician. ADON G stated per review of Resident #5's EHR, he stated there was not any documentation RN F contacted Resident #5's physician about the incident. Interview on 6/27/26 at 3:00 PM with the DON revealed she was not notified of the incident involving Resident #5 receiving the wrong dose of Senna-Docusate and Resident #5 not receiving a dose of Vancomycin due to the charge nurse not being able to re-insert the IV. She stated she could not speak to the incidents, but stated both incidents required the charge nurse to contact Resident #5's physician and report the change of condition. The DON stated not doing so could contribute to the resident's change in health status.

Based on observation, interview and record review the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 26 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) in that: The facility failed to ensure the vents were cleaned and rid of excess lent in Resident rooms #203, #213 and #215. This deficient practice could place residents at risk of being in an uncomfortable and unsanitary environment.Findings included: Observation on 6/27/26 at 11:35 PM during a tour of the secured unit with ADON D revealed the vents mounted on the ceiling in room [ROOM NUMBER], #213 and #215 and 3 of the vents in the dining room had black residue on the outside of the vents. The vents also had built up lint all around the edging of the vents. Interview with ADON D revealed the dirty vents could cause the residents to develop a respiratory infection and get sick. ADON D stated he understood the MS cleaned the vents on a schedule according to the maintenance application he used but did not know the last time the vents were cleaned in the secured unit. ADON D stated the vents were dirty. Interview on 6/26/26 at 10:30 AM with Resident #3's family member revealed she visited Resident #3 multiple times a week. The family member stated she noticed the vents in Resident #3's room were full of lint. The family member stated this could get Resident #3 sick as well as other residents in the secured unit. The family member stated she reported her concern to ADON D, the MS, the DON and the ADM. She stated the administrative staff did not listen to her. Interview on 6/27/26 at 12:30 PM with the DON revealed the MS was supposed to clean the vents in the secured unit during March 2026 when the concern was brought up to her and the ADM's attention. She stated Resident #3's family member complained about the vents being dirty in the secured unit. Record review of the facility's, undated, policy, General Housekeeping policies, read The facility provides sufficient housekeeping and maintenance personnel, equipment and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust and hazards.

Based on interview and record review the facility failed to ensure the resident had a right to and the facility provided prompt efforts to resolve grievances the resident may have for 1 of 5 Residents (Resident #3) reviewed for grievances. The facility failed to promptly act upon concerns a family member voiced to the ADM and DON on Resident #3's behalf involving her care during her stay in the secured unit. This deficient practice could place residents at risk of not being made aware of any corrective actions taken by the facility leading to frustration. The findings were: Record review of Resident #3's face sheet, dated 6/27/26, revealed she was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with late onset (developing after age [AGE] and characterized by progressive memory loss and cognitive decline) and Dementia in other Diseases classified elsewhere, severe, with other behavioral disturbance (severe cognitive decline where the exact type of dementia is not specifically identified, but the severity and behavioral disturbances are clearly documented). Record review of Resident #3's quarterly MDS assessment, dated 6/12/26, revealed her BIMS was 0 of 15 reflective of severe cognitive impairment. Record review of Resident #3's Care Plan, dated 8/22/23 revealed Admit to Cognitive Impairment Unit d/t poor safety awareness r/t to Dementia and high risk for elopement. One of the interventions was to Try to keep a routine such as bathing, dressing, and eating. Record review of incident/accident log for Resident #3 from October 2025 to June 2026 revealed the following incidents:On 10/17/25 Resident had a skin tear to her lower leg (shin area). CNA reported and Resident #5 was unable to state what happened. Cleansed with normal saline, pat dried, cleaned with st. gauze and covered with st. gauze.On 10/27/25 Resident had a skin tear on her right arm near the elbow. Noted a scant amount of blood to area. Cleansed with normal saline, pat dried, cleaned with st. gauze and covered with st. gauze. Resident unable to state what happened.On 12/26/26 Resident had abrasion to right foot 3rd toe and intact blister on right foot 4th toe. Wound care nurse provided treatment. Resident was unable to state what happened.On 1/24/26 Resident sustained skin tear to right shin while CNAs were transferring Resident from chair to bed. Resident sustained skin tear. Injury occurred due to sharp skin tie end attached to foam on chair. Family member expressed concern through camera and nurse explained what happened.On 1/28/26 read Female resident residing in the memory care unit was found in her room during routine CNA rounds with a male resident lying next to her in bed. Both residents appeared to be asleep at the time of discovery. No physical contact, sexual activity or inappropriate behavior was observed. Resident was unable to state what happened. Male resident was promptly removed from the room. Nurse assessed Resident and no injuries, redness, bruising or skin breakdown noted. Resident denied pain, at normal baseline.On 4/24/26 Resident had skin tear on outer forearm. CNA reported noted it when getting Resident ready to the dining room. Noted active bleeding. Area cleansed and appropriate dressing applied. Resident unable to state what happened.On 6/3/26 Resident had a skin tear on right medial calf. It was noted during wound treatment. Resident unable to state what happened. Area assessed by treatment nurse and cleansed per facility protocol. Record review of a letter written by Resident #3's family member, dated 3/27/26 and submitted to corporate office revealed the following concerns r/t Resident #3: a. skin tears incurred by Resident #3 on her arms and legs on multiple consecutive weeks.b. the lack of adequate nursing staff, lack of experience by some of the nursing staff and the lack of rounding on Resident #3 during the night shift by nursing staff;c. the lack of supervision in the secured unit leading to a male Resident (Resident #4) wandering into Resident #3's room on one occasion and lying in bed with Resident #3 for at least 30 minutes and on the second occasion Resident #4 laid in Resident #3's bed and was found sleeping for an underdetermined period of time. Record review of the facility grievances from October 2025 to June 2026 did not reveal any grievances related to the letter Resident #3's family member submitted to the corporate office dated 3/27/26. Interview on 6/26/26 at 10:13 AM with Resident #3's family member revealed she was disappointed and very unhappy with the care Resident #3 was receiving in the secured unit at the facility. She stated she tried to address her concerns with administrative staff including the ADM, DON, HR and ADON D to no avail. She stated they would not listen to her, consider her suggestions and would not provide answers to any of her questions regarding the skin tears she noted on Resident #3 or the incident when the male Resident walked into Resident #3's room. The family member stated she saw it on the camera and the male resident walked in and laid in bed with Resident #3 for about 30 minutes. She stated he would stick his left hand into his pants and with the same hand would lightly tap Resident #3's arm, chest area (over her gown) and tap his hand on her hair. The family member stated the male resident did not touch Resident #3 inappropriately but was disgusted by what she was viewing and did not understand how the facility could allow this to happen. The family member stated she would watch the footage on the camera in Resident #3's room and would often note the CNAs would not check in on Resident #3 between 10 and 12 hours at a time. She complained about the lack of supervision and stated Resident #3 was found on the floor. The family member stated she often complained to administrative staff about the lack of nurse staffing or the lack of experience some of the staff had who were assigned to the secure unit. She stated there were a number of CNAs who were exceptional and suggested to administrative staff assign these particular staff to work in the secured unit on a regular basis. The family member stated she was tired of staff ignoring her and decided to escalate her concerns and submitted a letter to the facility's corporate office and to HHSC. She stated to date no one from the facility had contacted her to address her concerns. Interview on 6/25/26 at 9:30 AM with the DON revealed Resident #3's family member submitted a lengthy letter to the corporate office. She stated she, the ADM and a Corporate Representative had a telephone conference with the RP. She stated they reviewed the letter and discussed the concerns with the RP as documented on the letter. The DON stated the RP did not express any concerns r/t care and was grateful Resident #3 was placed in the facility. The DON stated the RP told her she reviewed the video r/t the family member's concern involving the male resident who was lying in bed with Resident #3. The RP stated the male resident did not touch Resident #3 in a sexual manner; he laid in bed with Resident #3 but did not touch her inappropriately. The DON stated she completed two grievances and provided nursing staff an in-service r/t the letter the family submitted to the corporate office on 3/27/26 but again stated she discussed the findings with the RP. The DON stated she informed the family member staff were trained to manage resident's behaviors with a dementia diagnosis. She stated they did not have dedicated staff in the secured unit but all staff who worked in the unit received dementia training. Interview on 6/26/26 at 9:00 AM with the DON and ADM revealed the ADM was the grievance officer. The ADM stated he would appoint the grievances to department heads as the grievance applied to their department. The department heads would address the reported concerns and return the grievance back to him. He stated he also addressed a lot of the concerns himself, and he would call the person submitting the grievance to discuss corrective action the facility took to resolve the concerns. The ADM stated most individuals who he talked to were satisfied with the resolution. The ADM and DON stated their corporate office forwarded the letter the family member submitted to them. The DON again re-iterated details provided per the discussion on 6/25/26 at 9:30 AM. She and the ADM both stated they discussed the concerns provided in the letter written by the family member with the RP. They stated they addressed concerns r/t Resident #3's care right away with the RP but did not include the family member in any of their discussions. The DON stated the family member requested incident reports r/t Resident #3's s/t's and demanded explanations. The DON stated nursing staff would report all incidents to the RP. The ADM and DON stated the RP gave them permission to share information with the family member but made it clear she was the decision maker. They stated to avoid conflict they discussed concerns r/t to Resident #3's care with the RP even though they both stated typically the process would require they discuss the concerns and resolution with the person who reported the concern or who submitted a grievance. The ADM and RP stated they understood why Resident #3's family member believed they did not listen to her or believed nothing was being done. They stated they thought the RP and the family member talked about corrective action taken by the facility regarding any concerns the family member presented to them. Record review of the facility's policy, Resident and Family Grievances, dated 10/4/25, read It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal.Prompt efforts to resolve include facility acknowledgement of a complaint/grievance and actively working toward resolution of the complaint/grievance.1. Administrator has been assigned as the Grievance Officer.2. The Grievance Officer is responsible for overseeing the grievance process; receiving and tracking through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with the grievance; issuing written grievance decisions to the resident and coordinating with state and federal agencies as necessary in light of specific allegations.4. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns related to their LTC facility stay.7. Grievances may be filed in the following forums:a. Verbal complaint to a staff member or Grievance official.b. Written complaint to a staff member or Grievance official.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 Residents (Resident #1) reviewed for ADL's. Nursing staff failed to change Resident #1's shirt which was covered with skin flakes all over his chest area. This deficient practice could place residents at risk to feelings of dissatisfaction or poor self-esteem. The findings were: Record review of Resident #1's face sheet, dated 4/27/26, revealed he was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia, severe, with other behavioral disturbance (serious cognitive disorder marked by profound memory loss and significant behavioral changes), unspecified protein-calorie malnutrition (condition caused by insufficient intake or absorption of protein and calories, leading to impaired body function and tissue loss) and adult failure to thrive (syndrome of progressive decline in weight, nutrition, physical function, and cognitive or emotional health). Record review of Resident #1's Care Plan, dated 9/9/25, revealed The resident has an ADL self-care performance deficit r/t arthritis and SOB and one of the interventions included The resident requires limited assistance by staff to dress. Record review of Resident #1's 5-day MDS assessment, dated 6/10/26, revealed his BIMS score was 3 of 15 reflective of severe cognitive impairment. Resident #1 required substantial/maximal assistance with upper body and lower body dressing. Observation and attempted interview on 6/24/26 at 5:00 PM with Resident #1 revealed he was sitting at one of the dining room tables. He was leaning to the right side. He had a black sweatshirt on with multiple white speckled debris covering his chest. Attempted interview with Resident #1 revealed he did not respond to questions. Interview with LVN A revealed she did not know what was on Resident #1's shirt. She stated maybe it was something he ate earlier for lunch. Further interview with LVN A revealed she had not noticed the front of Resident #1's shirt was full of white debris, but staff should change a resident's shirt when it was dirty. Observation on 6/24/26 at 5:20 PM revealed CNA B approached Resident #1 who was sitting at one of the dining room tables. Interview with CNA B revealed she had not noticed Resident #1's shirt was dirty. ADON D joined CNA B and Resident #1. CNA B asked Resident #1 if he wanted her to change his shirt. He nodded, yes, and she propelled him out of the dining room. Interview on 6/24/26 at 6:00 PM with ADON D revealed he saw the front of Resident #1's shirt was full of white residue of some sort. He stated he did not see it until it was pointed out. ADON D stated the CNAs should help the residents maintain good hygiene by ensuring they were clean. ADON D stated it could be a dignity issue if Resident #1 felt embarrassed because he had on a dirty sweatshirt. He stated Resident #1 was cognitively impaired and probably would not notice his shirt was clean, but he might feel different if he was not cognitively impaired or a family member might be bothered Resident #1 was wearing a dirty shirt. Interview on 6/26/26 at 3:26 PM with LVN A revealed Resident #1's sweatshirt (chest area) was full of skin flakes. She stated she saw a few dry skin flakes on his neck before but never saw that many flakes on his person. LVN A stated any nursing staff who saw his shirt dirty should change it and keep him clean. LVN A stated it might be a dignity issue and Resident #1 might feel bad about himself while sitting in the dining room with a dirty shirt. Record review of the facility's policy, Activities of Daily Living (ADLs), dated 5/26/23 read The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure: Care and services will be provided for the following activities of daily living:bathing, dressing, grooming and oral care .

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 (Resident #4) reviewed for accidents and hazards. Nursing staff failed to ensure they cleaned up a puddle of water on the floor underneath Resident #4's chair during dinner time. This deficient practice could place residents at risk and of avoidable accidents. The findings were: Record review of Resident #4's face sheet, dated 6/27/26, revealed he was admitted to the facility on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, severe with other behavioral disturbance (occurs as a manifestation of another underlying disease), Alzheimer's disease with late onset (developing after age [AGE], characterized by progressive memory loss, cognitive decline, and changes in judgment and behavior) and Anxiety Disorder (frequently have intense, excessive and persistent worry and fear about everyday situations). Record review of Resident #4's Care Plan, dated 11/11/25 revealed Resident at risk of episodes of hypotension (low blood pressure with symptoms including dizziness and nausea), the resident is at high risk for falls r/t unsteady gait, history of falls, poor safety awareness. Interventions included needs a safe environment with: (SPECIFY: even floors free from spills. Record review of Resident #4's significant change in status MDS assessment, dated 6/10/26 revealed his BIMS score was 3 of 10 reflective of severe cognitive impairment. Observation and interview on 6/25/26 at 5:57 PM revealed Resident #4 sitting at one of the dining room tables eating dinner in the secured unit. Resident #4 was sitting and there was a large puddle of liquid underneath his chair. The staff were busy assisting other residents. Interview with LVN A revealed she did not see the puddle of what she thought was water. She went to get a towel and placed it over the puddle of liquid. LVN A stated Resident #4 was able to walk and was a fall risk. She stated the spilled water was a safety hazard. LVN A stated Resident #4 could slip and fall if he stepped on the spill. Interview on 6/25/26 at 6:10 PM with ADON D revealed he was in charge of the secured unit. He stated he did not see the spilled water underneath Resident #4's chair. ADON D stated the resident ambulated, was not steady and could slip and fall if he stood up and stepped on the water. He stated staff should be proactive and always consider the safety of the resident's first. ADON D stated Resident #4 could sustain injuries from a fall. Interview on 6/26/26 at 3:46 PM with LVN A revealed she did not believe the puddle underneath Resident #4's chair was urine because his pants were not wet and it did not smell like urine. LVN A stated Resident #4 was a fall risk because sometimes he tried to run and was not oriented to self or his surroundings. LVN A stated it was the responsibility of nursing staff to ensure the resident environment was free of accident hazards and should always be aware the surroundings. LVN A stated working the secured unit was a challenge because the residents were active, some would spontaneously stand and walk around while attending to another resident. She stated they had to be constantly looking around and watching the residents because they were a fall risk. LVN D stated the residents could get hurt if they had a fall. Record review of the facility's, undated, policy Fall Prevention Program, read Falls can cause people to restrict their activities, lead to depression, helplessness, social isolation, loss of confidence in independent mobility, injuries and even death. Most falls occur as a result of multiple intrinsic and extrinsic factors. A successful fall risk management program requires organizational commitment and an interdisciplinary team approach to prevent and minimize falls. Care Plan: A current care plan for fall risk management and injury prevention includes: Measurable goals for fall risk management and injury prevention.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals) to meet the needs of each resident for 1 of 5 Residents (Resident #5) reviewed for pharmacy services. RN F failed to administer the correct milligrams of Senna-Docusate to Resident #5. This deficient practice could place residents at risk of diarrhea and dehydration. The findings were: Record review of Resident #5's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare (involves the diagnosis, treatment, and management of conditions related to the bones, joints, and muscles) and driver injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter. Resident #5 was discharged from the facility on 2/14/26. Record review of Resident #5's physician's order summary report with active orders as of 10/15/25 revealed an order for Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth two times a day for constipation. Record review of Resident #5's quarterly MDS assessment, dated 1/19/26, revealed her BIMS score was 15 of 15 reflective of no cognitive impairment. Record review of Resident #5's Care Plan, dated 2/18/26, revealed The resident has constipation r/t decreased mobility, pain and one of the interventions was to monitor/document/report PRN s/sx of complications related to constipation. Record review of Resident #5's MAR for October 2025 revealed she received Senna-Docusate on 10/20/25 but it did not reflect any discrepancies. Telephone interview on 6/25/26 at 11:35 AM with former Resident#5 revealed on 10/20/25 she received two white pills, a generic brand for stool softener. Resident #5 stated she did not recognize the pills but took them anyway. She stated the more she thought about it the more it bothered her, so she asked RN F to bring her the bottle of pills. She stated RN F returned with another staff member and handed her the bottle of pills. Resident #5 stated she noted the Docusate in the bottle were 100 mg tablets. She stated she told the nurse she was taking 50 mg tablets and not 100 mg tablets. Resident #5 stated she was upset because RN F gave her double the amount of the medication and expressed her frustration to RN F. Resident #5 stated RN F commented it's just a laxative. Resident #5 stated she did not have an adverse reaction as a result. Interview on 6/25/26 at 6:25 PM with RN F revealed she remembered Resident #5 getting upset because she administered two 100 mg tables of Docusate instead of two 50 mg. tablets of Docusate. RN F stated she did not look at the orders and instead grabbed the OTC bottle of Docusate. She stated she thought Resident #5 was asking for a PRN dose and did not know it was scheduled. RN F stated administering the wrong milligrams would be considered a medication error but did not complete a medication error report which she was supposed to do. She stated she reported the incident to ADON G. Interview on 6/27/26 at 10:13 AM with ADON G revealed he was in charge of the hall where Resident #5 was previously placed. He stated he remembered talking with Resident #5 about RN F giving her two tablets of Docusate at 100 mg a piece instead of two 50 mg. tablets. ADON G stated he did not remember the exact conversation he had with Resident #5 and did not remember if RN F called him. ADON G stated the incident would be considered a medication error which would require RN F complete a medication error report, notify the doctor and enter a progress note describing the incident. ADON G stated per record review, RN F did not complete a medication error report and there was no documentation that she called Resident #5's doctor. ADON G stated Resident #5 could have developed diarrhea, lead to dehydration or contributed to a negative reaction with other prescribed medications. Record review of the facility's policy, Medication Administration, dated 10/24/22, read Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 1. Identify Resident by photo in the MAR.10. Review MAR to identify medication to be administered.11. Compare medication source (blister pack, vial, etc.) with MAR to verify resident name, medication name, form, source, dose, route and time.17. Sign MAR after administered. 20. Correct any discrepancies and report to nurse manager.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 Residents (Resident #5) reviewed for complete and accurate records. Nursing staff failed to complete a medication error report when RN F administered two 100 mg. versus two 50 mg tablets of Senna-Docusate to Resident #5 and failed to complete an SBAR when she was unable to successfully inject an IV into the back of Resident #5's right hand for the administration of Vancomycin (anti-biotic therapy) for the diagnosis of MRSA. ADON D failed to document a progress note reflecting he notified Resident #5 when an allergy medication was changed from scheduled to PRN administration. These deficient practices could place residents at risk for not having an accurate account of prescribed medications. The findings were: Record review of Resident #5's face sheet revealed she was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare (involves the diagnosis, treatment, and management of conditions related to the bones, joints, and muscles) and driver injured in collision with unspecified motor vehicles in traffic accident, subsequent encounter. Resident #5 was discharged from the facility on 2/14/26. Record review of Resident #5's physician order summary report with active orders as of 10/15/25 revealed an order for Senna-Docusate Sodium Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablets by mouth two times a day for constipation, Vancomycin HCl Intravenous Solution Reconstituted 1 GM (Vancomycin HCl) Use 1 application intravenously at bedtime for MRSA to surgical wound right rear malleolus (refers to the bony prominences on the right ankle) and right medial lateral foot, start date 11/14/25 until 11/24/25, and Loratadine Oral Tablet Chewable 10 MG (Loratadine) Give 1 tablet by mouth one time a day for seasonal allergies. Record review of Resident #5's quarterly MDS assessment, dated 1/19/26, revealed her BIMS score was 15 of 15 reflective of no cognitive impairment. Record review of Resident #5's Care Plan, dated 2/18/26, revealed The resident has constipation r/t decreased mobility, pain and one of the interventions was to monitor/document/report PRN s/sx of complications related to constipation; the resident has infection to surgical wound right rear malleolus and right medial lateral foot. One of the interventions included Administer antibiotic as per MD orders; Resident with dx: seasonal allergies receiving medication. One of the interventions was to administer medication per MD orders.Record review of Resident #5's MAR for October 2025 revealed she received Senna-Docusate on 10/20/25 but it did not reflect any discrepancies. Resident #5 received Loratadine per physician orders. Record review of Resident #5's MAR for November 2025 revealed on 11/17/26 it was coded 5 for the administration of Vancomycin which was defined as hold/see progress note and on 11/19/25 revealed it was coded 9 for the administration of Vancomycin which was defined as other/see progress note. Record review of Resident #5's progress notes for 11/17/26 and 11/19/26 did not reveal documentation to reflect why Resident #5 did not receive the dose of Vancomycin ABT on these dates. Further review did not reveal documentation to reflect Resident #5 received two 100 mg. tablets instead of two 50 mg. tablets of Senna Docusate (laxative) or that the allergy medication, Loratadine was changed from scheduled to a PRN basis during October or November 2025. Telephone interview on 6/25/26 at 11:35 AM with former Resident#5 revealed she had multiple problems during her stay at the facility. Resident #5 stated one evening she received two white pills, a generic brand for a stool softener. Resident #5 stated she did not recognize the pills but took them anyway. She stated the more she thought about it the more it bothered her, so she asked RN F to bring her the bottle of pills. She stated RN F returned with another staff member and handed her the bottle of pills. Resident #5 stated she noted the Docusate in the bottle were 100 mg tablets. She stated she RN F she was taking 50 mg tablets and not 100 mg tablets. Resident #5 stated she was upset because RN F gave her double the amount of the medication and expressed her frustration to RN F. Resident #5 stated RN F commented it's just a laxative. Resident #5 stated she developed MRSA on her surgical incision and was ordered Vancomycin ABT. She stated on the same night (dated unknown) when the medication error occurred, she noticed the drip of the IV was very slow. She alerted RN F who stated there was nothing wrong with the IV. Resident #5 stated she kept asking RN F to check the access point and then after checking it again RN F stated it was clogged. Resident #5 stated RN F made two attempts to re-insert the IV on the back of her right hand with no success. Resident #5 stated RN F did not want to try again and left the room without further explanation. She stated RN F did not tell her if she was going to get another nurse or if she was going to call anyone else to assist. Resident #5 stated she did not receive the dose of Vancomycin that night. Resident #5 also stated she was receiving allergy medication on a scheduled basis and learned the pharmacy changed it to be administered on a PRN basis. She stated she talked to ADON D the morning her throat was feeling swollen with mucous. She stated ADON D told her the pharmacy recommended the allergy medication be administered on a PRN and her physician agreed. Resident #5 stated she expressed concern and frustration because she had been hospitalized in the past when her allergies flared up causing her to have an asthma attack. She stated she did not remember the exact dates when all these incidents took place. Interview on 6/25/26 at 6:25 PM with RN F revealed she remembered Resident #5 getting upset because she administered two 100 mg tablets of Docusate instead of two 50 mg. tablets of Docusate. RN F stated administering the wrong milligrams would be considered a medication error but she did not complete a medication error report. RN F stated Resident #5 developed MRSA and was ordered Vancomycin ABT. She stated one night Resident #5 reported the IV was not dripping at a normal rate. She stated she checked and stated the IVs access point was clogged. RN F stated she attempted to re-inject the IV with two failed attempts. RN F stated she called ADON G for assistance, and he told her he was not available. RN F stated she did not administer the dose of Vancomycin that night; she stated she could not remember the date. RN F stated she did not complete a progress note or COC/SBAR for either incident per facility policy. She stated she should have followed facility policy and documented the incidents to ensure all nursing staff were aware of the changes involving Resident #5.Interview on 6/27/26 at 10:13 AM with ADON G revealed he was in charge of the hall where Resident #5 was previously placed. He stated he remembered talking with Resident #5 about RN F giving her two 100 mg tablets of Docusate instead of two 50 mg. tablets. ADON G stated he did not remember the exact conversation he had with Resident #5 and did not remember if RN F called him about it. ADON G stated the incident would be considered a medication error which would require RN F to complete a medication error report and to enter a progress note about the incident at the time it happened. ADON G stated after reviewing Resident #5's EHR, RN F did not complete a medication error report and did not write a progress note. ADON G further stated he did not remember anyone calling him about Resident #5 did not receiving a dose of Vancomycin. ADON G stated such an incident would warrant the completion of an SBAR and progress note at the time of the incident. He stated per review of Resident #5's EHR, there was not an SBAR or a progress note completed r/t to the incident. ADON G stated he remembered talking to Resident #5 about Loratadine being changed from scheduled to a PRN basis per pharmacy recommendation. He stated ADON D received all pharmacy recommendations and requested he talk to Resident #5 about her concerns regarding the changes. ADON G stated it was important to document all incidents to ensure the accurate accounting of medication administration. Interview on 6/27/26 at 11:06 AM with ADON D revealed he remembered the pharmacy recommended Loratadine, allergy medication, was administered on PRN basis instead of scheduled for Resident #5. He stated he contacted Resident #5's physician and he agreed. He stated he notified Resident #5 of the recommended changes but then a few days later she complained about it stating she should receive it regularly to keep her allergies under control. ADON D stated Resident #5 stated she was experiencing s/sx of not receiving the medication. ADON D stated he should have written a progress note of the changes of his discussion with Resident #5 but did not write a progress note. He stated it was important to document changes so all nursing staff were aware of the changes and for continuity of care. ADON D stated he did not remember the date the changes took place. Interview on 6/27/26 at 3:00 PM with the DON revealed she was not notified of the incidents involving Resident #5 including receiving the wrong dose of Senna-Docusate, (two 100 mg. tables instead of two 50 mg. tablets), her allergy medication being changed from scheduled to PRN and not receiving a dose of Vancomycin due to the charge nurse not being able to re-insert the IV. She stated she could not speak to what happened but stated nursing staff should complete an SBAR and or a progress note per facility policy for any changes of a resident's treatment. The DON stated she would provide a policy for maintaining complete and accurate medical records for the residents. The DON did not provide a policy.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 dining room in that: The facility failed to ensure the vents were cleaned and rid of excess lent in the dining room in the secured unit. This deficient practice could place residents at risk for feeling uncomfortable and lead to cross contamination. Findings included: Observation on 6/24/26 at 5PM in the secured unit revealed residents were walking around the hallway, and some residents were sitting in the dining room. Observation on 6/27/26 at 11:35 PM during a tour of the secured unit with ADON D revealed 3 of the vents in the dining room had black residue on the outside of the vents. The vents also had built up lint all around the edging of the vents. Interview with ADON D revealed the dirty vents could cause the residents to develop a respiratory infection and get sick. ADON D stated he understood the MS cleaned the vents on a schedule according to the maintenance application he used but did not know the last time the vents were cleaned in the secured unit. ADON D stated the vents were dirty. Interview on 6/26/26 at 10:30 AM with Resident #3's family member revealed she visited Resident #3 multiple times a week. The family member stated she noticed the vents in the dining room were especially dirty and covered with lint. The family member stated this could get Resident #3 sick as well as other residents in the secured unit. The family member stated she reported her concern to ADON D, the MS, the DON and the ADM. She stated the administrative staff did not listen to her. Interview on 6/27/26 at 12:30 PM with the DON revealed the MS was supposed to clean the vents in the secured unit during March 2026 when the concern was brought up to her and the ADM's attention. She stated Resident #3's family member complained about the vents being dirty in the secured unit. Record review of the facility's, undated, policy, General Housekeeping policies, read The facility provides sufficient housekeeping and maintenance personnel, equipment and supplies to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. All housekeeping personnel utilize the accepted practices and procedures to keep the facility free from offensive odors, accumulations of dirt, rubbish, dust and hazards.

Based on interview and record review, the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen observed. 1. The facility failed to maintain the temperature for puree bread at 135 F or above. These failures could place residents at risk for weight loss, poor quality of life and food borne illness. The findings included:During an observation on 12/11/2025 at 11:45 a.m., the cook took the temperature of the bread puree on serving line which reached 116 degrees.During an interview on 12/11/2025 at 11:49 a.m., COOK G stated the holding temperature for hot items should be 145 degrees or above. [NAME] G stated they can reheat the item in the microwave if they do not meet holding temperatures. [NAME] G stated the lower temperature could have an increased risk of bacteria in the food. During an interview on 12/11/2025 at 11:53 a.m., the DM stated the holding temperature for hot items should be 135 and above for regulation and safety. The DM stated they can reheat the item in the oven or microwave if foods are not meeting the appropriate holding temperatures. The DM stated there is a risk of poison and safety for residents when holding temperatures are not met. During an interview on 12/12/2025 at 11:23 a.m., the DON stated there had not been any foodborne illness outbreaks in the facility this year.Record review of the facility's policy Food Holding and Service, revised 06/01/2019, stated:1. Serve all hot foods at a temperature of 135 F or greater and all cold food at 41 F or less. Adjust the temperature to account for the time the food will be held prior to service on steam table and on the tray carts. 2. Hold foods prior to service for less than one hour, maintaining the temperatures notes above. Keep foods covered to maintain temperatures except for food that will be served crispy.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage safety. 1.The kitchen had an unsealed cheese bag dated 12/4/2025 in the fridge,2.The kitchen had an unsealed cilantro bag dated 12/5/2025 in the fridge.3.The kitchen had an unsealed pizza dough bag dated 10/26/2025 in the freezer.4.The kitchen had an undated macaroni container in the pantry5.The kitchen had a tomato that appeared to be spoiled in the fridge. This deficient practice could place residents who eat food from the kitchen at risk of foodborne illnesses.The findings include:During an observation on 12/09/2025 at 10:46 a.m. of kitchen refrigerator, the following items were unsealed: cheese bag date 12/04/20205, cilantro bag dated 12/05/2025. Observation of the kitchen refrigerator noted a spoiled tomato. During an observation on 12/09/2025 at 10:46 a.m. of kitchen freezer a pizza dough bag dated 10/26/2025 was observed unsealed. During observation of the kitchen pantry on 12/09/2025 at 10:52am, observation made of undated container containing macaroni pasta. During an interview on 12/09/2025 at 11:04 a.m., the DM stated once items were opened, they were to be put into a Ziploc bag, seal it, date it, and put it away. The DM stated when receiving pasta, she poured the pasta into a container and used a label to date the container. The DM stated tomatoes should be red and fresh and that the tomato found was not. The DM stated if they receive bad produce from the delivery, they return it but if the produce goes bad while at the facility they throw it away. The DM stated other foods can come in contact with unsealed foods and affect the safety of the food. The DM stated there could be a risk to resident safety if they are served non fresh produce. The DM stated the kitchen staff would not know when to and not to use the items if they are not dated. Record review of facility document titled Food Storage, revised 06/01/2019, states:1. Dry storage roomsd. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated2. Refrigerators d. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. 3. Freezers e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observations, interviews, and record review, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for 1 of 7 residents (Resident # 1 ) reviewed for call light. The facility failed to ensure Resident # 1's call light was within reach. This failure could place residents at risk of not achieving independent functioning, dignity, and well-being. Findings include: 1.Record review of Resident #1 's face sheet dated 12/9/25 revealed a [AGE] year-old male admitted to the facility 11/19/25.Resident # 1 had diagnoses that included diabetes mellitus, [is a chronic metabolic condition marked by high blood sugar levels], Dependence on renal dialysis [means your kidneys have failed requiring a machine to filter waste, extra fluid, and balance minerals in your blood for survival], and Myopathy[is a broad term for diseases affecting skeletal muscles, causing weakness, stiffness, cramps, and fatigue, stemming from muscle fiber dysfunction]. Record review of Resident # 1's admission MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated moderate cognitive impairment Record review of Resident 1's care plan dated 12/09/25 did not reveal a care plan addressing the call light. Observation and Interview on 12/9/25 in Resident #1's room at 10:10 AM revealed that the call light was found behind the nightstand, out of arm's reach. Resident #1 stated he never knows where his call light is and hopes and prays someone will come and check on him today. Interview with LVN F on 12/09/25 at 10:15 AM revealed she was the assigned nurse for Resident # 1 and confirmed the call light was behind the nightstand., She stated she did not know how the call light ended up behind the nightstand, but would place it within reach of Resident # 1 at once. LVN F stated that Resident # 1 could risk a possible fall if the call light was not within arm's reach. During an interview with the DON on 12/10/25, at 2:19 PM, she emphasized the importance of ensuring that the call light was accessible to all residents. She stated that the lack of accessibility to a call light for any resident could lead to a potential negative outcome if assistance was needed. The DON also mentioned that charge nurses currently monitor this task during their daily morning rounds, and the ADON oversees this process. Record review of facility policy Call Lights: Accessibility and Timely Response, dated 10/13/2022, revealed, The call light system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #68) reviewed for PASARR accuracy.1. The MDS Case Manager did not refer Resident #68 for a level II resident review upon newly evident serious mental health disorder.This deficient practice could place the residents at risk of not receiving the necessary care and services.The findings included:Record review of Resident #68's face sheet, dated 12/10/2025, revealed a [AGE] year-old male admitted to the facility on [DATE], with a primary diagnosis type 2 diabetes Mellitus with diabetic chronic kidney disease (condition caused by the way the body regulates and uses sugar as fuel). Record review of Resident #68's MDS, dated [DATE], revealed the resident's BIMS score a 4 out of 15 which suggested the resident's cognition was severely impaired for daily decision-making skills. Record Review of Resident #68's diagnosis information on the face sheet dated 12/10/2025 revealed a diagnosis of Major Depressive Disorder, recurrent severe without psychotic features (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life without behaviors not normal to resident) with an onset date of 10/27/2025.Record review of Resident #68's history and physical note dated 10/27/2025 revealed the resident had a diagnosis of major depressive disorder, recurrent severe without psychotic features. During an interview on 12/11/2025 at 10:50 a.m., the MDS Case Manager stated they were responsible for looking over PASSAR documents when a resident is admitted checking to see if they trigger a positive PASARR and if there is any IDD or MI. MDS stated if the resident has an MI or IDD there's a form they are to submit for update of diagnosis. The MDS Case Manger stated major depressive disorder was not a mental health illness that would trigger a PASARR positive (Preadmission Screening and Resident Review is positive when the screening reveals resident is suspected of having a condition such as serious mental illness, intellectual disability, developmental disability or any related conditions).During an interview on 12/11/2025 at 12:17 p.m., the MDS Case Manager stated when a resident has a new MI diagnosis they need to fill out and submit a form 1012 (form to assist nursing facilities in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level 1 screening, need further evaluation for mental illness) to the physician. When asked who, if any person, The MDS case manager stated the DON was responsible for informing MDS of residents with newly diagnosed MI or IDD diagnosis. During an interview on 12/11/2025 at 12:18 p.m., the RDS nurse stated when Resident #68 was diagnosed with major depressive disorder that form 1012 should have been filled out and submitted to the physician in order for the physician to decide if a PASARR would need to be redone. The RDS stated no risk to Resident #68's when form 1012 wasn't submitted. During an interview on 12/11/2025 at 3:35 p.m., the DON stated the MDS case manager was responsible for PASARR for the residents. The DON stated they were not sure of the process for who informs the MDS case manager when a resident has a newly diagnosed MI or IDD. The DON stated if the MDS case manager isn't informed of a resident's new diagnosis of an MI or IDD or the MDS case manager doesn't submit a form 1012 due to a new diagnosis the DON stated she wasn't sure what harm could be assesses. Record review of the policy given titled Form 1012, Mental Illness and Dementia Resident Review, no date, states:The NF completes form 1012 following:-an individual's diagnosis is changed

Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 resident (Resident # 83) of 24 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #83's care plan included Contact Isolation which was ordered to prevent spread of her infection C-diff and EBP for her infected wound which required treatment and a dressing. Resident #83's comprehensive person-centered care plan did not reflect the use of PPE as an intervention. This deficient practice affects residents with contagious infections and could result in increased transmission of the bacteria. The findings included: Record review of Resident #83's electronic face sheet dated 12/10/2025 reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: sepsis (a life-threatening medical emergency where the body's extreme overactive response to an infection damages its own tissues and organs), unspecified organism, enterocolitis due to clostridium difficile (a bacteria that is highly contagious from contact, and can cause diarrhea (loose stools) and colitis (inflammation in the colon (intestine), pseudomonas aeruginosa (common opportunistic pathogen (bacteria or virus that can cause disease) known for causing infections, and is notable for its antibiotic resistance), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness), pressure ulcer of right buttock, Stage 2 (characterized by partial-thickness skin loss, presenting as shallow, open wounds or blisters, and require proper treatment to prevent infection and further progression). Record review of Resident #83's quarterly MDS assessment dated [DATE] reflected that she could usually understand and be understood. She scored 9 of 15 on her BIMS which signified her cognitive status was moderately impaired. She had a UTI in the last 30 days. C-diff, sepsis (life threatening medical emergency caused by the body's overwhelming response to an infection), pseudomonas and pressure ulcer of right buttock were active diagnoses. Her pressure sore was noted in the MDS. Review of Section O-Special Treatments, Procedures and Programs reflected M1. Isolation or quarantine for active infectious disease was noted while she was a resident. She required substantial/maximal assistance with her ADLs. Record review of Resident #83's comprehensive person-centered care plan dated 11/24/2025 reflected Problem, has infection of the gastrointestinal tract, interventions, administer antibiotic per MD orders. Problem, pressure ulcer, resident has an alteration in skin integrity. Resident #83's comprehensive person-centered care plan did not reflect she required EBP for having a dressing to an open wound or contact isolation for her C-diff infection. Record review of Resident #83's lab results dated 11/17/2025 reflected that she assessed positive for C-Diff Toxin. Record review of Resident #83's Skin Check dated 11/29/2025 reflected that she had a skin issue on her right gluteal (buttock) area. Record review of Resident #83's Wound Culture report dated 11/22/25 reflected that she had a Pseudomonas Aeruginosa bacteria growing in her wound. Record review of Resident #83's Active Orders as of: 12/11/2025 reflected that she was readmitted to the facility on [DATE]. Her orders reflected Contact Isolation: CDIFF active as of 11/22/2025. She had a treatment order for Stage 2, right gluteus: cleanse with ns, pat dry 4x4 gauze, apply hydrogel (a mixture of materials that let air and solutions pass through and water used for wound healing), collagen particles (type of protein that forms a primary dressing for wound management) to wound bed, cover bordered gauze daily, active as of 11/25/2025. Further review reflected, Vancomycin HCL Oral Capsule 250 mg, give 1 capsule by mouth one time a day for C-Diff for 7 days, start date 11/23/2025 and end date 12/01/2025. Vancomycin HCL Oral Capsule 250 mg, give 1 capsule by mouth two times a day for C-Diff for 7 days, start date 12/09/2025 and end date 12/16/2025. Observation on 12/09/2024 at 11:20 am revealed Resident #83 had a plastic bin outside her room which contained paper gowns, gloves, and masks. No Contact Isolation sign or EBP sign were seen. A yellow sign which hung on the resident's door reflected Check with nurse before entering room. Interview on 12/11/2025 at 10:05 am with the DON, she stated it was important that Resident #83's isolation and EBP requirement be reflected in the comprehensive care plan. She stated the MDS triggered care areas, and the care plan needed to reflect the isolation for the type of PPE required. She stated staff would not know what type of contact precautions were required if the care plan was inaccurate and cross contamination and spread of infections could occur. Interview on 12/11/2025 at 10:40 am with RN D, the MDS nurse stated she was part of the IDT and responsible for Resident care plans and keeping them current. She stated Resident #83's infection was in the care plan, but not that she required contact isolation which was ordered by the provider since C-Diff was contagious. She stated Resident #83 was on antibiotics and with her wound which required a dressing, the EBP needed to be in Resident #83's care plan. She did not know how it was missing since it was an important part of her care. She stated the care plan needed to reflect the PPE required. She stated the wrong information about what a resident required, or care could be missed without the information being in the care plan. Record review of the facility policy and procedure titled Comprehensive Care Plans dated 10/24/2022 reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, and mental and psychosocial needs that are identified in a resident's comprehensive assessment.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 resident (Resident #30) of 3 residents reviewed for oxygen therapy. Resident #30's oxygen concentrator left side black foam filter was gray from being covered with air particles and dust. This deficient practice affects residents who receive oxygen therapy and could result in hypoxia (low oxygen) and difficulty breathing.The findings included: Record review of Resident #30's electronic face sheet dated 12/10/2025 reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: epilepsy (chronological neurological disorder characterized by recurrent seizures), anoxic brain damage (damage to the brain due to a lack of oxygen), respiratory failure with hypoxia (a condition where the body does not receive enough oxygen leading to insufficient oxygen in the tissues), dementia (loss of cognitive functioning that interferes with daily life activities) and quadriplegia (symptom of paralysis that affects all a person's limbs and body from the neck down). Record review of Resident #30's quarterly MDS assessment dated [DATE] reflected that he rarely understands and was rarely understood. He was not a candidate for a BIMS which signified his cognitive status was severely impaired. He was dependent on staff for his ADLs. He received oxygen therapy while he was a resident. The MDS reflected he was not interview-able. Record review of Resident #30's comprehensive person-centered care plan dated 09/13/2025 reflected Problem, has a tracheostomy (tube, and medical device that is inserted into a surgically created opening in the trachea (windpipe), allow direct airway access), at risk for hypoxia, interventions, administer O2 at 30 percent via collar mask oxygen and O2 at 2L/min. Record review of Resident #30's Active Orders as of: 12/10/2025 reflected Administer oxygen via trach collar mask at 2L/min with a start date of 04/08/2025. Observation on 12/09/2025 at 11:25 am of Resident #30 revealed he was lying in bed, clean and well-groomed. He had humidified oxygen via a trach collar and mask infusing. The oxygen concentrator setting was at 2L/min. The black foam filter on the right side of the machine was clean; the black foam filter on the left side of the machine was gray from dust and air particles (tiny solid bits (soot, pollen, smoke and liquid droplets). The surveyor was able to touch the filter and move the dust to display the black foam. Observation on 12/10/2025 at 08:30 am of Resident #30 revealed the left filter of his concentrator continued to be covered with dust and air particles which displayed as a gray film. Observation on 12/10/2025 at 07:45 am with the DON, she confirmed there was dust and dirt particles covering the left oxygen concentrator filter in Resident #30's room. During an interview on 12/11/2025 at 10:10 am, the DON stated she thought the oxygen concentrator filters for Resident #30 needed to be checked and cleaned once a week. She stated she had no guidelines or process for cleaning and checking oxygen concentrator filters, but she would put it in the physician orders to have nursing staff check, clean or change them in the future. She stated dust and air particles could clog the filter and prevent air flow which would result in hypoxia or difficulty breathing. Record review of the facility policy and procedure titled Oxygen Safety dated 0126/2024 reflected Oxygen in Use, Licensed staff using oxygen equipment will be trained in the operation, safety precautions, and manufacturer's instructions for using the equipment. Record review of the manufacturer recommendations for the concentrator titled Invacare System Compatible Oxygen Concentrator User Manual dated 01/2017 reflected page 23 7.2 Cleaning the Cabinet Filter, CAUTION! To avoid damage from clogging, DO NOT operate the concentrator without the filter installed. Remove the filter and clean as needed, environmental conditions that may require more frequent inspection and cleaning of filter include but are not limited to high dust and air pollutants.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 (refrigerators in resident room [ROOM NUMBER]-B) of 5 residents' refrigerators reviewed in that: The personal refrigerator in resident's room [ROOM NUMBER] B contained unlabeled, undated food items. This deficient practice could place residents at risk of foodborne illness due to consuming foods which could be spoiled. The findings were: Observation on 12/10/2025 at 9:05 a.m. revealed that the personal refrigerator in resident room [ROOM NUMBER]-B contained an ice-cream pint, opened, with an expiration date of 03/15/26, which was unlabeled and undated. Observation on 12/11/2025 at 08:50 a.m. revealed the personal refrigerator in resident room [ROOM NUMBER]-B contained an ice-cream pint, opened, with an expiration date of 3/15/2026, which was unlabeled and undated. Further observation on 12/11/2025 at 12:54 p.m. revealed that the ice cream was still present in the refrigerator in room [ROOM NUMBER]-B. Interview on 12/11/2025, at 2:00 p.m., during an interview with LVN F, it was confirmed that the refrigerator in resident room # 301- B contained an ice-cream pint, with an expiration date of 3/15/2026, which was unlabeled and undated. During an interview with the DON on 12/12/2025, at 9:30 a.m., the DON confirmed that perishable food in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled food. The DON stated that the night shift nurses are responsible for overseeing this and it was not currently being monitored. Record review of the facility policy, Use and Storage of Food Brought in by Family or Visitors , dated ,1/27/2023, revealed, All food items that the family or visitor already prepares must be labeled with the contents and dated; if not consumed by 3 days, the facility staff will throw the food away.

Based on observations, interviews and record reviews, 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 for 2 residents (Resident #36 and #83) who were reviewed for infection control. The findings included: 1. The facility failed to post a sign which indicated enhanced barrier precautions (EBP) for Resident #36 who had an open wound with treatment. 2. The facility failed to post signs on Resident #83's door that indicated she was on contact isolation for C-Diff. and required EBP for having an open wound which required a dressing. This deficient practice affects residents with infections and wounds and could result in increased transmission or cross contamination. The findings include: Record review of Resident #36's face sheet, dated 12/10/2025, revealed a [AGE] year-old male and admitted to the facility on [DATE], with a primary diagnosis for orthopedic aftercare following surgical amputation. Record review of Resident #36's MDS, dated [DATE], revealed the resident's BIMS score a 11 out of 15 which suggested the resident's cognition was intact for daily decision making. Record review of Resident #36's active order summary dated 12/11/2025 revealed the following orders: Stage 2 Buttocks- generalized: cleanse with ns pat dry 4x4 gauze, apply collagen powder, cover with exuderm satin hydrocolloid wound dressing. Daily as needed that had a start date of 12/10/2025. Stage 2 Buttocks- generalized: cleanse with ns pat dry 4x4 gauze, apply collagen powder, cover with exuderm satin hydrocolloid wound dressing. Daily one time a day that had a start date of 12/11/2025. During an observation on 12/11/2025 at 10:04 a.m., Resident #36 did not have EBP (Enhanced Barrier Precautions) signage by the door. During an observation on 12/11/2025 at 2:15 p.m., Resident #36 did not have EBP signage by the door. During an interview on 12/11/2025 at 2:18 p.m., LVN E stated EBP signage was required for all residents who have wounds, new surgical sights, tube feeding, Clostridioides difficile (bacterium that primarily affects the colon), respiratory, droplet, infection of the wound and more. LVN E stated the reason for EBP signage is to prevent the spread of infection to the residents. LVN E stated Resident # 36 should have EBP signage if he had a wound yes. LVN E stated Resident # 36 is at increased risk of changes of infection to the wound when appropriate EBP signage is not in place. During an interview on 12/11/2025 at 2:22 p.m., RN A stated EBP signage was required for any open wounds and any surgeries. RN A stated Resident #36 would need EBP signage. RN A stated EBP signage was needed for residents to not spread infections to other residents. RN A stated themselves or LVN C are responsible for putting up the EBP signage During an interview on 12/11/2025 at 3:26pm, LVN C, who was one ADON, stated EBP signage was required for any resident who has open wounds, foley, dialysis, peg tubes, and anything that could get an infection. LVN C stated ADON's or the wound care treatment nurse are responsible for putting up EBP signage. LVN C stated Resident #36 should have EBP signage up due to their wound. LVN C stated there was a risk to Resident # 36 not having the EBP signage but it was minimal. 2.Record review of Resident #83's electronic face sheet dated 12/10/2025 reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: sepsis ,( life-threatening medical emergency where the body's extreme, overactive response to an infection damages unspecified organism, enterocolitis due to clostridium difficile (a bacteria that is highly contagious from contact, and can cause diarrhea (loose stools) and colitis (inflammation in the colon (intestine), pseudomonas aeruginosa (common opportunistic pathogen (bacteria or virus that can cause disease) known for causing infections, and is notable for its antibiotic resistance), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness), pressure ulcer of right buttock, Stage 2 (characterized by partial-thickness skin loss, presenting as shallow, open wounds or blisters, and require proper treatment to prevent infection and further progression). Record review of Resident #83's quarterly MDS assessment dated [DATE] reflected that she could usually understand and be understood. She scored 9 of 15 on her BIMS which signified her cognitive status was moderately impaired. She had a UTI in the last 30 days. C-diff, sepsis (life threatening medical emergency caused by the body's overwhelming response to an infection), pseudomonas and pressure ulcer of right buttock were active diagnoses. Her pressure sore was noted in the MDS. Review of Section O-Special Treatments, Procedures and Programs reflected M1. Isolation or quarantine for active infectious disease was noted while she was a resident. She required substantial/maximal assistance with her ADLs. Record review of Resident #83's comprehensive person-centered care plan dated 11/24/2025 reflected Problem, has infection of the gastrointestinal tract, interventions, administer antibiotic per MD orders. Problem, pressure ulcer, resident has an alteration in skin integrity. Record review of Resident #83's lab results dated 11/17/2025 reflected that she assessed positive for C-Diff Toxin. Record review of Resident #83's Skin Check dated 11/29/2025 reflected that she had a skin issue on her right gluteal (buttock) area. Record review of Resident #83's Wound Culture report dated 11/22/25 reflected that she had a Pseudomonas Aeruginosa bacteria growing in her wound. Record review of Resident #83's Active Orders as of: 12/11/2025 reflected that she was readmitted to the facility on [DATE]. Her orders reflected Contact Isolation: CDIFF active as of 11/22/2025. She had a treatment order for Stage 2, right gluteus: cleanse with ns, pat dry 4x4 gauze, apply hydrogel (a mixture of material that allow solutions and air to enter and water used for wound healing), collagen particles (type of protein that forms a primary dressing for wound management) to wound bed, cover bordered gauze daily, active as of 11/25/2025. Further review reflected, Vancomycin HCL Oral Capsule 250 mg, give 1 capsule by mouth one time a day for C-Diff for 7 days, start date 11/23/2025 and end date 12/01/2025. Vancomycin HCL Oral Capsule 250 mg, give 1 capsule by mouth two times a day for C-Diff for 7 days, start date 12/09/2025 and end date 12/16/2025. Observation on 12/09/2025 at 11:20 am revealed Resident #83 had a plastic bin outside her room which contained paper gowns, gloves, and masks. No Contact Isolation sign or EBP sign was seen. Observation on 12/09/2025 at 11:20 am and review of a yellow sign which hung on Resident #83's door reflected Check with nurse before entering room. Observation on 12/10/2025 at 08:20 am of Resident #83's door to her room revealed she had no EBP or Contact Isolation signs which reflected staff were required to use PPE when they entered the room. Observation on 12/10/2025 at 07:45 am with the DON, she confirmed there was no EBP or Contact Isolation sign outside Resident #83's room to indicate she required isolation and contact precautions with use of PPE. During an interview on 12/10/2025 at 09:33 am, RN A, the Treatment Nurse stated that she knew Resident #83 had C-Diff and a wound that was being treated with a gauze dressing. She stated she did not notice EBP or contact isolation signs were not placed; however, she used PPE from the bin next to the room. She stated it was important to place signs to communicate to others what type of PPE the resident required for her care or cross contamination could occur. During an interview on 12/11/2025 at 10:10 am, the DON stated she thought the yellow sign was enough for people to go to the nurse and then find out what the resident needed. She stated the resident had assessed positive for C-Diff and was ordered antibiotics, placed on contact isolation as ordered by the MD and was in a single room. She stated staff would know to use PPE because the plastic bin with PPE was outside Resident #83's door. She stated she would educate staff on EBP and isolation procedures. She stated that Resident #83 had an open wound and received treatment and a dressing and should have EBP and did not know why she did not. She stated she was accountable for nursing care in the facility. During an interview on 12/11/2025 at 10:21 am, LVN B who readmitted Resident #83 to the facility on [DATE] stated she saw the order of contact isolation and knew Resident #83 was infected with C-Diff. She stated she knew Resident #83 had an open wound with treatment orders to include dressing the wound with gauze. She stated she was trained in isolation precautions and EBP and signs should have been posted by the resident's room, and she did not know why she did not post them. During an observation on 12/11/2025 at 2:15 p.m., Resident #83 did not have EBP signage by the door. During an interview on 12/11/2025 at 2:18 p.m., LVN E stated EBP signage was required for all residents who have wounds, new surgical sites, tube feeding, Clostridioides difficile (bacterium that primarily affects the colon), respiratory, droplet, infection of the wound and more. LVN E stated the reason for EBP signage is to prevent the spread of infection to the residents. When asked if Resident #83 should have had EBP signage by their door, LVN E stated if he had a wound yes. When asked what the risk was to Resident #83 with not having EBP signage, LVN E stated an increased risk of infection to the wound. During an interview on 12/11/2025 at 2:22 p.m., RN A stated EBP signage was required for any open wounds and any surgeries. When asked if Resident #83 should have EBP signage, RN A stated Resident #83 would need EBP signage. When asked what the risk was to Resident #83 with not having EBP signage, RN A stated EBP signage was needed for residents to not spread infections to other residents. When asked who was responsible for putting up EBP signage for residents, RN A stated themselves or LVN C. During an interview on 12/11/2025 at 3:26pm, LVN C, who was one ADON, stated EBP signage was required for any resident who has open wounds, foley catheter, dialysis, peg tubes, and anything that could get an infection. When asked who was responsible for putting up EBP signage, LVN C stated ADONs or the wound care treatment nurse. When asked if Resident #83 should have EBP signage, LVN C stated Resident #83 should have EBP signage up due to their wound. When asked what the risk was to Resident #83 with not having EBP signage, LVN C stated there was a risk, but it was minimal. During an interview on 12/12/2025 at 08:34 am, Resident #83 stated that staff wear PPE when they assist her with care. Review of LVN B's Charge Nurse Orientation Checklist dated 10/17/2025 reflected she satisfactorily completed isolation procedures. Review of facility staff training titled EBP dated 11/13/2025 reflected LVN B had attended the training. Record review of the facility policy and procedure titled Enhanced Barrier Precautions dated 11/24/2025 reflected, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: EBP will be implemented for residents with wounds such as pressure ulcers, high contact resident care activities include wound care: any skin opening requiring a dressing. Record review of the policy and procedure titled Infection Prevention and Control Program dated 05/13/2023 reflected The facility has established and maintained 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 as per accepted national standards and guidelines. Review of cdc.gov/c-diff/hcp/clinical-guidanceindex.html (current) reflected Isolate and initiate contact precautions for suspected or confirmed C-Diff infection.

Based on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (300-hall medication cart), reviewed for security. LVN B left the 300-hall medication cart unattended and unlocked. This failure could place residents at risk for having their medications uncontrolled. The findings included: During an observation and interview on 9/17/2025 11:28 AM revealed the 300-hall nurse cart was stationed at the end of the 300-hall and was unattended and unlocked. LVN A locked the cart and stated the cart was assigned to LVN B. During an interview on 9/17/2025 at 11:32 AM LVN B stated she had left the 300-hall medication cart unattended and unlocked while she stored a bottle of enteral feeding formula in the facility's resident pantry. LVN B stated she could not visualize the 300-hall medication cart from within the resident pantry. During an interview on 9/17/2025 at 11:45 AM the Administrator and the DON stated the facility's expectations were for all medication carts to be secured and locked when not directly attended and the potential risk for residents was the loss of control of their medications. A record review of the facility's policy dated 2007, titled Security of Medication Cart revealed, Policy Interpretation and Implementation, The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of the nurse's view.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 1 residents pantry refrigerators reviewed for food safety. The facility stored resident's foods in the Resident's pantry refrigerator without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.The findings included:During an observation and interview on 9/17/2025 at 11:34 AM revealed the facility's Resident's Pantry room had a refrigerator. The refrigerator presented with signage which read, Resident Food Storage . food should have a name, room number, and a date when placed into storage . refrigerator will be checked daily and disposed of not labeled food . LVN B stated the refrigerator had unlabeled containers of food which included berries, various desserts stored in small foam containers, 1 - 1/2 sandwich, and 1 cookie, which all did not have and labeling to reveal if the foods were safe to serve. During an interview on 9/17/2025 at 11:45 AM the Administrator and the DON stated the facility's expectation was for the resident's pantry refrigerator to be inspected daily by the nursing staff to ensure residents' food had labels and dates to ensure foods were safe to eat. The Administrator stated foods without labels to include dates could be unsafe to serve to residents. The Administrator and the DON stated the potential negative outcome to residents could be food borne illnesses. A record review of the facility's policy dated 2022 titled Food Receiving and Storage revealed, Refrigerated/Frozen Storage, . Foods and Snacks Kept on Nursing Units, All food items to be kept at or below 41 F are placed in the refrigerator located at the nurses' station and labeled with a use by date.2. All foods belonging to residents are labeled with the resident's name, the item and the use by date.3. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines.4. Beverages are dated when opened and discarded after twenty-four (24) hours.5. Other opened containers are dated and sealed or covered during storage.6. Partially eaten food is not kept in the refrigerator.

Based on observations, interviews, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #54) reviewed for quality of care. The facility failed to ensure Resident #54 was properly secured in the facility transport van on 08/22/24 and sustained a fall resulting in fractures to the third and fourth left hand fingers and a fracture to the right elbow. The noncompliance was identified as PNC. The IJ began on 08/22/204 and ended on 08/24/2024. The facility had corrected the noncompliance before the survey began. Assessment of Resident #54. Inservice training to all staff related to Abuse and Neglect and Reporting Incidents to MD and RP. Van safety training with 7 van drivers to include proper use of van lift and proper ways to secure residents in wheelchairs. Safe surveys with 48 residents using facility transportation. Termination of Van Driver AL (responsible for the incident) post facility investigation. This failure could place residents who use wheelchairs and access the facility's van for transport, at risk for accidents resulting in serious injury, serious impairment, or death. The Findings were: Record review of Resident #54's EMR revealed: the resident was a [AGE] year-old female who admitted on [DATE] (initial 9/9/2022) with diagnoses that included: Metabolic encephalopathy (brain disorder), seizures, Acute kidney failure, Type 2 DM (diabetes), Anxiety, Dementia, Aphasia (language disorder that affects the resident's ability to communicate, for instance, resulting from a stroke. Dysphagia (difficulty swallowing), Traumatic subarachnoid hemorrhage (5/19/2020) (brain bleed) . RP was listed as a family member. BIMS score dated 8/22/24 was 03 (severely impaired) WC bound for transport. Record review of Resident #54's Quarterly MDS assessment dated [DATE] revealed: resident was dependent on transfers and transportation. Record review of Resident #54's Physician orders dated September 2024 reflected: Pain medications regiment in place, Depakote for seizures [evidence revealed that the resident did not have a seizure in the van]. Resident on aspirin and Plavix increasing her risk for bruising and bleeding. Record review of Resident #54's EMR revealed the timeline for the incident on 8/22/24 was: 8/22/24 resident had appointment on 8/22/24 at 3:00 PM at a local clinic and fell in the van on the way to the clinic. [Record review of Nurse Note] Resident #54 returned to the facility at 5:00 PM. At 5:21 PM resident showed signs of redness. At 8:47 PM, pain present and resident sent to ER. Resident returned on 8/23/24 at 54 AM. On 8/23/24 the resident was sent back to the MD clinic for follow-up for the x-ray fracture results. MD AO resend the resident to the ER for a re-evaluation and possible admissions. The Resident returned to the facility on [DATE] at 2:45 PM. Record review of Intake #526868 reflected: On 8/23/24 resident [#54] attended a doctor's appointment, transported by our facility van. Resident returned to facility with redness to right side of face. As per Van Driver [AL] van door closed on resident hitting her face. Resident developed more discolorations and was sent to Emergency Dept. X-ray findings [ Closed nondisplaced fracture of proximal phalanx of the ring finger, head of rt. radius, proximal of left middle finger.] Record review of Resident #54's Fall risk assessment on 08/22/24 showed the resident to be at high risk for falls. Record review of Resident #54's nursing assessment on 8/22/24 at 8:47 AM reflected: resident had no pain, skin intact and able to move all extremities. Discoloration to left hand 2nd digit, left lower leg right upper eyelid, right cheek, right upper arm, right knee. Record review of Resident #54's hospital record dated 8/22/24 reflected: X-ray findings closed non-displaced fracture of proximal (closer) phalanx (bone) of the ring finger, head of right radius (elbow), proximal of left middle finger. Record review of Resident #54's Nurse Progress Notes reflected: 8/22/2024 17:21 [5:21 PM] NURSING - Nurse Note Note Text: Upon Head-to-toe assessment minimal swelling to right side of face, discoloration redness in color noted to upper eyelid, skin intact, redness discoloration to lateral side of right elbow, skin intact, resident able to move upper extremities, with no discomfort noted, minimal swelling and discoloration to left middle finger, abrasion to right knee noted, resident able to move lower extremities as tolerated. MD [AO] notified. Assisted resident to dining room for dinner. Signed by LVN [AM]. 8/22/2024 17:20 [5:20 PM] NURSING - Nurse Note Text: Notified by transportation aide [Van Driver AL] that resident [Resident #54] got hurt by the door of the facility van. Resident going to appointment, transportation aide notified Doctor {MD AO] of incident, no new orders written on communication sheet. Resident laughing stated I don't have pain I want water. Face assessed noticed redness, swelling and right side of face, bump on forehead and small skin tear approximately 1 cm x 1 cm on right eye. resident denies pain or discomfort, resident in dining area having cup of water and waiting for supper. BP (blood pressure);135/95 P (pulse):98 R (respiration):16 T (temperature): 98.5 o2 (oxygen): 96% room air . unable to contact, incoming nurse made aware to follow up. Neurochecks initiated. Signed by LVN [AM]. 8/23/2024 05:5 NURSING - Nurse Note Text: Resident [#54] return from ER resident in bed at lowest position, v/s (vital signs) taken and wnl. [with normal limits] Resident sleeping does not display signs of pain or discomfort. DON MD [AO] AND RP notified. New Order: F/U (follow up) with orthopedic [MD AP] to 3rd and 4th finger l-hand signed LVN [AM]. Record review of written statement from Van Driver AL reflected: 8/23/24: he admitted the resident [Resident #54] had sustained a fall in the Van. Van Driver AL stated, Resident fell on her knees then on her right side. Van Driver AL assisted the resident back to her w/c and went to PCP appointment. The straps were noted in place, the seat belt was noted loose. The resident was assessed at the MD appointment and no injury were noted at the time. Observation and interview on 9/9/24 at 8:29 AM [witnessed by CMA AJ per resident's request], revealed Resident #54 was in her room lying in bed attempting to sleep, the resident was alert and oriented to person and place. Further observation of the resident revealed: fading bruise color blue/yellow to right side of face and right hand bandaged with middle and ring finger purple discoloration with a finger brace. The resident grimaced. Call light was in reach; room was cleaned; there were no fall hazards; and the room was homelike. The Resident stated that she fell in the van on the right side and suffered pain. The resident stated that the WC fell with her during the fall in the van. The resident could not remember the date of the fall in the van. The resident stated that the driver pushed the breaks hard which resulted in the fall. The resident did not provide other details involving the fall. During an interview on 09/09/24 11:04 AM CMA AJ stated the resident said, she was in the van with a strap on her upper body sitting on a WC .the WC fell to the right side .and that she had pain in the left hand .and that she had fallen. Record review of facility's investigation file, after the incident, revealed the following interventions: Observation and interview with residents on abuse and neglect. [interview sheets] In-service for all staff on abuse and neglect [98 staff with a completion rate of 100%] Training completed 8/24/24. [signature sheets] Head to toe assessment completed on Resident #54, MD AO and RP notified of the incident. [skin assessment] Van Driver AL suspended [and eventually terminated] [termination form] Facility van grounded until all 7 van drivers were certified on van safety by an outside contractor. [certification sheet] Future medical transport for Resident #54 would be by contracted van stretcher. [progress note] Facility's Safe surveys dated 8/23/24 were completed on the residents [48 resident eligible for transport] that have been transported by the van driver and no negative findings. [safety survey sheets] Self-report to HHS was submitted and the facility' finding was inconclusive. [5-day report] Record review of Driver evaluation [Van Driver AL] road test form revealed completion on 8/28/24. Record review of facility's investigation file dated on 8/23/24 reflected: Van Driver AL was asked for statement on incident and stated that resident had fall in van. [Van Driver AL stated Resident #54 hit her hand on the van door.] Record review of Van Driver AL employee filed revealed: Current driver's license. Counseling form dated 9/3/24 with termination of employee for not providing correct information on the incident on 8/22/24. Completion on 7/4/24 of Strategies for Transporting Passengers continuing education. Completion on 1/9/24 of Safe Lifting continuing education. Van Driver Job Description undated reflected: Assist residents .in and out of the vehicle .Perform pre-trip inspections . Completion of Driver's Orientation Checklist dated 1/17/23 which included: Wheelchair lifts & restraints . Completion of Abuse and Neglect training on 8/11/24. No negative information on the EMR 2 (2024) and Criminal History Check (1/16/2023) Observation on 9/9/24 at 12:30 PM of van safety revealed Van Driver AK properly demonstrated the lifting of the WC from the back door and securing the WC with anchors and safety belt and harness strap. Van Driver AK stated she received training on the proper securing of residents with WCs in a van. During an interview with the facility's Maintenance Supervisor on 9/9/24 at 12:35 PM, he stated he could not explain how Resident #54 injured herself on 8/22/24 except that she was not properly secured in the van. The Maintenance Supervisor stated that after the accident a contracted company gave the van drivers [total of 7] instruction on the proper securing of a WC. The Maintenance Supervisor stated since the accident on 8/23/24 there had been no other accidents in the van. The Maintenance Supervisor stated that, monthly, he checked on van safety especially on the proper securing on residents with wheelchairs; and checked periodically. During an interview on 9/9/24 at 12:40 PM, the Administrator stated there was confusion over how the injury on 08/22/24 occurred in the van. The Administrator stated that Van Driver AL changed the incident from the resident striking her finger on the door to the resident having a loose safety belt. The Administrator stated Van Driver AL was terminated for not providing the correct information involving the incident on 8/22/24. The Administrator stated that the Resident #54 likely suffered an injury to the hand due to a loose safety belt/ shoulder strap. The Administrator stated that after the incident the van drivers, a total of seven, were in-serviced by an outside contractor on van safety and the proper securing of a WC. During a telephone interview on 9/9/24 at 1:02 PM, (former) Van Driver AL stated he was taking the Resident #54 to a PCP and had to push the breaks hard to avoid a car accident. Van Driver C stated, Resident #54 fell forward first on her knees and then to her face; the WC did not fall with the resident. Van Driver AL stated that he had secured the seat belt prior to the trip to the PCP. Van Driver AL stated that the seat belt/shoulder strap was likely loose prior to the accident. Van Driver AL stated that he should have checked the tightness of the seat belt/ shoulder strap prior to embarking on the trip to ensure safety of the resident passengers. During a joint interview on 9/9/24 at 1:16 PM, Van Driver AQ and Van Driver AR stated the highlights of the in-service received two weeks ago by an outside vendor [8/23/24-8/28/24] included: van safety, proper securing of WC from start to finish involving a resident; and double checking the proper fitting of the seat belt and shoulder strap prior to leaving on a trip for the residents. During an interview on 9/9/24 at 1:33 PM, LVN AM stated on 8/22/24 Resident #54 returned from her appointment and she LVN D saw her face (Resident #54) and it was red with minimal swelling. LVN AM stated she inquired of Van Driver [AL] and he stated that the van door hit the resident on the right side. LVN AM stated that a bruise was developing, and Van Driver AL again said the door hit her hand. LVN AM stated the resident had no pain. LVN AM did a full assessment in the evening around 8:00 PM and the resident face revealed a bruise. LVN AM stated that the DON spoke to the MD [AO] and decision was made to refer the resident to the ER. LVN AM stated, we later found out the resident had a fracture to the third and fourth left fingers and right elbow fracture. LVN AM stated she received an in-service on van safety on 8/24/24. During an interview on 9/10/24 at 8:30 AM, the DON stated that Resident #54 did not ride the van for medical appointments. The DON stated Resident #54 was transported by a contracted van stretcher company for medical appointments. During a joint interview on 9/10/24 at 9:55 AM, the Administrator and DON stated the only 7 certified van drivers were allowed to transport residents in the facility's van and no other staff. The Administrator stated that the 7 current van drivers were trained and certified on van safety and the proper securing of a WC and seat/harness in the facility van. Observation on 9/10/24 at 12:01 PM of van safety procedures revealed, Van Driver AK properly secured Resident# 52 on the van lift, anchored the WC in the van, and checked the seat belt and shoulder strap; no deficiencies or violations were noted. Observation on 9/10/24 at 1:30 PM of van safety procedures revealed, Van Driver AK properly removed Resident #52 with W\C from the van with no incidents. Record review of facility's grievance log for the past 6 months (February 2024-September 2024) revealed no grievances filed involving van safety. Record review of in-service certification conducted on 8/27/24 on van safety for 7 van drivers was done by an outside transportation contractor. Record review of in-service training on the topics of van safety, fall prevention, and van safety was given to all staff from 8/23/24 to 8/27/24. Record review of facility's Fall Prevention Program undated revealed: one was present an in-effect. [the policy did not address van safety techniques or procedures]. During the exit conference on 9/11/24 at 2:00 PM, the Administrator and the DON were informed that evidence revealed a past non-compliance IJ (immediate jeopardy) for inadequate supervision of Resident #54 on 8/22/24.

Based on observation, interview and record review, the facility failed to implement the facility's policies and procedures that prohibit neglect for 1 of 7 residents (#8) reviewed for neglect in that: Resident #8 had a recent amputation of his toes and was prescribed Tylenol #3 for pain management. Resident #8's Tylenol #3's prescription was not refilled for 4 days which led to in ineffective pain control. This failure could affect 37 residents who were on a pain management program and could result in ineffective pain control. The findings were: Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE] with the primary physician listed as Medical Director AA. Review of Resident #8's Pain assessment dated [DATE] revealed Resident #8 had an Transmetatarsal Amputation. Review of Resident #8's Pain assessment dated [DATE] revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Lower Extremity 5. Type of pain: External 6. Description of Pain: Dull 7. Onset of pain: Acute 8. Frequency of pain: Occasional 9. Pain intensity: 7/10 11. Non verbal signs of pain: Facial grimacing, irritable, [MEDICAL CONDITION], restless 12. Pain relieved by: Medication 13. Effects of pain: Sleep affected 14. Conclusion: Pain issues, management is effective; see care plan Completed by LVN J Review of Pain Assessment completed 6/14/16 revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Not Described 5. Type of pain: External 6. Description of Pain: Unchecked 7. Onset of pain: Acute 8. Frequency of pain: Unchecked 9. Pain intensity: 3/10 11. Non verbal signs of pain: None Observed 12. Pain relieved by: Medication 13. Effects of pain: Changes in ADL's 14. Conclusion: No pain, no intervention needed Review of Resident #8's Minimum Data Set completed 6/14/16 revealed Resident #8's BIMS was a 13 (cognitively intact). Review of Resident #8's Care Plan completed 6/14/16 revealed the following: Problem/Need-Resident at risk for increased Pain R/T (related to) recent TMA (Transmetatarsal amputation) with wound vac in place: Goal & Target Date- -Resident will have relief from pain when prn medication is used x 90 days 9/14/16 -Resident will maintain his tolerable pain level of 3/10 with use of prn medications 9/14/16 Approaches- -Monitor resident for s/s of pain: restlessness, tearfulness, moaning, anxiety, agitation, actual c/o. -Make resident as physically comfortable as possible by repositioning, using positioning pillows, giving back rubs, etc -Give prn pain medications per MD orders -Monitor for effectiveness of prn pain med -Notify MD/RP if pain medication isn't effective in relieving pain, if injury has occurred, or if pain increases in freq or intensity -Follow MD orders after notification Interview, during initial tour, on 6/28/2016 at 12:07 p.m., with LVN J, revealed Resident #8 had his left toes amputated and had a wound vac attached to his left foot. Resident #8 was experiencing pain in his left foot, at this time, according to LVN J (after speaking to Resident #8 in Spanish), and said Resident #8 was prescribed Tylenol #3 for pain and LVN J notified the assigned 200 hall nurse, LVN O, that Resident #8 was in need of pain medications. Review of Resident #8's nursing note on 6/24/16 at 11:08 a.m. revealed LVN O called Medical Director AA's office at 10:00 a.m. and spoke with clerk to notify that a prescription for Tylenol #3 one tab PO Q 4hrs PRN was needed. The Clerk said that she would notify MD and return phone call once it was ready. Interview on 6/30/16 at 2:40 p.m. with the clerk of Medical Director AA revealed the clerk recalled LVN O calling on 6/24/16 to request Tylenol #3 prescription for Resident #8 and was told Resident #8 would need to be seen by the doctor. Since Resident #8 had no insurance, he was not accepted as a patient for Medical Director AA and LVN O was notified of this. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was administered Tylenol 325 mg x 2 at 12:15 p.m., pain being assessed at 10 out of 10. Observation and interview on 6/28/16 at 3:20 p.m. with LVN O revealed Resident #8 did not have any Tylenol #3 available in the medication cart. LVN O said Resident #8's Tylenol #3 had not been administered since 6/24/16. LVN O further said although Resident #8 had been reporting a pain level of 5 or 6 out of 10, the Tylenol #3 medication had ran out on 6/24/16 and Resident #8 had been requesting medication for pain every 4 hours. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed Medical director AA did not fill Resident #8's Tylenol #3 prescription and did not accept Resident #8 as a patient due to having no insurance. The interview further revealed the other Medical Directors on staff were out of town when Resident #8's Tylenol #3 ran out. Review of the 24 hour log for Resident #8 on 6/28/16 revealed the following entries: 6/18/16-Need MD appointment 6/19/16-Need MD appointment setup as soon as possible pending insurance clearance 6/21/16-Need MD appointment setup as soon as possible pending insurance clearance 6/23/16-Need MD appointment setup as soon as possible 6/24/16-MD appointment setup as soon as possible 6/26/16-MD appointment setup as soon as possible needs Tylenol #3 6/27/16-Appointment setup as soon as possible needs Tylenol #3. Appointment 1:30 p.m. 6/28/16, evening pass on reports the same. 6/28/16-Appointment physician assistant at 1:30 p.m. Review of Resident #8's Pharmacy Services Individual Drug Record revealed Resident #8's Tylenol#3 was stopped being administered on 6/24/16 and then began to be administered again on 6/30/16. Review of Resident #8's June 2016 MAR indicated [REDACTED]. Interview on 7/1/16 at approximately 12:30 p.m. with Regional Nurse W revealed PRN Tylenol #3 not indicated as administered on Resident #8's Control Medication Log on 6/29/16 due to being administered from E-Kit. Interview on 7/1/16 at 12:07 p.m. with Regional Nurse W revealed Resident #8's medication count for controlled substance had not been documented in all 3 areas: MARS, nurses notes and controlled substance logs. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was assessed for pain 7/10 was re-assessed at 6:00 p.m., resident stating pain diminished. Interview on 6/28/16 at 5:36 p.m. with Resident #8 revealed Resident #8 reported current pain level at 5 out of 10 with regular Tylenol 650 mg but said he had not been able to sleep in over 5 days. Resident #8 indicated he had been able to sleep when Tylenol #3 was administered and found it to be effective for pain. Resident #8 said he went to see doctor today (6/28/16) and Tylenol#3 prescription was issued. Resident #8 indicated in the past few days regular Tylenol had not been effective for pain. Resident #8 did not know why he had to wait 4 days for his Tylenol #3. Interview on 6/29/16 9:15 a.m. with Physician Assistant CC of Medical Director BB revealed Resident #8 was examined by PA CC on 6/28/16 in the office. PA CC reported resident #8's pain to be severe upon examination. Resident was prescribed Tylenol #3 for pain. PA CC was asked if Tylenol 650 mg would be an appropriate dose to manage pain for resident at this time. PA CC reported no, it would be like chewing bubble gum. Review of Resident #8's physical examination conducted on 6/28/16 at the office of Medical Director BB, conducted by PA CC for pain to Resident #8's left foot revealed Resident #8 moaning and groaning from pain during examination. Further review of this same document under Impression revealed severe pain to patient. Further review of this same document revealed a prescription was written for Tylenol #3 for pain. Interview on 6/28/16 at 4:40 p.m. with LVN J stated Resident #8 has always assessed pain at 7 out of 10. LVN J further indicated Resident #8 usually asked for more pain medication at night around 8:00 p.m. to 9:00 p.m. and Resident #8 could usually sleep after receiving his pain medications. Interview and observation on 6/29/16 at 7:43 a.m. of Resident #8 revealed Resident #8 was moaning and groaning, face grimacing and appeared to be in much pain. Resident #8 said he was having convulsions in his foot. Resident #8 said he still did not have the Tylenol #3 available to him. Resident #8 reported his pain level as stronger than 10 out of 10. Resident #8 was offered Tylenol 650 mg but he refused the medication and indicated it was not effective. Resident #8 further said he wanted to be discharged from the facility. Resident #8 indicated he had been in severe pain for the past 5 days and was having trouble sleeping. Interview on 7/1/16 at 8:45 a.m. with CNA Y (night shift on 200 hall) revealed Resident #8 frequently complained of pain. Resident #8 was frequently asking for pain medications and would ask CNA Y if wound vac was working because of the pain he was continuing to experience. CNA Y further indicated Resident #8 would wake up 4-8 times a night due to pain. CNA Y indicated that when Resident #8 ran out of Tylenol #3 pain medication he was aware of it and stopped asking for it. He continued to be in pain however. Interview on 6/29/16 at 8:11 a.m. with LVN O revealed the Tylenol #3 would not be available from the pharmacy until 6:00 p.m. (on 6/29/16). Interview on 6/29/16 at 8:25 a.m. with the DON revealed she did not know why Resident #8's Tylenol #3 had not been given from the emergency medication kit. The DON asked LVN O who said, at 5:00 p.m. the prior day 6/28/16 Resident #8 was given Tylenol 650 mg which appeared to be effective for pain. LVN O indicated that she called for a code this a.m. to get access to emergency kit and should be given the code in next 10 minutes. Review of Resident #8's Nursing Notes dated 6/29/16 revealed at 8:55 a.m. the pharmacy was called to request authorization number to administer PRN Tylenol #3 1 tablet. Tylenol #3 was administered and the resident states pain 10/10 from scale 1-10 being the worst. Rechecked resident again at 9:20 a.m. and reported pain subsided. Review of nursing notes 6/29/16 of LVN O revealed Resident #8 was administered Tylenol 325 mg x 2 at 7:45 a.m., pain being assessed at 10 out of 10. Interview on 6/29/16 at 10:12 a.m. with DON and the Administrator revealed Resident #8's pain was being effectively managed with Tylenol 650 mg dose. Surveyor explained that the resident had an amputation of toes and regular Tylenol was not sufficient to manage pain, according to Resident #8 himself. DON reported that amputation took place three weeks ago. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed staff documentation in nursing notes indicated Tylenol 650 mg dose was effective to manage pain on Resident #8. Review of the facility's Abuse Prohibition and Procedure policy on 6/30/16 revealed: As a general overall policy, the facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of of the facility's Pain Assessment policy 6/30/16 revealed the following relevant components: Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: - A comprehensive pain assessment should be complete as part of the initial nursing assessment with development of a pain management program as indicated. -Evaluation and reporting of pain indicators is expected with routine resident interaction. -Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with resident's established goals. Steps in procedure: -Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene per plan of care. -Offer non-pharmacological interventions as appropriate -Offer any prn [MEDICATION NAME] mediations as appropriate -Document administration and effectiveness of prn medication. Review of CMS form 672 dated 6/28/16 revealed there were 37 residents who were on a pain management program.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures that prohibited neglect for 1 of 7 residents (#8) reviewed for neglect in that: Resident #8 had a recent Transmetatarsal Amputation and was prescribed Tylenol #3 for pain management. Resident #8's Tylenol #3's prescription was not refilled for 4 days which led to in ineffective pain control. This deficient practice could affect 37 residents who were on a pain management program and could result ineffective pain control. The findings were: Review of the facility's Abuse Prohibition and Procedure policy on 6/30/16 revealed: As a general overall policy, the facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of of the facility's Pain Assessment policy 6/30/16 revealed the following relevant components: Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: - A comprehensive pain assessment should be complete as part of the initial nursing assessment with development of a pain management program as indicated. -Evaluation and reporting of pain indicators is expected with routine resident interaction. -Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with resident's established goals. Steps in procedure: -Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene per plan of care. -Offer non-pharmacological interventions as appropriate -Offer any prn [MEDICATION NAME] mediations as appropriate -Document administration and effectiveness of prn medication. Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE] with the primary physician listed as Medical Director AA. Review of Resident #8's Pain assessment dated [DATE] revealed Resident #8 had an Transmetatarsal Amputation. Review of Resident #8's Pain assessment dated [DATE] revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Lower Extremity 5. Type of pain: External 6. Description of Pain: Dull 7. Onset of pain: Acute 8. Frequency of pain: Occasional 9. Pain intensity: 7/10 11. Non verbal signs of pain: Facial grimacing, irritable, [MEDICAL CONDITION], restless 12. Pain relieved by: Medication 13. Effects of pain: Sleep affected 14. Conclusion: Pain issues, management is effective; see care plan Completed by LVN J Review of Pain Assessment completed 6/14/16 revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Not Described 5. Type of pain: External 6. Description of Pain: Unchecked 7. Onset of pain: Acute 8. Frequency of pain: Unchecked 9. Pain intensity: 3/10 11. Non verbal signs of pain: None Observed 12. Pain relieved by: Medication 13. Effects of pain: Changes in ADL's 14. Conclusion: No pain, no intervention needed Review of Resident #8's Minimum Data Set completed 6/14/16 revealed Resident #8's BIMS was a 13 (cognitively intact). Review of Resident #8's Care Plan completed 6/14/16 revealed the following: Problem/Need-Resident at risk for increased Pain R/T (related to) recent TMA (Transmetatarsal amputation) with wound vac in place: Goal & Target Date- -Resident will have relief from pain when prn medication is used x 90 days 9/14/16 -Resident will maintain his tolerable pain level of 3/10 with use of prn medications 9/14/16 Approaches- -Monitor resident for s/s of pain: restlessness, tearfulness, moaning, anxiety, agitation, actual c/o. -Make resident as physically comfortable as possible by repositioning, using positioning pillows, giving back rubs, etc -Give prn pain medications per MD orders -Monitor for effectiveness of prn pain med -Notify MD/RP if pain medication isn't effective in relieving pain, if injury has occurred, or if pain increases in freq or intensity -Follow MD orders after notification Interview, during initial tour, on 6/28/2016 at 12:07 p.m., with LVN J, revealed Resident #8 had his left toes amputated and had a wound vac attached to his left foot. Resident #8 was experiencing pain in his left foot, at this time, according to LVN J (after speaking to Resident #8 in Spanish), and said Resident #8 was prescribed Tylenol #3 for pain and LVN J notified the assigned 200 hall nurse, LVN O, that Resident #8 was in need of pain medications. Review of Resident #8's nursing note on 6/24/16 at 11:08 a.m. revealed LVN O called Medical Director AA's office at 10:00 a.m. and spoke with clerk to notify that a prescription for Tylenol #3 one tab PO Q 4hrs PRN was needed. The Clerk said that she would notify MD and return phone call once it was ready. Interview on 6/30/16 at 2:40 p.m. with the clerk of Medical Director AA revealed the clerk recalled LVN O calling on 6/24/16 to request Tylenol #3 prescription for Resident #8 and was told Resident #8 would need to be seen by the doctor. Since Resident #8 had no insurance, he was not accepted as a patient for Medical Director AA and LVN O was notified of this. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was administered Tylenol 325 mg x 2 at 12:15 p.m., pain being assessed at 10 out of 10. Observation and interview on 6/28/16 at 3:20 p.m. with LVN O revealed Resident #8 did not have any Tylenol #3 available in the medication cart. LVN O said Resident #8's Tylenol #3 had not been administered since 6/24/16. LVN O further said although Resident #8 had been reporting a pain level of 5 or 6 out of 10, the Tylenol #3 medication had ran out on 6/24/16 and Resident #8 had been requesting medication for pain every 4 hours. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed Medical director AA did not fill Resident #8's Tylenol #3 prescription and did not accept Resident #8 as a patient due to having no insurance. The interview further revealed the other Medical Directors on staff were out of town when Resident #8's Tylenol #3 ran out. Review of the 24 hour log for Resident #8 on 6/28/16 revealed the following entries: 6/18/16-Need MD appointment 6/19/16-Need MD appointment setup as soon as possible pending insurance clearance 6/21/16-Need MD appointment setup as soon as possible pending insurance clearance 6/23/16-Need MD appointment setup as soon as possible 6/24/16-MD appointment setup as soon as possible 6/26/16-MD appointment setup as soon as possible needs Tylenol #3 6/27/16-Appointment setup as soon as possible needs Tylenol #3. Appointment 1:30 p.m. 6/28/16, evening pass on reports the same. 6/28/16-Appointment physician assistant at 1:30 p.m. Review of Resident #8's Pharmacy Services Individual Drug Record revealed Resident #8's Tylenol#3 was stopped being administered on 6/24/16 and then began to be administered again on 6/30/16. Review of Resident #8's June 2016 MAR indicated [REDACTED]. Interview on 7/1/16 at approximately 12:30 p.m. with Regional Nurse W revealed PRN Tylenol #3 not indicated as administered on Resident #8's Control Medication Log on 6/29/16 due to being administered from E-Kit. Interview on 7/1/16 at 12:07 p.m. with Regional Nurse W revealed Resident #8's medication count for controlled substance had not been documented in all 3 areas: MARS, nurses notes and controlled substance logs. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was assessed for pain 7/10 was re-assessed at 6:00 p.m., resident stating pain diminished. Interview on 6/28/16 at 5:36 p.m. with Resident #8 revealed Resident #8 reported current pain level at 5 out of 10 with regular Tylenol 650 mg but said he had not been able to sleep in over 5 days. Resident #8 indicated he had been able to sleep when Tylenol #3 was administered and found it to be effective for pain. Resident #8 said he went to see doctor today (6/28/16) and Tylenol#3 prescription was issued. Resident #8 indicated in the past few days regular Tylenol had not been effective for pain. Resident #8 did not know why he had to wait 4 days for his Tylenol #3. Interview on 6/29/16 9:15 a.m. with Physician Assistant CC of Medical Director BB revealed Resident #8 was examined by PA CC on 6/28/16 in the office. PA CC reported resident #8's pain to be severe upon examination. Resident was prescribed Tylenol #3 for pain. PA CC was asked if Tylenol 650 mg would be an appropriate dose to manage pain for resident at this time. PA CC reported no, it would be like chewing bubble gum. Review of Resident #8's physical examination conducted on 6/28/16 at the office of Medical Director BB, conducted by PA CC for pain to Resident #8's left foot revealed Resident #8 moaning and groaning from pain during examination. Further review of this same document under Impression revealed severe pain to patient. Further review of this same document revealed a prescription was written for Tylenol #3 for pain. Interview on 6/28/16 at 4:40 p.m. with LVN J stated Resident #8 has always assessed pain at 7 out of 10. LVN J further indicated Resident #8 usually asked for more pain medication at night around 8:00 p.m. to 9:00 p.m. and Resident #8 could usually sleep after receiving his pain medications. Interview and observation on 6/29/16 at 7:43 a.m. of Resident #8 revealed Resident #8 was moaning and groaning, face grimacing and appeared to be in much pain. Resident #8 said he was having convulsions in his foot. Resident #8 said he still did not have the Tylenol #3 available to him. Resident #8 reported his pain level as stronger than 10 out of 10. Resident #8 was offered Tylenol 650 mg but he refused the medication and indicated it was not effective. Resident #8 further said he wanted to be discharged from the facility. Resident #8 indicated he had been in severe pain for the past 5 days and was having trouble sleeping. Interview on 7/1/16 at 8:45 a.m. with CNA Y (night shift on 200 hall) revealed Resident #8 frequently complained of pain. Resident #8 was frequently asking for pain medications and would ask CNA Y if wound vac was working because of the pain he was continuing to experience. CNA Y further indicated Resident #8 would wake up 4-8 times a night due to pain. CNA Y indicated that when Resident #8 ran out of Tylenol #3 pain medication he was aware of it and stopped asking for it. He continued to be in pain however. Interview on 6/29/16 at 8:11 a.m. with LVN O revealed the Tylenol #3 would not be available from the pharmacy until 6:00 p.m. (on 6/29/16). Interview on 6/29/16 at 8:25 a.m. with the DON revealed she did not know why Resident #8's Tylenol #3 had not been given from the emergency medication kit. The DON asked LVN O who said, at 5:00 p.m. the prior day 6/28/16 Resident #8 was given Tylenol 650 mg which appeared to be effective for pain. LVN O indicated that she called for a code this a.m. to get access to emergency kit and should be given the code in next 10 minutes. Review of Resident #8's Nursing Notes dated 6/29/16 revealed at 8:55 a.m. the pharmacy was called to request authorization number to administer PRN Tylenol #3 1 tablet. Tylenol #3 was administered and the resident states pain 10/10 from scale 1-10 being the worst. Rechecked resident again at 9:20 a.m. and reported pain subsided. Review of nursing notes 6/29/16 of LVN O revealed Resident #8 was administered Tylenol 325 mg x 2 at 7:45 a.m., pain being assessed at 10 out of 10. Interview on 6/29/16 at 10:12 a.m. with DON and the Administrator revealed Resident #8's pain was being effectively managed with Tylenol 650 mg dose. Surveyor explained that the resident had an amputation of toes and regular Tylenol was not sufficient to manage pain, according to Resident #8 himself. DON reported that amputation took place three weeks ago. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed staff documentation in nursing notes indicated Tylenol 650 mg dose was effective to manage pain on Resident #8. Review of CMS form 672 dated 6/28/16 were revealed there were 37 residents who were on a pain management program.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 7 of 18 residents (#8, 18, 1, 5, 3, 17, and 15) reviewed for care in that: 1. Resident #8 had a recent amputation of his toes and was prescribed Tylenol #3 for pain management. Resident #8's Tylenol #3's prescription was not refilled for 4 days which led to in ineffective pain control. 2. Resident #18 did not receive his [MEDICATION NAME] for two days and experienced a pain level of 8 (Scale of 1-10). 3. Resident #1's indwelling urinary catheter was raised above the level of the bladder during a hoyer lift. 4. Resident #5's suprapubic catheter was not anchored to his leg to prevent trauma. 5. Resident #17 was not listed on the non pressure wound log. 6. Resident #3's indwelling urinary catheter bag was raised above the bladder during care by CNA F and I. 7. Resident #15's cardiac implanted pacemaker was not listed as a diagnoses, was not on the physician's orders, did not have parameters for monitoring and was not care planned. These deficient practices could affect 37 residents who were on a pain management program, 11 residents with pacemakers, 1 resident with suprapubic catheter, 6 residents with indwelling catheters, 4 residents on the non pressure list on the 300 Hall and could result ineffective pain control, place the residents at risk for complications due to cardiac pacemaker malfunction, residents not receiving the appropriate skin treatment and catheters being raised could result in infections. The findings were: 1. Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE] with the primary physician listed as Medical Director AA. Review of Resident #8's Pain assessment dated [DATE] revealed Resident #8 had an Transmetatarsal Amputation. Review of Resident #8's Pain assessment dated [DATE] revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Lower Extremity 5. Type of pain: External 6. Description of Pain: Dull 7. Onset of pain: Acute 8. Frequency of pain: Occasional 9. Pain intensity: 7/10 11. Non verbal signs of pain: Facial grimacing, irritable, [MEDICAL CONDITION], restless 12. Pain relieved by: Medication 13. Effects of pain: Sleep affected 14. Conclusion: Pain issues, management is effective; see care plan Completed by LVN J Review of Pain Assessment completed 6/14/16 revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Not Described 5. Type of pain: External 6. Description of Pain: Unchecked 7. Onset of pain: Acute 8. Frequency of pain: Unchecked 9. Pain intensity: 3/10 11. Non verbal signs of pain: None Observed 12. Pain relieved by: Medication 13. Effects of pain: Changes in ADL's 14. Conclusion: No pain, no intervention needed Review of Resident #8's Minimum Data Set completed 6/14/16 revealed Resident #8's BIMS was a 13 (cognitively intact). Review of Resident #8's Care Plan completed 6/14/16 revealed the following: Problem/Need-Resident at risk for increased Pain R/T (related to) recent TMA (Transmetatarsal amputation) with wound vac in place: Goal & Target Date- -Resident will have relief from pain when prn medication is used x 90 days 9/14/16 -Resident will maintain his tolerable pain level of 3/10 with use of prn medications 9/14/16 Approaches- -Monitor resident for s/s of pain: restlessness, tearfulness, moaning, anxiety, agitation, actual c/o. -Make resident as physically comfortable as possible by repositioning, using positioning pillows, giving back rubs, etc -Give prn pain medications per MD orders -Monitor for effectiveness of prn pain med -Notify MD/RP if pain medication isn't effective in relieving pain, if injury has occurred, or if pain increases in freq or intensity -Follow MD orders after notification Interview, during initial tour, on 6/28/2016 at 12:07 p.m., with LVN J, revealed Resident #8 had his left toes amputated and had a wound vac attached to his left foot. Resident #8 was experiencing pain in his left foot, at this time, according to LVN J (after speaking to Resident #8 in Spanish), and said Resident #8 was prescribed Tylenol #3 for pain and LVN J notified the assigned 200 hall nurse, LVN O, that Resident #8 was in need of pain medications. Review of Resident #8's nursing note on 6/24/16 at 11:08 a.m. revealed LVN O called Medical Director AA's office at 10:00 a.m. and spoke with clerk to notify that a prescription for Tylenol #3 one tab PO Q 4hrs PRN was needed. The Clerk said that she would notify MD and return phone call once it was ready. Interview on 6/30/16 at 2:40 p.m. with the clerk of Medical Director AA revealed the clerk recalled LVN O calling on 6/24/16 to request Tylenol #3 prescription for Resident #8 and was told Resident #8 would need to be seen by the doctor. Since Resident #8 had no insurance, he was not accepted as a patient for Medical Director AA and LVN O was notified of this. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was administered Tylenol 325 mg x 2 at 12:15 p.m., pain being assessed at 10 out of 10. Observation and interview on 6/28/16 at 3:20 p.m. with LVN O revealed Resident #8 did not have any Tylenol #3 available in the medication cart. LVN O said Resident #8's Tylenol #3 had not been administered since 6/24/16. LVN O further said although Resident #8 had been reporting a pain level of 5 or 6 out of 10, the Tylenol #3 medication had ran out on 6/24/16 and Resident #8 had been requesting medication for pain every 4 hours. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed Medical director AA did not fill Resident #8's Tylenol #3 prescription and did not accept Resident #8 as a patient due to having no insurance. The interview further revealed the other Medical Directors on staff were out of town when Resident #8's Tylenol #3 ran out. Review of the 24 hour log for Resident #8 on 6/28/16 revealed the following entries: 6/18/16-Need MD appointment 6/19/16-Need MD appointment setup as soon as possible pending insurance clearance 6/21/16-Need MD appointment setup as soon as possible pending insurance clearance 6/23/16-Need MD appointment setup as soon as possible 6/24/16-MD appointment setup as soon as possible 6/26/16-MD appointment setup as soon as possible needs Tylenol #3 6/27/16-Appointment setup as soon as possible needs Tylenol #3. Appointment 1:30 p.m. 6/28/16, evening pass on reports the same. 6/28/16-Appointment physician assistant at 1:30 p.m. Review of Resident #8's Pharmacy Services Individual Drug Record revealed Resident #8's Tylenol#3 was stopped being administered on 6/24/16 and then began to be administered again on 6/30/16. Review of Resident #8's June 2016 MAR indicated [REDACTED]. Interview on 7/1/16 at approximately 12:30 p.m. with Regional Nurse W revealed PRN Tylenol #3 not indicated as administered on Resident #8's Control Medication Log on 6/29/16 due to being administered from E-Kit. Interview on 7/1/16 at 12:07 p.m. with Regional Nurse W revealed Resident #8's medication count for controlled substance had not been documented in all 3 areas: MARS, nurses notes and controlled substance logs. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was assessed for pain 7/10 was re-assessed at 6:00 p.m., resident stating pain diminished. Interview on 6/28/16 at 5:36 p.m. with Resident #8 revealed Resident #8 reported current pain level at 5 out of 10 with regular Tylenol 650 mg but said he had not been able to sleep in over 5 days. Resident #8 indicated he had been able to sleep when Tylenol #3 was administered and found it to be effective for pain. Resident #8 said he went to see doctor today (6/28/16) and Tylenol#3 prescription was issued. Resident #8 indicated in the past few days regular Tylenol had not been effective for pain. Resident #8 did not know why he had to wait 4 days for his Tylenol #3. Interview on 6/29/16 9:15 a.m. with Physician Assistant CC of Medical Director BB revealed Resident #8 was examined by PA CC on 6/28/16 in the office. PA CC reported resident #8's pain to be severe upon examination. Resident was prescribed Tylenol #3 for pain. PA CC was asked if Tylenol 650 mg would be an appropriate dose to manage pain for resident at this time. PA CC reported no, it would be like chewing bubble gum. Review of Resident #8's physical examination conducted on 6/28/16 at the office of Medical Director BB, conducted by PA CC for pain to Resident #8's left foot revealed Resident #8 moaning and groaning from pain during examination. Further review of this same document under Impression revealed severe pain to patient. Further review of this same document revealed a prescription was written for Tylenol #3 for pain. Interview on 6/28/16 at 4:40 p.m. with LVN J stated Resident #8 has always assessed pain at 7 out of 10. LVN J further indicated Resident #8 usually asked for more pain medication at night around 8:00 p.m. to 9:00 p.m. and Resident #8 could usually sleep after receiving his pain medications. Interview and observation on 6/29/16 at 7:43 a.m. of Resident #8 revealed Resident #8 was moaning and groaning, face grimacing and appeared to be in much pain. Resident #8 said he was having convulsions in his foot. Resident #8 said he still did not have the Tylenol #3 available to him. Resident #8 reported his pain level as stronger than 10 out of 10. Resident #8 was offered Tylenol 650 mg but he refused the medication and indicated it was not effective. Resident #8 further said he wanted to be discharged from the facility. Resident #8 indicated he had been in severe pain for the past 5 days and was having trouble sleeping. Interview on 7/1/16 at 8:45 a.m. with CNA Y (night shift on 200 hall) revealed Resident #8 frequently complained of pain. Resident #8 was frequently asking for pain medications and would ask CNA Y if wound vac was working because of the pain he was continuing to experience. CNA Y further indicated Resident #8 would wake up 4-8 times a night due to pain. CNA Y indicated that when Resident #8 ran out of Tylenol #3 pain medication he was aware of it and stopped asking for it. He continued to be in pain however. Interview on 6/29/16 at 8:11 a.m. with LVN O revealed the Tylenol #3 would not be available from the pharmacy until 6:00 p.m. (on 6/29/16). Interview on 6/29/16 at 8:25 a.m. with the DON revealed she did not know why Resident #8's Tylenol #3 had not been given from the emergency medication kit. The DON asked LVN O who said, at 5:00 p.m. the prior day 6/28/16 Resident #8 was given Tylenol 650 mg which appeared to be effective for pain. LVN O indicated that she called for a code this a.m. to get access to emergency kit and should be given the code in next 10 minutes. Review of Resident #8's Nursing Notes dated 6/29/16 revealed at 8:55 a.m. the pharmacy was called to request authorization number to administer PRN Tylenol #3 1 tablet. Tylenol #3 was administered and the resident states pain 10/10 from scale 1-10 being the worst. Rechecked resident again at 9:20 a.m. and reported pain subsided. Review of nursing notes 6/29/16 of LVN O revealed Resident #8 was administered Tylenol 325 mg x 2 at 7:45 a.m., pain being assessed at 10 out of 10. Interview on 6/29/16 at 10:12 a.m. with DON and the Administrator revealed Resident #8's pain was being effectively managed with Tylenol 650 mg dose. Surveyor explained that the resident had an amputation of toes and regular Tylenol was not sufficient to manage pain, according to Resident #8 himself. DON reported that amputation took place three weeks ago. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed staff documentation in nursing notes indicated Tylenol 650 mg dose was effective to manage pain on Resident #8. Review of the facility's Abuse Prohibition and Procedure policy on 6/30/16 revealed: As a general overall policy, the facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of of the facility's Pain Assessment policy 6/30/16 revealed the following relevant components: Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: - A comprehensive pain assessment should be complete as part of the initial nursing assessment with development of a pain management program as indicated. -Evaluation and reporting of pain indicators is expected with routine resident interaction. -Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with resident's established goals. Steps in procedure: -Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene per plan of care. -Offer non-pharmacological interventions as appropriate -Offer any prn [MEDICATION NAME] mediations as appropriate -Document administration and effectiveness of prn medication. 2. Review of Resident #18's face sheet dated 7/7/16, revealed he was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Minimum (MDS) data set [DATE] revealed Resident #18 had a BIMS of 15 (cognitively Intact). Review of Resident #18's Physician's Telephone Order dated 6/17/16 revealed [MEDICATION NAME] 50 mg 1 tab po bid for pain. Review of Resident #18's care plan completed 6/15/16 revealed: Problem/Need: Resident at risk for alteration in comfort R/T diabetic [MEDICAL CONDITION]: Goal & Target Date: Resident will have relief from pain when prn medication is used x 90 days 9/15/16 Approaches: Give prn pain medication per MD orders Review of Resident #18's June 2016 MAR indicated [REDACTED]. Further review of this same document revealed [MEDICATION NAME] was not administered to Resident #18 on 6/18/16 or the evening dose of 6/17/16. Further review of this same document revealed the following: 6/17/16 at 4:18 p.m. [MEDICATION NAME] pending rx. 6/18/16 at 7:33 a.m. [MEDICATION NAME] pending arrival. 6/18/16 at 4:21 p.m. [MEDICATION NAME] pending rx. 6/18/16 11:31 a.m. [MEDICATION NAME] pending arrival for pharmacy. Review of Resident #18's Nursing Notes dated 6/17/16 revealed receive new order as follow [MEDICATION NAME] 50 mg administer 1 tablet by mouth twice a day. Review of Resident #18's Nursing Notes dated 6/20/16 inputted at 10:26 a.m. revealed called Medical Director AA's office and left message of need RX for [MEDICATION NAME]. Will return call when RX to be pickup. Review of Resident #18's Nursing Notes dated 6/20/16 inputted at 5:50 p.m. revealed received RX for [MEDICATION NAME]. Fax to pharmacy pending medication arrival. Interview on 7/1/16 at approximately 10:00 a.m. with Resident #18 revealed he had experienced a pain level of 8 (scale 1-10) for the 2 days that he did not receive his [MEDICATION NAME] but it did not affect his functional abilities. Interview with LVN O on 7/1/16 at 11:02 a.m. revealed the [MEDICATION NAME] medication came in on 6/20/16. LVN O said she did not know why Resident #18 did not receive [MEDICATION NAME] for 2 days because she was not involved in the process. Interview with Regional Nurse W on 7/1/16 at 3:00 p.m. revealed Resident #18 was not administrated [MEDICATION NAME] on 6/17/16 and 6/18/16 and was not sure why the nurse did not utilize the emergency medication kit and thought possibly the nurse may not have known the [MEDICATION NAME] was available in the emergency medication kit. Resident #18's family member had brought in [MEDICATION NAME] from home that was administrated on the evening of the 19th and on the 20th. Regional Nurse W further indicated Resident #18's [MEDICATION NAME] blister pack was dated 6/21/16. 3. Review of resident #1's face sheet, dated 06/29/16, revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 06/29/16 at 4:50 p.m. revealed CNA's B and EE transferred resident #1 via hoyer lift from her bed to her gerichair. Further observation revealed CNA B raised the indwelling urinary catheter bag above the level of the bladder while passing it to CNA EE. CNA EE kept the urinary catheter bag below the level of the bladder during the transfer. Interview with CNA B on 06/29/16 immediately following the hoyer lift transfer revealed she realized she had raised the indwelling urinary catheter bag above the level of the bladder. During an interview with the DON and the Nurse Consultant on 06/30/16 at 10:05 a.m., they confirmed resident #1 was admitted to the facility with an indwelling urinary catheter and they confirmed that the indwelling urinary catheter bag should not have been raised above the level of the bladder during the hoyer lift transfer. Review of resident #1's MDS, dated [DATE], revealed under Section H-Bladder and Bowel resident's urinary continence was a 9 and this indicated that she had an indwelling urinary catheter. Review of resident #1's care plan dated 06/03/16 revealed the resident had an indwelling urinary catheter with goals that the staff would anticipate and meet need daily and as needed. Review of a facility policy titled Catheter Care, Urinary dated 07/15 revealed The urinary drainage bag should be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. 4. Review of the face sheet, dated 06/29/16 for resident #5 revealed he was initially admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the consolidated physician's orders for June 2016 revealed an order may use leg strap to help cath in place. Observation on 06/28/16 at 11:53 a.m. during initial rounds revealed resident #5 had an indwelling supra pubic catheter. The catheter was not anchored or secured to the abdomen or leg to prevent trauma. In an interview with LVN A on 06/29/16 at 11:53 a.m. she stated that it was the CNA's and the nurses' responsibility to ensure that a leg strap was in place. During an interview with the DON and the Nurse Consultant on 06/30/16 at 10:00 a.m. they confirmed that resident #5 should have had a leg strap in place to secure the catheter. The DON confirmed the residents' supra pubic catheter was inserted on 11/03/14 as he was a quadraplegic. Review of a facility policy titled Catheter Care, Urinary dated 07/15, revealed Secure catheter tubing to prevent pulling. 5. Review of resident #17's face sheet, dated 5/16/16 revealed she was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the pressure and non-pressure wound logs, dated 6/27/16, provided by the facility did not reveal resident #17 listed on the wound logs. Review of resident #17's Wound Assessment Report, dated 6/27/16 revealed wound location was left buttock and was described as denuded (stripping of outside layer). The cause was listed as self-inflicted scratching/picking. The measurements were 5.0 cm x 3.0 cm x 0.00 cm. Review of resident #17's Physician's Telephone Order dated 6/14/16 revealed an order for [REDACTED]. The order had a stop date of 6/28/16. Review of resident #17's June 2016 eTAR revealed an entry for [MEDICATION NAME] cream apply to affected area twice a day. The order started on 6/14/16 and stopped on 6/28/16. Observation and interview on 7/1/16 at 9:20 a.m. revealed perineal care for resident #17 was provided by CNA DD and F. Open area with pink tissue was revealed on the left buttocks and the right buttocks had small open areas on the buttocks. The entire buttocks area was red. CNA F said the area looked better. CNA F said the nurses were treating the area. The CNAs applied periguard to the buttocks. Interview on 7/1/16 at 9:45 a.m. with the treatment nurse confirmed resident #17 was not listed on the wound sheets. She confirmed she was not doing any treatments. She said she would check on resident #17's treatments. Interview with the treatment nurse on 7/1/16 at 11:30 a.m. revealed she had been off for a couple of months and had returned this week. She revealed resident #17 did not have any treatments to the buttocks. She said she measured resident #17's wounds on the buttocks and the right buttock with the small areas was measured as one area and it measured 4.0 x 4.0 cms. The left buttock measured 5.0 cm x 1.0 cm. The treatment nurse said the areas heal and then resident #17 scratches and the areas re-open. 6. Review of resident #3's face sheet, dated 6/29/16, revealed he was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/29/16 at 7:50 a.m. revealed catheter and perineal care was provided for resident #3 by CNA F and I. During the care CNA F handed the indwelling urinary catheter bag over the bed above the level of the bladder to CNA I. Interview on 6/29/16 at 12:58 p.m. with CNA I revealed she passed the indwelling urinary catheter bag over the bed above the level of the bladder. CNA I said she was trying not to touch the sheets with the catheter bag. 7. Review of Resident #15's undated Face Sheet, revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], [MEDICAL CONDITIONS], and vitamin deficiency. There was no indication in the [DIAGNOSES REDACTED]. Review of Resident #15's medical record revealed a chest x-ray, dated 11/22/14, that indicated the resident had a cardiac pacemaker. Observation of Resident #15's chest on 7/1/16 at 10:07 a.m. with LVN O revealed a cardiac pacemaker was inserted in the upper right side of the resident's chest, with a surgical scar below the clavicle bone. LVN O reported she was able to palpate the pacemaker. LVN O asked the resident in Spanish if he had a pace maker and the resident nodded his head up and down to indicate yes. Review of Resident #15's Quarterly MDS, assessment reference date of 6/1/16, revealed no documentation of a pacemaker. Review of Resident #15's care plans revealed the pacemaker was not addressed. Review of Resident #15's clinical record revealed there was no documentation identifying Resident #15's pacemaker's normal pulse limits (parameters). Review of Resident #15's clinical record from 5/18/2015 to 6/30/2016 revealed in the progress notes section and physician's notes, no indication the resident had been seen by a cardiologist to evaluate the resident's pacemaker. An interview with LVN O on 7/1/16 at 10:18 a.m., she confirmed Resident #15 had a cardiac pacemaker, there was no documentation regarding the normal pulse limits (parameters) for Resident #15's pacemaker, and there was no care plan for the pacemaker. LVN O was able to show the surveyor Resident #15's medical cards for the pacemaker with the make, model and physician to contact. LVN O reported she did not know when the resident's pacemaker was last checked by the physician. Review of Resident #15's pacemaker medical cards revealed the pacemaker was implanted on 3/12/2012. Review of the pacemaker manufacturer's online manual <http://manuals.medtronic.com/manuals/search?country=us&cfn=ADVDD01&manualType=Patient+Manual&manualLanguage=EN> for Resident #15's pacemaker revealed on pages 48, 49 and 52 the pacemaker should be checked by the physician's office at least once a year to check the pacemaker's settings, battery status, and how the pacemaker lead interacts with the heart. Interview with ADON T on 7/1/16 at 3:50 p.m. confirmed Resident #15's face sheet, physician's orders did not include a [DIAGNOSES REDACTED]. A handwritten sheet provided by the facility revealed 11 residents with pacemakers, 1 resident with suprapubic catheter, 6 residents with indwelling catheters, 4 residents on the non pressure list on the 300 Hall. Review of CMS form 672 dated 6/28/16 revealed there were 37 residents who were on a pain management program.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to assure the accurate administering of all drugs, to include accurate documentation of administration, to meet the needs of each resident for 11 of 21 residents (#8,13, 3, 22, 23, 24, 25, 9, 4, 26 and 18) reviewed and failed to remove expired medications in 2 of 6 medication carts (Hall 200, 300). 1. Resident #8 a. Resident #8 had a recent amputation of his toes and was prescribed Tylenol #3 for pain management. Resident #8's Tylenol #3's prescription was not refilled for 4 days which led to in ineffective pain control. b. Resident #8's prn pain medication was not being consistently documented on the Medication Administration Record after being administrated. 2. Resident #18 did not receive his Lyrica for two days and experienced a pain level of 8 (Scale of 1-10). 3. Resident #13 had Tramadol scheduled to be given at 12:00 p.m. and Ibuprofen scheduled to be given at 1:00 p.m., however, the resident went to dialysis 3 days a week and was not given the medications as ordered. 4. Resident #3 received Epogen that was held without hold parameters. 5. Humulin R insulin was not available to be administered to Resident #25 when the residents blood sugar was 320 and it was ordered to administer 6 units of Humulin R. 6. Resident #9 did not receive the full dose of Merrem (IV antibiotic) before the IV medication infusion was stopped. 7. Bisacodyl suppository was not available for LVN M to administer to resident #4 during the scheduled medication administration. 8. Resident #26 was not administered 6 scheduled doses of Sinemet 10/100 mg as ordered by the physician for 4 days. 9. Expired medications: a. 200 Hall nurse medication cart: One bottle of Nitrostat which was opened for longer than a year for resident #23. One bottle of Nitrostat which had an expiration date of 4/2016 for resident #24. b. 300 Hall nurse medication cart: Fluphenazine [DATE] mg/ml did not have an open date for resident #22. These deficient practices could affect 3 residents on 400 Hall who received Tramadol, 3 residents on 400 Hall who received Ibuprofen, 4 residents who received Epogen, 5 residents who received Nitrostat on 200 Hall, 1 resident who received Fluphenazine on the 300 Hall, 1 resident who received sliding scale Humulin R insulin on the 100 Hall, 3 residents who received IV antibiotics, 1 resident who received dulcolax on 400 Hall, 37 residents who were on a pain management program, and 2 residents who received Sinemet on 200 Hall and could result in the residents not receiving a therapeutic dose or medication errors, could cause adverse reactions and result in antibiotic resistant bacteria. The findings were: 1a. Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE] with the primary physician listed as Medical Director AA. Review of Resident #8's Pain assessment dated [DATE] revealed Resident #8 had an Transmetatarsal Amputation. Review of Resident #8's Pain assessment dated [DATE] revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Lower Extremity 5. Type of pain: External 6. Description of Pain: Dull 7. Onset of pain: Acute 8. Frequency of pain: Occasional 9. Pain intensity: 7/10 11. Non verbal signs of pain: Facial grimacing, irritable, insomnia, restless 12. Pain relieved by: Medication 13. Effects of pain: Sleep affected 14. Conclusion: Pain issues, management is effective; see care plan Completed by LVN J Review of Pain Assessment completed 6/14/16 revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Not Described 5. Type of pain: External 6. Description of Pain: Unchecked 7. Onset of pain: Acute 8. Frequency of pain: Unchecked 9. Pain intensity: 3/10 11. Non verbal signs of pain: None Observed 12. Pain relieved by: Medication 13. Effects of pain: Changes in ADL's 14. Conclusion: No pain, no intervention needed Review of Resident #8's Minimum Data Set completed 6/14/16 revealed Resident #8's BIMS was a 13 (cognitively intact). Review of Resident #8's Care Plan completed 6/14/16 revealed the following: Problem/Need-Resident at risk for increased Pain R/T (related to) recent TMA (Transmetatarsal amputation) with wound vac in place: Goal & Target Date- -Resident will have relief from pain when prn medication is used x 90 days 9/14/16 -Resident will maintain his tolerable pain level of 3/10 with use of prn medications 9/14/16 Approaches- -Monitor resident for s/s of pain: restlessness, tearfulness, moaning, anxiety, agitation, actual c/o. -Make resident as physically comfortable as possible by repositioning, using positioning pillows, giving back rubs, etc -Give prn pain medications per MD orders -Monitor for effectiveness of prn pain med -Notify MD/RP if pain medication isn't effective in relieving pain, if injury has occurred, or if pain increases in freq or intensity -Follow MD orders after notification Interview, during initial tour, on 6/28/2016 at 12:07 p.m., with LVN J, revealed Resident #8 had his left toes amputated and had a wound vac attached to his left foot. Resident #8 was experiencing pain in his left foot, at this time, according to LVN J (after speaking to Resident #8 in Spanish), and said Resident #8 was prescribed Tylenol #3 for pain and LVN J notified the assigned 200 hall nurse, LVN O, that Resident #8 was in need of pain medications. Review of Resident #8's nursing note on 6/24/16 at 11:08 a.m. revealed LVN O called Medical Director AA's office at 10:00 a.m. and spoke with clerk to notify that a prescription for Tylenol #3 one tab PO Q 4hrs PRN was needed. The Clerk said that she would notify MD and return phone call once it was ready. Interview on 6/30/16 at 2:40 p.m. with the clerk of Medical Director AA revealed the clerk recalled LVN O calling on 6/24/16 to request Tylenol #3 prescription for Resident #8 and was told Resident #8 would need to be seen by the doctor. Since Resident #8 had no insurance, he was not accepted as a patient for Medical Director AA and LVN O was notified of this. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was administered Tylenol 325 mg x 2 at 12:15 p.m., pain being assessed at 10 out of 10. Observation and interview on 6/28/16 at 3:20 p.m. with LVN O revealed Resident #8 did not have any Tylenol #3 available in the medication cart. LVN O said Resident #8's Tylenol #3 had not been administered since 6/24/16. LVN O further said although Resident #8 had been reporting a pain level of 5 or 6 out of 10, the Tylenol #3 medication had ran out on 6/24/16 and Resident #8 had been requesting medication for pain every 4 hours. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed Medical director AA did not fill Resident #8's Tylenol #3 prescription and did not accept Resident #8 as a patient due to having no insurance. The interview further revealed the other Medical Directors on staff were out of town when Resident #8's Tylenol #3 ran out. Review of the 24 hour log for Resident #8 on 6/28/16 revealed the following entries: 6/18/16-Need MD appointment 6/19/16-Need MD appointment setup as soon as possible pending insurance clearance 6/21/16-Need MD appointment setup as soon as possible pending insurance clearance 6/23/16-Need MD appointment setup as soon as possible 6/24/16-MD appointment setup as soon as possible 6/26/16-MD appointment setup as soon as possible needs Tylenol #3 6/27/16-Appointment setup as soon as possible needs Tylenol #3. Appointment 1:30 p.m. 6/28/16, evening pass on reports the same. 6/28/16-Appointment physician assistant at 1:30 p.m. Review of Resident #8's Pharmacy Services Individual Drug Record revealed Resident #8's Tylenol#3 was stopped being administered on 6/24/16 and then began to be administered again on 6/30/16. Review of Resident #8's June 2016 MAR revealed Resident #8 was not administered Tylenol #3 for pain 6/24/16-6/29/16. Interview on 7/1/16 at approximately 12:30 p.m. with Regional Nurse W revealed PRN Tylenol #3 not indicated as administered on Resident #8's Control Medication Log on 6/29/16 due to being administered from E-Kit. Interview on 7/1/16 at 12:07 p.m. with Regional Nurse W revealed Resident #8's medication count for controlled substance had not been documented in all 3 areas: MARS, nurses notes and controlled substance logs. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was assessed for pain 7/10 was re-assessed at 6:00 p.m., resident stating pain diminished. Interview on 6/28/16 at 5:36 p.m. with Resident #8 revealed Resident #8 reported current pain level at 5 out of 10 with regular Tylenol 650 mg but said he had not been able to sleep in over 5 days. Resident #8 indicated he had been able to sleep when Tylenol #3 was administered and found it to be effective for pain. Resident #8 said he went to see doctor today (6/28/16) and Tylenol#3 prescription was issued. Resident #8 indicated in the past few days regular Tylenol had not been effective for pain. Resident #8 did not know why he had to wait 4 days for his Tylenol #3. Interview on 6/29/16 9:15 a.m. with Physician Assistant CC of Medical Director BB revealed Resident #8 was examined by PA CC on 6/28/16 in the office. PA CC reported resident #8's pain to be severe upon examination. Resident was prescribed Tylenol #3 for pain. PA CC was asked if Tylenol 650 mg would be an appropriate dose to manage pain for resident at this time. PA CC reported no, it would be like chewing bubble gum. Review of Resident #8's physical examination conducted on 6/28/16 at the office of Medical Director BB, conducted by PA CC for pain to Resident #8's left foot revealed Resident #8 moaning and groaning from pain during examination. Further review of this same document under Impression revealed severe pain to patient. Further review of this same document revealed a prescription was written for Tylenol #3 for pain. Interview on 6/28/16 at 4:40 p.m. with LVN J stated Resident #8 has always assessed pain at 7 out of 10. LVN J further indicated Resident #8 usually asked for more pain medication at night around 8:00 p.m. to 9:00 p.m. and Resident #8 could usually sleep after receiving his pain medications. Interview and observation on 6/29/16 at 7:43 a.m. of Resident #8 revealed Resident #8 was moaning and groaning, face grimacing and appeared to be in much pain. Resident #8 said he was having convulsions in his foot. Resident #8 said he still did not have the Tylenol #3 available to him. Resident #8 reported his pain level as stronger than 10 out of 10. Resident #8 was offered Tylenol 650 mg but he refused the medication and indicated it was not effective. Resident #8 further said he wanted to be discharged from the facility. Resident #8 indicated he had been in severe pain for the past 5 days and was having trouble sleeping. Interview on 7/1/16 at 8:45 a.m. with CNA Y (night shift on 200 hall) revealed Resident #8 frequently complained of pain. Resident #8 was frequently asking for pain medications and would ask CNA Y if wound vac was working because of the pain he was continuing to experience. CNA Y further indicated Resident #8 would wake up 4-8 times a night due to pain. CNA Y indicated that when Resident #8 ran out of Tylenol #3 pain medication he was aware of it and stopped asking for it. He continued to be in pain however. Interview on 6/29/16 at 8:11 a.m. with LVN O revealed the Tylenol #3 would not be available from the pharmacy until 6:00 p.m. (on 6/29/16). Interview on 6/29/16 at 8:25 a.m. with the DON revealed she did not know why Resident #8's Tylenol #3 had not been given from the emergency medication kit. The DON asked LVN O who said, at 5:00 p.m. the prior day 6/28/16 Resident #8 was given Tylenol 650 mg which appeared to be effective for pain. LVN O indicated that she called for a code this a.m. to get access to emergency kit and should be given the code in next 10 minutes. Review of Resident #8's Nursing Notes dated 6/29/16 revealed at 8:55 a.m. the pharmacy was called to request authorization number to administer PRN Tylenol #3 1 tablet. Tylenol #3 was administered and the resident states pain 10/10 from scale 1-10 being the worst. Rechecked resident again at 9:20 a.m. and reported pain subsided. Review of nursing notes 6/29/16 of LVN O revealed Resident #8 was administered Tylenol 325 mg x 2 at 7:45 a.m., pain being assessed at 10 out of 10. Interview on 6/29/16 at 10:12 a.m. with DON and Administrator GG revealed Resident #8's pain was being effectively managed with Tylenol 650 mg dose. Surveyor explained that the resident had an amputation of toes and regular Tylenol was not sufficient to manage pain, according to Resident #8 himself. DON reported that amputation took place three weeks ago. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed staff documentation in nursing notes indicated Tylenol 650 mg dose was effective to manage pain on Resident #8. Review of the facility's Abuse Prohibition and Procedure policy on 6/30/16 revealed: As a general overall policy, the facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of of the facility's Pain Assessment policy 6/30/16 revealed the following relevant components: Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: - A comprehensive pain assessment should be complete as part of the initial nursing assessment with development of a pain management program as indicated. -Evaluation and reporting of pain indicators is expected with routine resident interaction. -Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of analgesic medication in relieving pain to a level that is in line with resident's established goals. Steps in procedure: -Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene per plan of care. -Offer non-pharmacological interventions as appropriate -Offer any prn analgesic mediations as appropriate -Document administration and effectiveness of prn medication. b. Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE]. Review of Resident #8's Physician Telephone Order dated 6/11/16 revealed Acetaminophen-COD #3 1 tab po q 4 hours prn. Review of Resident #8's June 2016 Consolidated Physician order [REDACTED]. Review of Resident #8's Individual Control Drug Record revealed Acetaminophen-COD #3 was administered on 6/23/16 at 1:00 a.m., 9:50 a.m. and 5:45 p.m. Review of Resident #8's June 2016 MAR revealed there were no entries for Acetaminophen-COD #3 for 6/23/16 as being administered. Review of Resident #8's Individual Control Drug Record revealed Acetaminophen-COD #3 was administered twice on 6/24/16. Review of Resident #8's June 2016 MAR revealed Resident #8 received the Acetaminophen-COD only once on 6/24/16. Review of Resident #8's Nursing Notes dated 6/25/16 inputted at 5:47 p.m. revealed administrated Tylenol 650 mg at 8:00 a.m. and at 3 p.m. Review of Resident #8's June 2016 MAR revealed there was no entries indicated Acetaminophen 650 mg was administrated for 6/25/16. Review of Resident #8's Nursing Notes dated 6/27/16 inputted at 12:45 a.m. revealed administered Acetaminophen 650 mg. Review of Resident #8's June 2016 MAR revealed there was no entries indicated Acetaminophen 650 mg was administrated for 6/27/16. Review of Resident #8's Nursing Notes dated 6/26/16 inputted at 5:59 p.m. revealed 4:30 p.m. administer Tylenol 325 mg 2 tabs. Review of Resident #8's Nursing Notes dated 6/26/16 inputted at 10:06 a.m. revealed Administered Tylenol 325 mg 2 tabs for pain. Review of Resident #8 June 2016 MAR revealed there were no entries indicated Acetaminophen 650 mg was administrated for 6/26/16. Review of Resident #8's Nursing Note dated 6/28/16 inputted at 2:47 a.m. revealed Administered Acetaminophen 650 mg PO for pain. Review of Resident #8's June 2016 MAR revealed only 1 entry for Acetaminophen 650 mg which was entered in at 5:54 p.m for 6/28/16. Interview on 7/1/16 at 12:07 p.m. with Regional Nurse W revealed Resident #8's medication count for controlled substance had not been documented in all 3 areas, Mars, nurses notes and controlled substance logs. 2. Review of Resident #18's face sheet dated 7/7/16, revealed he was admitted to the facility on [DATE] and re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's Minimum (MDS) data set [DATE] revealed Resident #18 had a BIMS of 15 (cognitively Intact). Review of Resident #18's Physician's Telephone Order dated 6/17/16 revealed Lyrica 50 mg 1 tab po bid for pain. Review of Resident #18's care plan completed 6/15/16 revealed: Problem/Need: Resident at risk for alteration in comfort R/T diabetic neuropathy: Goal & Target Date: Resident will have relief from pain when prn medication is used x 90 days 9/15/16 Approaches: Give prn pain medication per MD orders Review of Resident #18's June 2016 MAR revealed Lyrica 50 mg 1 tab PO BID ordered for pain start date 6/17/16 and end date 6/23/16. Further review of this same document revealed Lyrica was not administered to Resident #18 on 6/18/16 or the evening dose of 6/17/16. Further review of this same document revealed the following: 6/17/16 at 4:18 p.m. Lyrica pending rx. 6/18/16 at 7:33 a.m. Lyrica pending arrival. 6/18/16 at 4:21 p.m. Lyrica pending rx. 6/18/16 11:31 a.m. Lyrica pending arrival for pharmacy. Review of Resident #18's Nursing Notes dated 6/17/16 revealed receive new order as follow Lyrica 50 mg administer 1 tablet by mouth twice a day. Review of Resident #18's Nursing Notes dated 6/20/16 inputted at 10:26 a.m. revealed called Medical Director AA's office and left message of need RX for Lyrica. Will return call when RX to be pickup. Review of Resident #18's Nursing Notes dated 6/20/16 inputted at 5:50 p.m. revealed received RX for Lyrica. Fax to pharmacy pending medication arrival. Interview on 7/1/16 at approximately 10:00 a.m. with Resident #18 revealed he had experienced a pain level of 8 (scale 1-10) for the 2 days that he did not receive his Lyrica but it did not affect his functional abilities. Interview with LVN O on 7/1/16 at 11:02 a.m. revealed the Lyrica medication came in on 6/20/16. LVN O said she did not know why Resident #18 did not receive Lyrica for 2 days because she was not involved in the process. Interview with Regional Nurse W on 7/1/16 at 3:00 p.m. revealed Resident #18 was not administrated Lyrica on 6/17/16 and 6/18/16 and was not sure why the nurse did not utilize the emergency medication kit and thought possibly the nurse may not have known the Lyrica was available in the emergency medication kit. Resident #18's family member had brought in Lyrica from home that was administrated on the evening of the 19th and on the 20th. Regional Nurse W further indicated Resident #18's Lyrica blister pack was dated 6/21/16. 3. Review of resident #13's face sheet revealed he was admitted to the facility on [DATE], had a re-admitted [DATE], and [DIAGNOSES REDACTED]. Review of resident #13's June 2016 Consolidated Physician order [REDACTED]. Further review of resident #13's June 2016 Consolidated Physician order [REDACTED]. Review of resident #13's June 2016 MAR revealed the Tramadol was scheduled for 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. The MAR also revealed the Ibuprofen was scheduled for 9:00 a.m., 1:00 p.m. and 5:00 p.m. Closer observation of resident #13's June 2016 MAR revealed the resident did not receive his 12:00 p.m. dosage of Tramadol and his 1:00 p.m. dosage of Ibuprofen 3 days a week on Monday, Wednesday, and Friday for the month of June 2016. Interview on 6/30/16 at 10:40 a.m. with ADON T confirmed the resident was out to dialysis on Monday, Wednesday and Friday when he was suppose to receive his 12:00 p.m. dosage of Tramadol and his 1:00 p.m. dosage of Ibuprofen, however, she thought the orders had been changed to prn (as needed), but would look into it. Interview with ADON T on 6/30/16 at 11:14 a.m. revealed the resident's other medications had the times to be given changed or orders to hold the medication when the resident was out to dialysis, however, the Tramadol and Ibuprofen had not been changed to reflect when the resident was out of the facility. 4. Review of resident #3's face sheet, dated 6/29/16, revealed he was admitted on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Review of resident #3's June 2016 Consolidated physician's orders [REDACTED]. Administer 0.7 ml every Tuesday for anemia. (The order did not have hold parameters). Review of resident #3's June 2016 MAR revealed Epogen 10,000 units/ml administer 0.7 ml every Tuesday. On 6/21 and 6/28 the Epogen was scheduled to be administered. Interview on 6/30/16 at 12:05 p.m. with LVN A revealed she held and did not administer resident #3's Epogen on 6/21/16 because his hemoglobin was above 10. Interview on 7/1/16 at 10:45 a.m. with LVN K revealed she held and did not administer resident #3's Epogen on 6/28/16 because his hemoglobin was above 10. 5. Review of resident #25's undated face sheet, revealed she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #25's June 2016 Consolidated physician's orders [REDACTED].=3 units of insulin; 251-300=4 units; 301-350=6 units; 351-400=9 units; and 401-500=12 units. Observation on 6/28/16 at 5:00 p.m. of LVN A during medication administration revealed the nurse obtained an accucheck blood sugar level of 320 from resident #25. LVN A looked in the medication cart for resident #25's Humulin R insulin and could not find it. LVN A then went into the medication room and looked in the refrigerator and the pixis ekit for the Humulin R for resident #25 and did not find the insulin. Interview on 6/28/16 at 5:15 p.m. LVN A confirmed that Humulin R insulin was not available to be administered to resident #25. Interview on 6/28/16 at 6:36 p.m. with LVN A revealed she had completed a medication error report since the insulin was not available. Review of the Medication Administration Incident Report, dated 6/28/16, revealed at 5:15 p.m. the medication Humulin R was not administered as ordered when resident #25's blood sugar was 320 due to the medication was unavailable. The resident's physician was notified who gave orders to perform a one-time accucheck at 9 p.m., notify him if the blood sugar was greater than 350, and to monitor for any signs or symptoms of high blood sugar. Review of the June 2016 MAR for resident #25 revealed the one-time accucheck that was done at 9 p.m. on 6/28/16 had a blood sugar level of 305. The MAR also revealed the last time insulin had been administered to resident #25 was on 6/26/16 at 4 p.m. when 3 units were administered for a blood sugar level of 228. Interview on 6/30/16 at 2:57 p.m. with LVN R, who administered the 4 p.m. dose of insulin to resident #25 on 6/26/16, revealed she did not remember how much insulin was in the vial of Humulin R. 6. Review of resident #9's undated face sheet, revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #9's June 2016 Consolidated physician's orders [REDACTED]. Further review of Resident #9's June 2016 Consolidated physician's orders [REDACTED]. Observation on 6/29/16 from 7:02 a.m. to 7:16 a.m. of medication administration revealed LVN M initiated IV administration of Merrem to resident #9 via IV piggy back. Prior to connecting the IV medication Merrem to resident #9's IV port, the resident stated the ambulance would pick him up at 7:30 a.m. so he could go to the hyperberics chamber. LVN M continued with the process of connecting the IV medication to resident #9's IV port and started to administer the medication. LVN M reported it would take 1 hour for the medication Merrem to infuse into resident #9's IV port. Observation on 6/29/16 at 8:14 a.m. revealed resident #9 was not in his room and the IV medication Merrem hung on the IV pole and the medication bag was 3/4 full. Interview on 6/29/16 at 8:16 a.m. with LVN M revealed resident #9 left the facility for his hyperberics treatment. LVN M confirmed the IV medication Merrem did not infuse completely prior to resident #9's departure from the facility. 7. Review of resident #4's undated face sheet revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #4's June 2016 Consolidated physician's orders [REDACTED]. Observation on 6/29/16 at 9:06 a.m. with LVN M revealed the bisacodyl suppository was not in the medication refrigerator in the medication room for resident #4. Interview with LVN M, at this time confirmed the medication was not available to administer to resident #4. 8. Review of resident #26's undated face sheet, revealed he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #26's June 2016 Consolidated physician's orders [REDACTED]. Observation on 6/29/16 from 7:35 a.m. to 7:49 a.m. revealed MA N did not administer Sinemet 10-100 mg tablet to resident #26 during medication administration. MA N reported resident #26 was out of the Sinemet after she looked at the blister medication packs in the medication cart. MA N reported she would have the nurse obtain the medication. Observation on 6/29/16 at 9:00 a.m. revealed LVN O and MA N looked through the bottom of the MA medication cart for resident #26's Sinemet and reported the medication was not there. LVN O then went to the pixis ekit to look for the Sinemet and reported the machine did not have the dosage she needed. Interview on 6/29/16 at 10:09 a.m. with LVN O revealed she had contacted the pharmacy who reported resident #26's Sinemet medication was delivered on 6/27/16. The LVN reported she had looked through two of the facility's medication carts and had not located the medication. Further interview on 6/29/16 at 4:48 p.m. with MA N revealed she still had not found resident #26's Sinemet medication and confirmed she did not administer the 2 p.m. dose. The MA reported the medication was received by the night nurse whom they were trying to contact. Interview on 6/30/16 at 11:42 a.m. with the DON revealed the facility had located resident #26's Sinemet on 6/29/16 and did not know where or when they found it. Interview on 6/30/16 at 12:15 p.m. with MA Q revealed resident #26's Sinemet was on her medication cart and she was able to administer the medication. The MA looked into the computerized eMAR and showed the surveyor that MA Q had administered the 8 p.m. dose of Sinemet 10-100 to resident #26 on 6/27/16 and 6/28/16; and another MA had administered the 8 p.m. dose on 6/29/16. The MA confirmed the eMAR indicated the 2 p.m. dose on 6/27/16 and 6/28/16 had not been administered to resident #26. Observation on 6/30/16 at 12:20 p.m. with MA Q of resident #26's blister package of Sinemet 10-100 revealed the label was dated 6/27/16 with Carbidopa/Levodopa in very large print and underneath in small print was Sinemet. Five pills of Sinemet had been dispensed from the blister package. MA Q showed the surveyor two more blister packages of Sinemet 10-100 that each contained 30 tablets. Review of resident #26's June 2016 eMAR revealed on 6/26/16 the 2 p.m. and 8 p.m. doses of Sinemet were not marked as administered. On 6/27/16 and 6/28/16 the 2 p.m. doses of Sinemet were not marked as administered. Review of resident #26's June 2015 eMAR notes revealed MA S noted on 6/26/16 the 2 p.m. & 8 p.m. doses of Sinemet were NOT IN STOCK, and on 6/27/16 & 6/28/16 the 2 p.m. doses of Sinemet were NOT IN STOCK. Interview on 6/30/16 at 5:20 p.m. with MA S, confirmed the 2 p.m. & 8 p.m. doses of Sinemet were not administered to resident #26 on 6/26/16, and the 2 p.m. doses on 6/27/16 & 6/28/16 due to the medication was not in stock. MA S reported she did not remember seeing a medication labeled Carbidopa/Levodopa in the medication cart. 9a. Observation on 6/30/16 at 10:22 a.m. of the 200 Hall nurse medication cart with ADON E and LVN L revealed: One bottle of Nitrostat (used for chest pain) 0.4 mg with an open date of 5/10/14 for resident #23. One bottle of Nitrostat 0.4 mg with an expiration date of 4/2016 for resident #24. Interview with ADON E and LVN L during the observation revealed the Nitrostat was expired. b. Observation on 6/30/16 at 10:00 a.m. of the 300 Hall nurse medication cart with ADON E revealed Fluphenazine Dec (antipsychotic) 25 mg/ml, 5 ml vial. Directions read to inject 0.5 ml bi monthly on the 1st and 15th. The bottle was dispensed on 5/10/16. There was no open date or date when mixed. Interview with ADON E during the observation confirmed there was no open date on the vial for resident #22. Review of the f

Based on interview and record review the medical director failed to coordinate the medical care in the facility for 1 of 7 residents (Resident #8) who was reviewed for pain in that: Resident #8 had a recent amputation of his toes and was prescribed Tylenol #3 for pain management. Resident #8's Tylenol #3 prescription was not refilled for 4 days as the Medical Director office would not schedule Resident #8 a physician appointment due to lack of insurance. These deficient practices could affect 37 residents who were on a pain management program and could result ineffective pain control. The findings were: Review of Resident #8's face sheet dated 7/1/16 revealed Resident #8 was admitted [DATE] with the primary physician listed as Medical Director AA. Review of Resident #8's Pain assessment dated [DATE] revealed Resident #8 had an Transmetatarsal Amputation. Review of Resident #8's Pain assessment dated [DATE] revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Lower Extremity 5. Type of pain: External 6. Description of Pain: Dull 7. Onset of pain: Acute 8. Frequency of pain: Occasional 9. Pain intensity: 7/10 11. Non verbal signs of pain: Facial grimacing, irritable, [MEDICAL CONDITION], restless 12. Pain relieved by: Medication 13. Effects of pain: Sleep affected 14. Conclusion: Pain issues, management is effective; see care plan Completed by LVN J Review of Pain Assessment completed 6/14/16 revealed the following: 1. Does the resident have a [DIAGNOSES REDACTED].? (Yes)-Transmetatarsal Amputation 2. Is the resident able to verbalize pain? (Yes) 3. Does the resident have pain? (Yes) 4. Pain location: Not Described 5. Type of pain: External 6. Description of Pain: Unchecked 7. Onset of pain: Acute 8. Frequency of pain: Unchecked 9. Pain intensity: 3/10 11. Non verbal signs of pain: None Observed 12. Pain relieved by: Medication 13. Effects of pain: Changes in ADL's 14. Conclusion: No pain, no intervention needed Review of Resident #8's Minimum Data Set completed 6/14/16 revealed Resident #8's BIMS was a 13 (cognitively intact). Review of Resident #8's Care Plan completed 6/14/16 revealed the following: Problem/Need-Resident at risk for increased Pain R/T (related to) recent TMA (Transmetatarsal amputation) with wound vac in place: Goal & Target Date- -Resident will have relief from pain when prn medication is used x 90 days 9/14/16 -Resident will maintain his tolerable pain level of 3/10 with use of prn medications 9/14/16 Approaches- -Monitor resident for s/s of pain: restlessness, tearfulness, moaning, anxiety, agitation, actual c/o. -Make resident as physically comfortable as possible by repositioning, using positioning pillows, giving back rubs, etc -Give prn pain medications per MD orders -Monitor for effectiveness of prn pain med -Notify MD/RP if pain medication isn't effective in relieving pain, if injury has occurred, or if pain increases in freq or intensity -Follow MD orders after notification Interview, during initial tour, on 6/28/2016 at 12:07 p.m., with LVN J, revealed Resident #8 had his left toes amputated and had a wound vac attached to his left foot. Resident #8 was experiencing pain in his left foot, at this time, according to LVN J (after speaking to Resident #8 in Spanish), and said Resident #8 was prescribed Tylenol #3 for pain and LVN J notified the assigned 200 hall nurse, LVN O, that Resident #8 was in need of pain medications. Review of Resident#8's nursing note on 6/24/16 at 11:08 a.m. revealed LVN O called Medical Director AA's office at 10:00 a.m. and spoke with clerk to notify that RX for Tylenol #3 one tab PO Q 4hrs PRN was needed. Clerk said that she would notify MD and return phone call once it was ready. Interview on 6/30/16 at 2:40 p.m. with the clerk of Medical Director AA revealed the clerk recalled LVN O calling on 6/24/16 to request Tylenol #3 prescription for Resident #8 and was told Resident #8 would need to be seen by the doctor. Since Resident #8 had no insurance, he was not accepted as a patient for Medical Director AA and LVN O was notified of this. Review of Resident #8's nursing notes (documented by LVN O) dated 6/28/16 revealed Resident #8 was administered Tylenol 325 mg x 2 at 12:15 p.m., pain being assessed at 10 out of 10. Observation and interview on 6/28/16 at 3:20 p.m. with LVN O revealed Resident #8 did not have any Tylenol #3 available in the medication cart. LVN O said Resident #8's Tylenol #3 had not been administered since 6/24/16. LVN O further said although Resident #8 had been reporting a pain level of 5 or 6 out of 10, the Tylenol #3 medication had ran out on 6/24/16 and Resident #8 had been requesting medication for pain every 4 hours. Interview on 6/28/16 at 5:36 p.m. with Resident #8 revealed Resident #8 reported current pain level at 5 out of 10 with regular Tylenol 650 mg but said he had not been able to sleep in over 5 days. Resident #8 indicated he had been able to sleep when Tylenol #3 was administered and found it to be effective for pain. Resident #8 said he went to see doctor today (6/28/16) and Tylenol#3 prescription was issued. Resident #8 indicated in the past few days regular Tylenol had not been effective for pain. Resident #8 did not know why he had to wait 4 days for his Tylenol #3. Interview and observation on 6/29/16 at 7:43 a.m. of Resident #8 revealed Resident #8 was moaning and groaning, face grimacing and appeared to be in much pain. Resident #8 said he was having convulsions in his foot. Resident #8 said he still did not have the Tylenol #3 available to him. Resident #8 reported his pain level as stronger than 10 out of 10. Resident #8 was offered Tylenol 650 mg but he refused the medication and indicated it was not effective. Resident #8 further said he wanted to be discharged from the facility. Resident #8 indicated he has been in severe pain for the past 5 days and was having trouble sleeping. Interview on 6/30/2016 at 2:20 p.m. with Medical Director AA revealed he wrote the original Tylenol #3 order for 7 days but indicated he gave no further orders for Tylenol #3. Medical Director AA further stated a written script would be required since medication is a controlled substance. Medical Director also indicated he recalled no further phone requests called in by nursing home staff. Review of the 24 hour log for Resident #8 on 6/28/16 revealed the following entries: 6/18/16-Need MD appointment 6/19/16-Need MD appointment setup as soon as possible pending insurance clearance 6/21/16-Need MD appointment setup as soon as possible pending insurance clearance 6/23/16-Need MD appointment setup as soon as possible 6/24/16-MD appointment setup as soon as possible 6/26/16-MD appointment setup as soon as possible needs Tylenol #3 6/27/16-Appointment setup as soon as possible needs Tylenol #3. Appointment 1:30 p.m. 6/28/16, evening pass on reports the same. 6/28/16-Appointment physician assistant at 1:30 p.m. Review of Resident #8's Pharmacy Services Individual Drug Record revealed Resident #8's Tylenol#3 was stopped being administered on 6/24/16 and then began to be administered again on 6/30/16. Review of Resident #8's June 2016 MAR indicated [REDACTED]. Interview on 6/29/16 9:15 a.m. with Physician Assistant CC of Medical Director BB revealed Resident #8 was examined by PA CC on 6/28/16 in the office. PA CC reported resident #8's pain to be severe upon examination. Resident was prescribed Tylenol #3 for pain. PA CC was asked if Tylenol 650 mg would be an appropriate dose to manage pain for resident at this time. PA CC reported no, it would be like chewing bubble gum. Review of Resident #8's physical examination conducted on 6/28/16 at the office of Medical Director BB, conducted by PA CC for pain to Resident #8's left foot revealed Resident #8 moaning and groaning from pain during examination. Further review of this same document under Impression revealed severe pain to patient. Further review of this same document revealed a prescription was written for Tylenol #3 for pain. Interview on 6/28/16 at 4:40 p.m. with LVN J stated Resident #8 has always assessed pain at 7 out of 10. LVN J further indicated Resident #8 usually asked for more pain medication at night around 8:00 p.m. to 9:00 p.m. and Resident #8 could usually sleep after receiving his pain medications. Interview on 7/1/16 at 8:45 a.m. with CNA Y (night shift on 200 hall) revealed Resident #8 frequently complained of pain. Resident #8 was frequently asking for pain medications and would ask CNA Y if wound vac was working because of the pain he was continuing to experience. CNA Y further indicated Resident #8 would wake up 4-8 times a night due to pain. CNA Y indicated that when Resident #8 ran out of Tylenol #3 pain medication he was aware of it and stopped asking for it. He continued to be in pain however. Interview on 6/30/16 at 2:55 p.m. with the Administrator, ADON E, the Regional Director, & Regional Nurse W revealed Medical director AA did not fill Resident #8's Tylenol #3 prescription or to accept Resident #8 as patient due to having no insurance. The interview further revealed the other Medical Directors on staff were out of town when Resident #8's Tylenol #3 ran out. Review of the facility's Abuse Prohibition and Procedure policy on 6/30/16 revealed: As a general overall policy, the facility will use reasonable efforts, through operational policies, so that abuse, neglect, involuntary seclusion and misappropriation of property or other forms of mistreatment of [REDACTED]. Review of of the facility's Pain Assessment policy 6/30/16 revealed the following relevant components: Purpose: The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: - A comprehensive pain assessment should be complete as part of the initial nursing assessment with development of a pain management program as indicated. -Evaluation and reporting of pain indicators is expected with routine resident interaction. -Pain should be evaluated and documented when present and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is in line with resident's established goals. Steps in procedure: -Evaluate residents for pain indicators during routine interactions. If pain present, establish intensity and intervene per plan of care. -Offer non-pharmacological interventions as appropriate -Offer any prn [MEDICATION NAME] mediations as appropriate -Document administration and effectiveness of prn medication. Review of CMS form 672 dated 6/28/16 revealed there were revealed there were 37 residents who were on a pain management program.