Every finding on record at Our Lady of Prompt Succor Nursing Facility

Based on interview and record review, the facility failed to provide adequate supervision and toileting assistance according to the resident's assessed needs in the plan of care to prevent accidents for 1 (#2) out of 3 (#1, #2, #3) sampled residents. This deficient practice resulted in a harm on 05/23/2026 at 4:00 a.m. when S7CNA failed to assist Resident #2 with a transfer to the toilet. As a result, the resident fell prior to getting to the toilet. The resident was transferred to a local hospital emergency room on [DATE] at 1:22 a.m. An x-ray was performed on 05/24/2026 at 9:52 a.m. with findings of a left impacted femoral neck fracture. The resident was admitted to the hospital and underwent a percutaneous screw fixation of left femoral neck fracture on 05/26/2026. Findings: Review of the facility's policy titled, Fall Prevention, with a last review date of 03/19/2026, read in part: Fall Risk Assessments: . 2. Residents who are assessed as being high risk for falls will have individualized interventions implemented as needed to help prevent falls.Assessment and Care Planning Process: A comprehensive assessment will be performed and an interdisciplinary care plan for each resident at high risk for falls to address specific factors that may contribute to his or her risk for falls.Examples.7. Increased monitoring by staff. Review of Resident #2's EHR (Electronic Health Record) revealed the resident was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to, primary generalized osteoarthritis and unspecified dementia. The resident was diagnosed with fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing on 05/29/2026. Review of Resident #2's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed in section GG: Functional Abilities, that the resident was coded as needing supervision or touching assistance for toilet transfer (The ability to get on and off the toilet). Review of Resident #2's most recent quarterly MDS assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident's cognition was intact. Review of Resident #2's current care plan, revealed the following focuses and interventions in part: -Focus: Risk for ADL (Activities of Daily Living) self-care performance deficit r/t (related to) generalized weakness, RA (Rheumatoid Arthritis), OA (Osteoarthritis).Intervention: Transfers: Independent, assist as needed. Date Initiated: 8/29/2025. Revision On: 02/10/2026.-Focus: Risk for falls related to unsteady gait, use of assistive device, RA, OA, decreased mobility, history of falls, poor safety awareness.Intervention: 10/12/2025: Staff re-educated to offer, encourage, and assist to toilet on rounds during hours of sleep to reduce risk for falls . Date Initiated 10/31/2025. Revision On: 02/04/2026. Review of Resident #2's ADL task documentation from 05/01/2026 to 05/23/2026 revealed toilet use self- performance was documented as 2 (indicating Limited Assistance- Resident highly involved in activity ; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) 14 times on evening shift (2:00 p.m.-10:00 p.m.) and 19 times on night shift (10:00 p.m.-6:00 p.m.). Further review revealed toilet use support provided was documented as 2 (indicating One person physical assist) 14 times on evening shift and 19 times on night shift. Review of a facility incident report for Resident #2 completed by S9RN dated 05/23/2026 at 11:55 a.m. revealed in part: Nursing description: Noted resident ambulating in her room with walker. She complained of pain in left hip. After multiple questions, she informed me that she went to the bathroom last night at approximately 2:00 a.m. She was standing near the lavatory, lost her balance, and fell sitting on buttocks. Denies hitting her head. She informed me that staff assisted her off floor and back to bed.Review of Resident #2's nursing progress notes revealed the following note written by S2DON dated 05/23/2026 at 11:57 p.m. that read: Received x-ray results of left hip. Findings concerning for left femoral neck fracture. If clinically warranted it could be correlated with the CT scan . Attempted to reach [Physician] and [Nurse Practitioner]. No response at this time. Sending to ER for evaluation and x-ray findings. Resident has 8/10 pain to left hip. No bruising or discoloration observed. Did notify me that she has been walking back and forth to the bathroom today with walker. Voiced she fell yesterday morning; Saturday morning (05/23/2026) in the bathroom. She had ambulated with her walker to the toilet and lost her balance. Review of Resident #2's fall investigation provided by the facility revealed the following part: Statement written by S7CNA dated 05/24/2026.Saw/assisted resident prior to incident, saw/assisted resident following incident.Statement: I went into Resident #2's room at around 4:00 in the morning to wake her up to go to the restroom. I woke her up, made sure she had her walker before I told her to go to the restroom while I go across the hall to change another resident. When I went back in there to check on her, I found her sitting on the floor. When I asked her what happened, she said she fell on the floor. I asked her if she was hurt and did she hit her head and she said she was fine and still needed to use the restroom. I picked her up and placed her on the toilet when she started to complain of hip pain. I got the nurse to assess her and asked again if she was okay . Review of Resident #2's hospital records dated 05/24/2026 revealed the following in part: Radiology: Examination- X-ray hip with pelvis when performed 2 or 3 views left.Findings: Impacted left femoral neck fracture. Review of an operative report dated 05/26/2026 revealed in part: Preoperative Diagnosis: Left valgus impacted femoral neck fracture.Procedure Performed: Percutaneous screw fixation of left femoral neck fracture.Indications for procedure: Resident #2 had a fall in her nursing facility. She sustained a valgus impacted femoral neck fracture. On 07/14/2026 at 9:50 a.m., an interview was conducted with S2DON. S2DON confirmed that the resident had a fall on 05/23/2026 at 4:00 a.m. while attempting to use the bathroom without staff assistance. S2DON stated that the resident ended up having a femoral neck fracture and surgery was performed. On 7/14/2026 at 10:55 a.m., a phone interview was conducted with S7CNA who stated she had worked with the resident before and was familiar with her care needs. She stated that the resident ambulated with a walker, but she still required standby assistance and required staff in the room with her during transfers for toileting/ambulation because the resident was unsteady on her feet at times. S7CNA confirmed that she was the resident's CNA (Certified Nursing Assistant) on the morning of 05/23/2026 when she fell. S7CNA stated that she went into the resident's room on 05/23/2026 at around 4:00 a.m. to wake her up so that she could get ready for the day. She stated she typically went into the resident's room at this time to help her to get ready. S7CNA stated that she guided the resident to the bathroom and told the resident to go ahead and sit down on the toilet, use the bathroom, and that she would be back to assist her after checking on another resident. S7CNA stated she did not wait to ensure the resident made it to the toilet. When she returned after 5 minutes, she found the resident sitting on the floor in front of the toilet. The resident told her that she was trying to sit down on the toilet and slipped and fell. The resident was begging her to get her up off the floor because she still needed to urinate. S7CNA stated that she got the resident up and placed her on the toilet, and that is when the resident complained of pain to her leg. S7CNA stated that she then alerted the nurse on duty, S5LPN, and told him that the resident fell and that her hip was hurting. S7CNA stated that she was trained on not picking up a resident off of the floor prior to this incident and she knew she shouldn't have picked the resident up off the floor prior to notifying the nurse. S7CNA also stated that she should have guided the resident to the toilet, should not have left her in the bathroom alone, and that she knew she should not have left the resident alone. On 07/14/2026 at 12:09 p.m., an interview was conducted with S6LPN who provided care to Resident #2 and was familiar with her care needs. S6LPN stated that prior to the resident's fall and subsequent hip fracture, the resident would ambulate from bed to wheelchair and bed to bathroom using her walker. She could ambulate independently using the walker, but the staff would still provide supervision assistance because the resident had poor safety awareness. Sometimes, the resident would leave her walker near the door, and use furniture in the room to support her when ambulating. S6LPN further stated that Resident #2 was continent, but staff would take her to the bathroom to ensure that she safely completed the toileting task. On 07/14/2026 at 12:12 p.m., an interview was conducted with S8CNA who provided care to Resident #2 and was familiar with her care needs. S8CNA stated prior to Resident #2's incident, she ambulated with her walker but was not always steady on her feet. Because of this, she would not leave the resident alone and unsupervised. She stated she would remain with the resident while she was in the bathroom to ensure her safety. On 07/14/2026 at 1:54 p.m., a joint interview was conducted with S2DON and S3MDS who was responsible for developing Resident #2's care plan. S2DON stated Resident #2 was independent with transfers at the time of the fall. A review of the resident's MDS assessment dated [DATE] was reviewed with S2DON and S3MDS. S3MDS confirmed that the resident was coded as needing supervision for toileting, but that was based on the look back period the resident usually ambulated with her walker independently. However, sometimes the resident needed assistance with transfers. S2DON stated being that the CNAs and nurses reported the resident was not steady on her feet, S7CNA should have supervised the resident during toileting assisted her as needed, and should not have left the room. On 07/15/2026 at 9:00 a.m., an interview was conducted with Resident #2. The resident confirmed that she had a fall while alone in the bathroom, and ended up breaking her hip. She stated on the morning of her fall (05/23/2026), the CNA (S7CNA) came into the room to help her get up and to go to the bathroom. She stated that she was ambulating to the toilet without staff assistance, overestimated herself and slipped and missed the toilet. She stated she was not assisted to the toilet and that the CNA (S7CNA) was not present with her at the time of her fall. The resident stated that the CNA (S7CNA) came back into the bathroom and picked her up off of the floor and placed her on the toilet. She stated she was in pain at the time. The resident further stated that she was later brought to the hospital and had to have surgery.On 07/15/2026 at 9:25 a.m., a joint interview was conducted with S1ADM, S2DON, S3MDS, and S4MDS. All confirmed that Resident #2 was at risk for falls. A review of Resident #2's ADL documentation for May 2026 was then conducted. S2DON confirmed that the resident was coded as needing limited assistance from the CNAs for most of the evening and night shifts. A review of the resident's careplan was also conducted. S4MDS referred to the focus that read : Risk for falls related to unsteady gait, use of assistive device, RA, OA, decreased mobility, non- compliance with calling for assistance, history of falls, poor safety awareness. She stated that an intervention was added to re-educate the staff to offer, encourage, and assist the resident to go to toilet on rounds during hours of sleep, and that the staff was supposed to assist the resident at 4:00 a.m. with ambulating to the toilet and the toileting task because she was unstable at night. S4MDS stated the staff was informed and educated that they needed to assist the resident at night with ambulating to the toilet and completing the toileting task prior to the fall on 05/23/2026. S2DON stated that based on the resident's careplan, S7CNA should have supervised the resident and remained with the resident throughout the toileting process.

Based on observations and interview, the facility failed to ensure staffing information that was posted daily was accurate and current. The facility's census was 112.Findings:On 02/23/2026 at 8:20 a.m., an observation of the daily posted staffing information revealed a date of 02/20/2026. On 02/23/2026 at 1:39 p.m., a second observation of the daily posted staffing information remained unchanged with a date of 02/20/2026.On 02/23/2026 at 4:15 p.m., a third observation of the daily posted staffing information remained unchanged with a date of 02/20/2026. An interview was conducted at this time with S2HR. S2HR stated she posts the staffing information from the day prior and not the current date. S2HR also affirmed that no staffing information was posted for the weekend dates.

Based on observations, record reviews and interviews, the facility failed to implement a comprehensive person-centered plan of care and follow physician's orders for 2 (Resident #3 and Resident #74) out of 38 sampled residents as evidenced by failing to: 1. implement the comprehensive plan of care for keeping the resident's call light in reach and bed in the lowest position for Resident #3, and2. implement the comprehensive plan and physician's order for two person assistance when transferring Resident #74. Findings:Resident #3 Resident #3 was admitted to the facility on [DATE] with the following diagnoses including, but not limited to: dementia with psychotic disturbance, atrial fibrillation, long term (current) use of anticoagulants and repeated falls. Review of Resident #3's February 2026 physician's orders revealed an order dated 10/24/2025, ensure bed is in lowest position. Review of Resident #3's care plan revealed the resident was at risk for falls r/t (related to) decreased mobility, poor safety judgement. Interventions in part were to: Ensure bed is in lowest position; keep call light within easy reach. Resident at risk for bleeding and bruising related to AC (anticoagulant) therapy related to atrial fibrillation with an intervention to take precautions to avoid falls. Further review of Resident #3's care plan revealed Resident #3 had an ADL (Activities of Daily Living) deficit related to impaired balance.history of falls, psychotropic medications and poor safe awareness at times. Interventions in part were: Staff to provide the appropriate amount of assistance with ADLs to maintain adequate level of functioning and to encourage the resident to use bell to call for assistance. Review of Resident #3's daily tasks revealed S7CNA documented the task of ensuring the resident's bed was in lowest position for safety as completed on 02/25/2026 at 8:57 a.m. On 02/25/2026 at 9:50 a.m., Resident #3 was observed in bed. The resident's bed was observed not in the lowest position and his call bell was wrapped around his right upper side rail with the button hanging off the rail not in the resident's reach. On 02/25/2026 at 10:25 a.m., an interview was conducted with S8LPN who was familiar with Resident #3 and verified the resident attempts to get out of bed at times and had periods of confusion. She confirmed S7CNA provided morning care for Resident #3 earlier today. At this time, S8LPN observed the resident in bed with his bed not in the lowest position and his call bell was out of reach. S8LPN confirmed the resident's bed should have been in the lowest position and his call bell should have been within his reach. On 02/25/2026 at 2:25 p.m., an interview was conducted with S1DON who verified Resident #3's bed should have been in the lowest position and his call bell should be within reach due to resident having poor safety awareness and history of falls. Resident #74 Review of Resident #74's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified sequelae of cerebral infarction and unspecified dementia. Review of Resident #74's Order Summary Report which contained the resident's physician orders revealed an order dated 03/12/2025, Assist times 2 with transfers. Review of Resident #74's most recent Care Plan Report, revealed in part Focus- The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Activity Intolerance, Confusion, Dementia. Interventions- Requires Assist Times 2 with all transfers initiated 03/12/2025. Review of a nurse's note for Resident #74 dated 02/16/2026 at 1:35 p.m. by S15LPN, revealed in part, Notified per staff that resident got skin tear this a.m. transferring from bed to wheelchair with assist times one. Review of a statement by S16CNA dated 02/16/2026, revealed in part, I was assisting Resident #74 to transfer from bed to wheelchair. She is a one person assist. During the transfer she bumped her lower, lateral, right leg on wheelchair. On 02/25/2026 at 11:09 a.m., an interview was conducted with S16CNA. She stated on 02/16/2026, she was assisting Resident #74 with transferring from the bed to the wheelchair when she bumped her leg on her wheelchair and obtained a skin tear. She stated she was the only staff member assisting with the transfer because Resident #74 was a one person assist. On 02/25/2026 at 12:41 p.m., an interview and record review was conducted with S4ADON. She confirmed that on 02/16/2026, Resident #74 should have been transferred by two staff members according to her physician order and care plan, when she bumped her leg on her wheelchair. On 02/25/2026 1:14 p.m., an interview was conducted with S1DON. She confirmed that on 02/16/2026, Resident #74 should have been transferred by two staff members according to her physician order and care plan, when she bumped her leg on her wheelchair.

Based on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (#10) of 5 residents (#5, #8 #10, #74, #98) investigated for accidents. Findings:Review of the facility's policy with a review date of 08/20/25 titled Abuse Prevention and Investigation, read in part; IV. Identification of Abuse, Neglect and Exploitation. B. Possible indicators of abuse include, but are not limited to. 3. Physical injury of a resident, of unknown source.; VII. Reporting/ Response. 1. Reporting of all alleged violations to the Administrator, state agency. within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury. Serious Bodily Injury means an injury. requiring medical intervention. Review of Resident #10's electronic medical records revealed he was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, vitamin D deficiency, major depressive disorder, anxiety, unspecified intellectual disabilities. Review of Resident #10's annual MDS (Minimum Data Set) with a review date of 06/02/2025 revealed in Section C0100 indicated: Should brief interview for mental status be conducted; No resident is rarely/ never understood. On 02/24/2026 at 10:10 a.m., an interview was conducted with S9LPN. S9LPN stated that on 02/23/2025 at approximately 6:35 a.m., she read the results of the x-ray that was completed on 02/22/2025 for Resident #10. S9LPN confirmed, she called S4ADON at approximately 6:40 a.m. and notified her of Resident #10's x-ray results which read fracture of 5th metatarsal of right hand. On 02/24/2026 at 10:18 a.m., an interview was conducted with S4ADON. S4ADON stated that she was notified by telephone of Resident #10's x-ray results at approximately 06:38 a.m. by S9LPN. S4ADON stated she immediately notified S1DON and S14ADM. On 02/24/2026 11:30 a.m., an interview was attempted with Resident #10. Resident #10 was non interviewable due to his cognitive state. This surveyor observed Resident #10 had a splint with an ace bandage wrapped around his right hand that extended approximately six to eight inches down his forearm. On 02/24/2026 at 1:00 p.m., and interview was conducted with S14ADM. S14ADM confirmed an x-ray was performed on 2/22/2025 of Resident #10's right hand. On 02/23/2025 at approximately 6:35 a.m., the facility read the results of the x-ray that revealed a fracture of the 5th metatarsal. S14ADM stated Resident #10 was transported to the hospital on [DATE] due to the fractured 5th metatarsal. S14ADM stated the facility was not sure of how the injury occurred. S14ADM stated the resident was not able to communicate with staff and therefore could not determine origin of injury from Resident #10. S14ADM stated an investigation was ongoing in the facility and no staff member was able to confirm how this injury occurred. S14ADM confirmed that the facility was unable to determine how the injury occurred to Resident #10's hand and had not reported it to the state agency.

Based on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 126 residents. Findings:Resident #6Review of Resident #6's completed Level I PASARR form, dated 11/16/2024, revealed it was completed prior to the resident's admission to the nursing home. Section III Mental Illness section revealed a question that read, Do you suspect the applicant has, or has the applicant ever been diagnosed as having a mental illness? The response checked was no, indicating the resident did not have a mental illness.Review of Resident #6's nursing home admission record revealed she was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to: major depressive disorder, recurrent, unspecified onset date 12/19/2024. Further review of her admission record also revealed a readmission date of 01/03/2025 with diagnoses that included but were not limited to: major depressive disorder, single episode, severe with psychotic features onset date 01/03/2025. Review of Resident #6's care plan revealed in part: Altered mood, thought processes, and behavior related to underlying psychiatric illness and cognitive impairment as evidenced by history of major depressive disorder, recurrent, unspecified, psychotic features, & personal history of other mental and behavioral disorders.Further review of Resident #6's medical record revealed no evidence that a referral was submitted to the appropriate state-designated authority for Level II PASARR evaluation and determination. On 02/25/2026 at 8:44 a.m., an interview and record review was conducted with S4ADON. S4ADON confirmed there was only a Level I PASARR in Resident #6's medical record that was completed on 11/16/2024 which was prior to Resident #6's admission date of 12/19/2024. S4ADON confirmed Resident #6's medical record did not include a Level II PASARR submitted by the facility. On 02/25/2026 at 9:14 a.m., an interview was conducted with S5SSD. S5SSD stated that she was responsible for PASARRs along with S6ASSD. S5SSD confirmed that Resident #6's medical record revealed a diagnosis of major depressive disorder, recurrent, unspecified with an onset date of 12/19/2024; and major depressive disorder, single episode severe with psychotic features with an onset date of 01/03/2025. S5SSD confirmed that the facility did not submit a Level II PASARR for Resident #6, but the facility should have.

Based on record reviews, policy review, personnel file review, and interviews, the facility failed to treat each resident with respect and dignity in a manner and in an environment that promotes maintenance of his or her quality of life for 1 (#44) out of a finalized sample of 38 residents. Findings: A review of the facility's policy, Resident Rights, with a last review date of 08/20/2025, revealed in part: 5. Respect and dignity. The resident has a right to be treated with respect and dignity. A review of the facility's policy, Promoting/Maintaining Resident Dignity, with a last review date of 08/20/2025, revealed in part: Compliance Guidelines: 10. Speak respectfully to residents; avoid discussions about residents that may be overheard. A review of Resident's [NAME] of Rights Acknowledgment signed by Resident #44's representative on 02/12/2026, revealed in part: 9.The right to be treated courteously, fairly, and with the fullest measure of dignity. A review of Residents Rights In-Service on 07/23/2025, revealed S3CNA completed an in-service on Resident Rights including in part, The resident has a right to be treated with respect and dignity. A review of S3CNA's personnel file revealed a job summary for Nursing Assistant completed by S3CNA on 07/23/2025, revealing in part, Qualifications: 5. Is courteous in working with residents, families, and employees. Review of Resident #44's Electronic Health Record revealed the resident was admitted to the facility on [DATE] with diagnoses which included in part, chronic inflammatory demyelinating polyneuritis and type 2 diabetes mellitus with diabetic polyneuropathy. Review of Resident #44's BIMS (Brief Interview of Mental Status) on 02/23/2026 revealed a BIMS score of 5, which indicated the resident's cognition was severely impaired. On 02/23/2026 at 9:00 a.m., an interview was conducted with Resident #44 and his wife and roommate, Resident #43. Resident #44 stated that last night at around 1:30 a.m. to 2:00 a.m., a staff member had just exited his room when he (the resident) made the statement son of b***h due to his pain. The staff member (later identified as S3CNA) walked back into the room and accused him of calling her a b***h. He stated that he tried to tell her that he did not call her that, and he was just making the statement son of a b***h. He said the staff argued with him, left the room, and returned with another staff member, and continued to accuse him of calling her a b***h with an attitude. Resident #44 stated this made him feel aggravated. Resident #43 confirmed Resident #44's statement as she stated she was a witness to the incident. Review of Resident #43's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15, which indicated the resident's cognition was intact. A review of a statement dated 02/23/2026 by S12LPN revealed in part, At approximately 1:40 a.m., S3CNA approached the nursing station requesting that I speak with Resident #44. She reported that as she was exiting his room, he called her a b***h. I then spoke with Resident #44 regarding the allegation. Due to both parties going back and forth and in an effort to prevent further escalation, I asked S3CNA to exit the room. On 02/24/2026 at 12:34 p.m., a phone interview was conducted with S3CNA. S3CNA stated that she did have an altercation with Resident #44. She stated that when she walked out of Resident #44's room she heard him call her a b***h. She then reported the incident to S12LPN and they returned together to the resident's room, along with S13CNA. She stated that S12LPN and herself confronted Resident #44 about what he said. She stated they went back and forth angrily on both sides, herself and Resident #44. When questioned about protocol regarding confronting disrespectful behavior from a resident, she stated that it was not the protocol for her to confront the behavior with the resident. On 02/24/2026 at 3:19 p.m., an interview was conducted with S1DON. She confirmed that at no time should a CNA (Certified Nursing Assistant) confront or argue with a resident about disrespectful behavior. On 02/25/2026 at 8:40 a.m., a phone interview was conducted with S12LPN. She confirmed that on the night shift of 02/22/2026, S3CNA reported that she overheard Resident #44 call her a b***h as she was walking out of the room. S12LPN stated that she returned to the room with S3CNA and S13CNA to ask about the situation. She stated that S3CNA was trying to get her point across to the resident that she heard what he called her. S12LPN confirmed that it was not proper protocol for S3CNA to confront a resident. On 02/25/2026 at 8:49 a.m., an interview was conducted with S13CNA. She stated that on the night shift of 02/22/2026, she was asked by S12LPN to enter Resident #44's room to talk to him about S3CNA reporting that he called her son of a b***h. She stated while S12LPN was asking him about the incident, S3CNA entered the room and she was just making her point of what she heard. S13CNA confirmed that it was not protocol for a CNA to confront a resident about disrespectful behavior like what occurred in this incident. On 02/25/2026 at 2:47 p.m., an interview was conducted with S14ADM. She confirmed that a CNA should report a residents' disrespectful behavior to a supervisor and should not confront or argue with a resident about it.

Based on observations, interviews and record and policy review, the facility failed to maintain an effective infection prevention and control program, by failing to ensure:1. Staff wore appropriate Personal Protective Equipment (PPE) while providing incontinence care to a resident on enhanced barrier precautions (EBP) for Resident #39; and 2. Resident #63's urinary catheter drainage bag avoided contact with the floor.Findings:Resident #39 Record review of the facility's policy last reviewed 08/20/2025, titled Enhanced Barrier Precautions read in part, It is the policy of the facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). EBP refers to the use of gown and gloves for use during high-contact resident activities for residents known to be colonized or infected with a MDRO. Implementing of EBP-a. Gowns and gloves will be available immediately near the residents room.High Contact residents care activities: d. providing hygiene, f. Changing briefs or assisting with toileting. Record review revealed Resident #39 was admitted to the facility on [DATE]. She had diagnoses that were included, but not limited to, extended spectrum beta lactamase resistance (ESBL), dementia, aphasia, age related physical debility, and chronic kidney disease. Record review of Resident #39's physician's orders dated 02/2026 read in part, Contact Isolation related to ESBL. All care provided in provided room. Record review of Resident #39's Care Plan read in part, the resident has a urinary tract infection with ESBL (Extended Spectrum Beta Lactamase Resistance) in her urine. All care provided in room. The resident is incontinent of bladder. Perineal care provided every 2 hours and as needed .1/29/26: ESBL in Urine. On 02/23/2026 at 10:45 a.m., an observation revealed a sign on the side of Resident #39's door which read in part, Enhanced Barrier Precaution.Wear gloves and gown for the following high-contact resident care activities .Dressing.Providing hygiene.changing briefs or assisting with toileting. At this time it was observed that no PPE was on or near Resident #39's door. At 10:50 a.m., an observation inside the resident's room revealed S15CNA and S16CNA were providing incontinent care to Resident #39 without wearing gowns and gloves. On 02/23/2026 at 11:00 a.m., an interview was conducted with S17LPN who confirmed Resident #39 was on EBP for ESBL in her urine and the staff was to wear a gown and gloves when providing incontinent care to the resident. On 02/23/2026 at 11:30 a.m., an interview was conducted with S15CNA who confirmed Resident #39 was on EBP and the staff was to wear a gown and gloves when providing incontinent care and did not. On 02/25/2026 at 3:54 p.m., an interview with S10RN/IP who was responsible for the facility's infection prevention program. S10RN/IP confirmed that Resident #39 was on EBP for ESBL in her urine. She confirmed the staff were to wear a gown and gloves when providing incontinent care to the resident as required by the facility's policy. Resident #63 Review of a facility policy titled, Indwelling Urinary Catheters, with a last reviewed date of 07/16/2025, revealed in part, The urine collection bag must be kept below the level of the resident's bladder at all times including during transfers and during bathing and bag contact with floor must be avoided. Review of Resident #63's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, retention of urine and extended spectrum beta lactamase (ESBL) resistance. On 02/24/2026 at 12:15 p.m., an observation was made of Resident #63 in her room. Resident #63's indwelling catheter drainage bag was covered with a privacy bag. The bottom half of the privacy bag containing the indwelling catheter drainage bag was noted making contact with the floor. On 02/25/2026 at 11:23 a.m., a second observation was made of Resident #63 in her room. Resident #63's indwelling catheter drainage bag was covered with a privacy bag. The privacy bag containing the urinary catheter drainage bag was noted resting on the floor. On 02/25/2026 at 12:28 p.m., a third observation was made of Resident #63 in her room. Resident #63's indwelling catheter drainage bag was covered with a privacy bag. The privacy bag containing the urinary catheter drainage bag was noted resting on the floor. On 02/25/2026 at 12:29 p.m., a concurrent observation and interview was conducted with S9LPN. S9LPN confirmed that Resident #63's privacy bag containing the urinary catheter drainage bag was resting on the floor and it should not have been. On 02/25/2026 at 12:48 p.m., an interview was conducted with S10RN/IP who was responsible for the facility's infection prevention program. S10RN/IP confirmed that the Resident #63's privacy bag containing the urinary catheter drainage bag should not have been resting on the floor in Resident #63's room.

Based on observation, record review and interviews, the facility failed to maintain an accurately documented medical record in accordance with accepted professional standards and practices as evidenced by failing to accurately document the use of a CPAP (Continuous Positive Airway Pressure) machine in the resident's EHR (Electronic Health Record) for 1 (#16) out of a census of 112 residents.Findings:Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included, and not limited to: sleep apnea, chronic obstructive pulmonary disease, asthma, and stage 3 chronic kidney disease.Record review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her BIMS (Brief Interview for Mental Status) score was 11, meaning the resident had moderate problems with thinking and memory.On 02/23/2026 at 9:30 a.m., an observation and interview with Resident #16 revealed she had a CPAP machine on her night stand. Resident #16 stated she had been refusing to use it for the past two months. Record review of Resident #16's MAR (Medication Administration Record) read in part, CPAP at Hours of Sleep: Personal CPAP Settings Preset. Further review of this document revealed the nurses were documenting from 02/01/2026 to 02/23/2026 that they were putting the CPAP on for the resident every evening and taking it off in the morning. On 02/24/2026 at 11:32 a.m., Resident #16's son stated his mother had not used the CPAP machine since she had been admitted to the facility. On 02/24/2026 at 4:30 p.m., S1DON confirmed that after she talked with Resident #16, her family, and reviewed the resident's MAR, the resident's record was inaccurate. She stated the nurses should not have documented use of the CPAP on the resident's MAR because the resident was not wearing her CPAP.

Based on observations, record review and interview, the facility failed to store food in accordance with professional standards for food service safely as evidenced by the nursing staff failing to conduct and record daily temperatures for the resident snack/supplement refrigerator in the medication storage room. Findings: Review of the facility's policy with no revision date titled Refrigerators & Snack/Supplements Handling read in part, .Food kept on the nursing units must be maintained as indicated below: a. Refrigerator temperatures must be checked and recorded daily, maintaining temperature between 32-40 degrees Fahrenheit . On 01/08/2025 at 11:15 a.m., an observation was conducted with S3LPN of the medication room on the Hall B nurse's station. Review of the resident's snack/supplement refrigerator temperature logs for November 2024 through December 2024 revealed missing temperatures on the following dates: 11/01/2024, 11/02/2024, 11/03/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/16/2024,11/17/2024, 11/18/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024, 11/26/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/01/2024. 12/04/2024, and 12/10/2024. On 01/08/2025 at 11:30 a.m., an interview was conducted with S1DON who confirmed the nursing staff on the night shift should check and record the temperatures for the resident's snack/supplement refrigerators daily.

Based on observations, record review, and interview, the facility failed to ensure that medications were stored and labeled properly in accordance with current accepted professional principles by: 1. having loose medications at the bottom of a drawer in the medication cart; and 2. staff failing to conduct and record daily temperature on the medication refrigerator in the medication storage room. Findings: Review of the facility's policy, with no revision date, titled Medications-Storage read, The facility shall store all drugs and biologicals in safe, secure, and orderly manner .Policy Interpretation and Implementation .2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. On 01/07/2025 at 01:40 p.m., an observation was conducted of the medication cart on Hall A nurse's station with S2LPN (Licensed Practical Nurse). One peach and one white colored pill was observed on the bottom of the first large drawer in the medicine cart. During the observation, S2LPN confirmed that loose pills should not be in the bottom of any drawer on the cart. On 01/07/2025 at 01:54 p.m., an interview was conducted with S1DON (Director of Nursing) who confirmed there should not be loose pills in the bottom of the medication drawers on the medication cart and the pills should have been removed and discarded. 2. On 01/08/2025 at 11:15 a.m., an observation was conducted with S3LPN of the medication room on the Hall B nurse's station. Review of the medication refrigerator logs for November 2024 through December 2024 revealed missing temperatures on the following dates: 11/15/2024 through 11/29/2024, 12/01/2024, 12/04/2024, 12/10/2024, 12/14/2024, and 12/23/2024. On 01/08/2025 at 11:30 a.m., an interview was conducted with S1DON who confirmed the nursing staff on the night shift should check and record the temperatures for the medication refrigerators daily.

Based on interview, observations, and record review, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his or her own quality of life by failing to apply a privacy cover to an indwelling catheter urinary drainage bag for 1 (#37) of 32 sampled residents. Findings: Review of Resident #37's medical record revealed an admitted [DATE], with diagnoses that included in part .Dementia with Agitation, Alzheimer's Disease, Disorder of Kidney and Ureter, Acute Kidney Failure, and Encounter for Fitting and Adjustment of Urinary Device . Review of Resident #37's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/23/2024 revealed a BIMS score of 99, which indicated severe cognitive impairment. Resident #37 required extensive assistance with two person physical assistance for bed mobility and toilet use. Resident #37 used an indwelling urinary catheter for urine elimination. Review of Resident #37's current clinical physician's orders revealed an order date 12/18/2024 to change the resident foley catheter 22FR (French) monthly. On 01/06/2025 at 9:28 a.m., Resident #37 was observed lying in bed with the door open. From the doorway and hallway, the resident's indwelling catheter urinary drainage bag was viewed with 100-200ml (milliliters) yellow urine in the collection bag. Closer observations at the resident's bedside revealed her indwelling catheter urinary bag was without a privacy cover. On 01/06/2025 at 10:18 a.m., in an interview and observation with S1DON (Director Of Nursing). S1DON approached Resident #37's doorway and stated, I know what is wrong, her catheter bag should not be like that. S1DON confirmed the resident's urinary catheter drainage bag had yellow urine in it, and it did not have a privacy cover. S1DON also confirmed that the urinary catheter bag should have a privacy cover to maintain the resident's dignity.

Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for antibiotic use for 1 (#65) of 32 sampled residents whose records were reviewed. Findings: A review of Resident #65's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included Pneumonitis, Urinary Tract Infection, and Sepsis. A review of Resident #65's December 2024 Physician's Orders revealed an order for Levofloxacin (an antibiotic) 500mg (milligrams) via g-tube (gastrostomy tube) one time a day for infection for 10 days. A review of resident #65's EMAR (Electronic Medication Administration Record) for December 2024 revealed he received Levofloxacin 500mg once daily from 12/17/2024 through 12/27/2024. Further review of resident #65's medical record revealed a Quarterly MDS assessment with an ARD (Assessment Reference Date) of 12/22/2024, read in part . Section N. Medications .High Risk Drug Classes Use and Indication .antibiotics were not indicated. On 01/08/2025 at 11:20 a.m., a concurrent record review and interview was conducted with S5MDS. S5MDS confirmed Resident #65 received an antibiotic during the timeframe of 12/17/2024 through 12/27/2024. She reviewed the referenced MDS, and confirmed the antibiotics were not indicated on the assessment and should have been.

Based on observations, interview and record review the facility failed to assess 1 (#55) of 1 (#55) residents investigated to self -administer medication out of a finalized sample of 32 residents. The right to self-administer medications was the responsibility of the interdisciplinary team to assess and determine that this practice was clinically appropriate. Findings: Review of the facility's policy titled, Medications - Self-Administration without a review or revision date revealed in part: A resident who wishes to self-administer medications may do so after evaluation of competency by the care plan committee and upon approval and orders from the attending physician. 1.) The attending physician must write or give a verbal for the resident to self-administer medications and/or to keep at bedside. 2.) The resident must be evaluated by the care plan committee and be determined to be cognitively and physically competent to self-administer medications. This evaluation will be documented and maintained in the resident's chart. Review of Resident #55's EMR (Electronic Medical Record) revealed an admitted [DATE] with diagnoses that included; Mild Intermittent Asthma with Status Asthmaticus, Hypertensive Heart Disease, and Anemia. Review of Resident #55's January 2025 Physician's Orders failed to reveal an order for self-administration of medications. Review of Resident #55's EMR failed to reveal an evaluation or assessment had been completed by the care plan committee to determine the resident's physical and/or cognitive ability to self-administer medications. Review of Resident #55's January 2025 EMAR (Electronic Medication Administration Record) revealed Resident #55 had been administered Umeclidinium Br Aero Powder Breath Actuator (Incruse Ellipta) inhaler 62.5mcg/inh (micrograms per inhalation) on the morning of 01/06/2025 at 5:00 a.m. On 01/06/2025 at 10:25 a.m., an observation was made of Resident #55's room. A box containing an oral inhaler, with a label that read Resident #55's name and Incruse Ellipta 62.5mcg/inh was observed on the resident's nightstand. An interview was done with S6LPN (Licensed Practical Nurse) at that time. S6LPN observed the inhaler on Resident #55's nightstand. She confirmed the resident was not approved for self-administration of medication and confirmed it should not had been left at the resident's bedside. On 01/08/2025 at 11:15 a.m., a concurrent record review and interview was conducted with S5MDS (Minimum Data Set) who confirmed that residents who self-administer medications should have a Medications Self-Administration assessment that should be in the resident's EMR as well as a physician's order. S5MDS reviewed Resident #55's EMR and confirmed that she did not have a Medication Self-Administration assessment nor did she have a physician's order to do so. S5MDS confirmed Resident #55 should not have any medications left in her room.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (#86, #37) out of 32 sampled residents as evidenced by failing to ensure: 1. staff removed PPE (Personal Protective Equipment) prior to exiting a resident's room that was on enhanced barrier precautions for Resident #86; and 2. failing to maintain a resident's urinary catheter in a sanitary manner for Resident #37. Findings: 1. Review of the facility's policy and procedure titled Enhanced Barrier Precautions dated May 2023 read in part, Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . 47. Implementation of Enhanced Barrier Precautions- a. Gowns and gloves will be available outside of the resident's room . c. A trash can will be positioned inside the resident room and near the exit for discarding PPE (Personal Protective Equipment) after removal, prior to exit of the room . Resident #86 Review of Resident #86's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hemiplegia and Hemiparesis following Cerebrovascular Disease, Diabetes, Dysphagia, Gastrostomy, and Hypertensive Heart Disease without Heart Failure. Review of the resident's physician's orders for January 2025 revealed the resident had a PEG (Percutaneous Endoscopic Gastrostomy) tube in place. On 01/06/2025 at 9:35 a.m., S4CNA (Certified Nursing Assistant) was observed performing personal care to Resident #86. S4CNA was observed leaving the resident's room without removing gloves and then was observed getting items off of the linen cart wearing those same gloves. Enhanced Barrier Precaution sign was posted next to the resident's room door. On 01/06/2025 at 9:45 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She confirmed the CNA should have removed the gloves prior to leaving out of the resident's room. 51503 2. Resident #37 Review of a facility policy with an unknown date titled, Indwelling Urinary Catheter read in part .11. The urine collection bag must be kept below the level of the resident's bladder at all times including during transfers and during bathing, bag contact with floor must be avoided . Review of Resident #37's medical record revealed an admitted [DATE], with diagnoses that included in part . Dementia with Agitation, Alzheimer's Disease, Disorder of Kidney and Ureter, Acute Kidney Failure, and Encounter for Fitting and Adjustment of Urinary Device . Review of Resident #37's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/23/2024 revealed a BIMS score of 99, which indicated severe cognitive impairment. Resident #37 required extensive assistance with two person physical assistance for bed mobility and toilet use. Resident #37 used an indwelling urinary catheter for urine elimination. Review of Resident #37's current clinical physician's orders revealed an order date 12/18/2024 to change the resident foley catheter 22FR (French) monthly. On 01/06/2025 at 9:28 a.m., Resident #37 was observed in her room, with the door open. Upon entering the resident's room, the indwelling catheter drainage bag was observed hooked on the bed frame, her bed was in the lowest position and the urinary drainage bag was on the floor under the resident's bed. On 01/06/2025 at 10:18 a.m., in an interview and observation with S1DON (Director of Nursing). S1DON approached Resident #37's doorway and stated, I know what is wrong, her catheter bag should not be like that. At the bedside, S1DON confirmed the resident's indwelling catheter drainage bag was on the floor under the resident's bed. S1DON confirmed the urinary drainage bag should avoid contact with the floor at all times.

Based on interview, observations, and record review, the facility failed to ensure residents unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 2 (#1 and #27) out of 32 sampled residents. Findings: Review of a facility policy with an unknown date titled, Activities of Daily Living (ADLs) read in part .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Review of a facility policy with an unknown date titled, Nail Care read in part .1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .2. Routine nail care, to include trimming and filing . Resident #1 Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses that included in part . Hemiplegia and Hemiparesis Following Other Cerebrovascular Disease Affecting Left Non-Dominant Side, Contracture Left Wrist, and Contracture Left Hand. Review of Resident #1's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/11/2024 revealed a BIMS (Brief Interview of Mental Status) score of 9, which indicated moderate cognitive impairment. Resident #1 required extensive assistance with two person physical assist for bed mobility and total dependence with 2 person physical assist for transfers. Review of Resident #1's care plan revealed in part .the resident requires assistance with all ADLs, such as . grooming .related to decreased mobility initial date of 11/13/2022. On 01/06/2025 at 10:30 a.m., in an interview and observation with Resident #1 revealed the resident's nails on both hands were long and dirty fingernails with a brown substance underneath the nails. Resident #1 stated he would like his fingernails cleaned, and he likes them trimmed short. On 01/06/2025 at 10:43 a.m., in an observation and interview with S1DON (Director of Nursing) of the resident dining area, S1DON observed and confirmed Resident #1 had long and dirty fingernails with brown substance under nails on both hands. S1DON stated the resident's fingernails should be cleaned and cut short, but they were not. Resident #27 Review of Resident #27's medical record revealed and admitted [DATE] with diagnoses that included in part . Dementia in Other Diseases Classified Elsewhere, Mild, With Other Behavioral Disturbance, Type 2 Diabetes Mellitus Without Complications, and Muscle Weakness (Generalized) . Review of Resident #27's Quarterly MDS with an ARD of 10/25/2024 revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident #27 required extensive assistance with 2 person physical assistance with bed mobility and total dependence with 2 persons for transfer. Review of Resident #27's care plan revealed the resident was care planned for an ADL self-care performance deficit related to activity intolerance. Interventions include in part .required extensive assistance with .ADLS .initial date of 08/01/2024. On 01/06/2025 at 10:10 a.m., Resident #27 was observed sitting in her geri-chair in the day area. She was observed with black and grey colored facial hair to her upper lip and chin. On 01/06/2025 at 10:22 a.m., an interview and observation was conducted with S1DON. S1DON confirmed that Resident #27 had facial hair present on her lip and chin. S1DON confirmed the resident should have had her facial hair shaven this morning during her ADL care, but it was not. On 01/06/2025 at 11:09 a.m., in an interview with S7CNA (Certified Nursing Assistant), she confirmed that she was taking care of Resident #27 this morning and familiar with her care. S7CNA explained that in regards to facial hair, all CNAs were taught to shave facial hair during a resident's ADL care. S7CNA explained that S1DON did not allow female residents to remain with facial hair. S7CNA stated she had given the resident a bed bath this morning and did not notice the facial hair on Resident #27's lip and chin.

Based on interviews and record reviews, S4CNA (Certified Nursing Assistant) failed to utilize and implement effective approaches of care for a resident with dementia to assure resident safety as evidenced by the CNA failing to call for assistance when the resident (#1) became combative while providing care, resulting in the resident sustaining injuries to his face and left arm for 1 (#1) out of 3 (#1, #2, and #3) sampled residents. Findings: Review of Resident #1's electronic record revealed he was admitted to the facility on [DATE]. His diagnoses included in part, but not limited to, Dysphasia following other Cerebrovascular Disease, Hypertensive Heart Disease without Heart Failure, Aphasia following Cerebral Infarction, Unsteadiness on feet, Generalized Anxiety Disorder, Repeated Falls, Cognitive Communication Deficit, Unspecified Dementia, severe, with other behavioral disturbance, Muscle Weakness (generalized). Review of the resident's MDS (Minimum Data set) dated 10/23/2024 revealed the resident had a BIMS (Brief Interview of Mental Status) score of 2, indicating severely impaired cognition. Further review of the resident's MDS revealed under Section G-Functional Status, the resident required extensive assistance with 2+ person physical assist for bed mobility and transfers. Written documentation from a meeting held with the facility's administrative and S4CNA was reviewed. S2DON (Directed of Nursing), S3ADON Assistant Director of Nursing), and S1ADM (Administrator) were present in the meeting. According to the minutes of the meeting, S4CNA's explained that when she walked in the resident's room, he was lying on his left side facing the door, close to the rail. His incontinence brief was on the floor. His bed alarm was going off. His hands were full of sticky BM (bowel movement). She uncovered the resident and he had BM everywhere, smeared all over his body. He had scratched his body, and had blood on his scrotum. She didn't introduce herself, and just started cleaning him. At one time, he was attempting to get out of the bed. She struggled to keep him in the bed. She used the sheet to turn him from side to side. He was kicking his arms and legs. When asked why she didn't call for help, she stated To be honest, I did this a long time. I'm used to it. S4CNA stated that she peeked at the desk, but didn't see anyone, so she handled the resident herself. She stated she didn't know why she didn't use the call bell. S4CNA stated she and the resident were fighting against one another while she provided care to him. She had to dodge swings and kicks. The resident was positioned by the bed rails at times, moving back and forth during repositioning. She had to turn him a lot to clean him, and to prevent him from falling out of bed. She had to remove his hands from the bed rails. S4CNA stated that she noticed some blood on the fitted sheet, but thought it was from the resident's scrotum area. She stated by trying to prevent the resident from falling, she could have grabbed him too tight. While repositioning him with the sheet, she could have used too much power. When asked what she could have done better, she stated, She should have called for assistance. Physician progress note dated 11/04/2024 read, Resident discovered with bruising right upper face along with laceration along right naso-labial fold about 2 cm (centimeter) in length. Also found he have bruising to inner cheek with open wound appearing to match associated teeth on that side. An interview and observation of the resident was not conducted due to the resident being transferred to the hospital on 11/12/2024 at 10:00 a.m. On 11/12/2024 at 2:15 p.m., an interview was conducted with S6LPN (License Practical Nurse). She confirmed that she was the resident's nurse on 11/04/2024. She stated the CNA reported to her that the resident had blood on his sheets. When she assessed the resident she noted a skin tear to his left arm, bruising to his right ear and a bump in the middle of his forehead. She stated that the resident also had a scratch on the right side of his lip. She stated that the bruising did not look like an old bruise. She asked the resident what had happened and he stated that he did not know. She confirmed that the resident had behaviors and at times was combative with the staff. He would get upset when he had BM on him and he wanted staff to clean him right away. S6LPN stated that S4CNA did not inform her of the incident. On 11/12/2024 at 3:15 p.m., an interview was held with S2DON, S3ADON, S1ADM and S5CorpNurse (Corporate Nurse). S3ADON stated that in the meeting, S4CNA confirmed the resident was agitated and was kicking and fighting with her while she attempted to clean him up after he had a bowel movement. S4CNA reported that she was focused on getting the resident clean and not let him fall out of bed. She didn't think of calling for assistance. S4CNA also reported she didn't notice that the resident had hit his head or that she had caused a skin tear to the resident's left arm when she grabbed him to prevent him from falling out of bed. They all agreed that Resident #1's injuries could have been avoided if S4CNA would have called for assistance when the resident became agitated and use two person assistance as identified in the resident's comprehensive assessment. They all agreed that if a resident became agitated while providing care, the CNA should call for assistance. On 11/13/2024 at 8:30 a.m., S1ADM and S2DON confirmed that they had no means of contacting S4CNA. On 11/13/2024 at 9:56 a.m., a phone interview was conducted with S7CNA. She stated she worked with S4CNA on the 10 p.m. to 6 a.m. shift on 11/3/2024. She stated that she had informed S4CNA that the resident could become combative, especially in the evening and night hours (sundowner's). She stated that when the resident was combative, she always got someone to help with him. She also informed S4CNA that if she needed help with the resident to let her know. S7CNA confirmed that S4CNA did not ask her for help the entire shift.

Based on observations, record review, and interviews, the facility failed to develop and implement a person-centered care plan for 5 (#24, #47, #48, #53, and #91) out of 5 investigated for care plans out of a total sample of 37 residents by: 1. Failing to follow physician's orders for applying knee high compression stockings for Resident #24. 2. Failing to follow care plan by not monitoring edema for Resident #47. 3. Failing to develop a care plan for elevating lowering extremities and failing to implement a care plan for applying compression stockings for Resident #48. 4. Failing to develop a care plan to include interventions for the use of Regular Insulin for Resident #53. 5. Failing to develop the care plan to include interventions for the diagnosis of Dementia for the resident #91. Findings: Review of facility's policy, titled Care Plans-Comprehensive, read in part .Policy Explanation and Compliance Guidelines: .3. The comprehensive care plan will describe, at a minimum, the following: .f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated . Review of facility's policy, titled Care Plans-Goals and Objectives .read in part .2. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented . Resident #24 Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Atrial Fibrillation, Hyperlipidemia, Hypothyroidism, Hypertensive Chronic Kidney Disease, and Hypertensive Heart Disease with Heart Failure. Review of the physician's orders dated 3/13/2023 revealed an order for Compression Stockings (knee high) apply at 6 am and remove at 6 pm. On 12/5/2023 at 8:45 a.m., the resident was observed sitting up on the side of her bed eating breakfast. The resident's feet were dangling off the bed off the floor and observed to be swollen. During this observation, the resident was observed not wearing bilateral knee high compression stockings. On 12/5/2023 at 10:35 a.m., the resident was observed sitting up in wheelchair in her room. The resident's feet and ankles were swollen. During this observation, the resident was observed not wearing bilateral knee high compression stockings. On 12/5/2023 at 12:40 p.m., the resident was observed sitting up in chair in her room. The resident's feet were observed placed flat on floor and swollen. The resident was not wearing knee high compression stockings. The resident stated that she was waiting for the staff to apply the compression stockings. The compression stockings were observed on the resident's bed. On 12/5/2023 at 1:00 pm, S4TN (Treatment Nurse) was in the resident's room completing wound care. The resident mentioned sending someone to apply her compression stockings and S4TN stated that she would put them on for her. The surveyor asked S4TN if the compression stockings should have been on at this time. She stated that the night shift was responsible for applying the compression stockings since it was ordered to be applied at 6 a.m. S4TN confirmed the resident should have been wearing the compression stockings at this time. 41419 Resident #47 Review of Resident #47's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Chronic ischemic heart disease, Hypertensive heart disease, Chronic kidney disease, stage 4, Acute kidney failure, Heart disease, and Fracture upper end of right humerus. Review of Resident #47's Quarterly MDS (Minimum Data Set) dated 08/27/2023 revealed she had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #47's current Care Plan included the following: Problem: Risk for dehydration related to receiving Lasix. (Diuretic, also known as Furosemide) Interventions: Monitor for and report edema Problem: Renal disease - Chronic kidney disease Interventions: Monitor edema and notify physician of changes Problem: Impaired cardiovascular status related to Hypertensive heart disease, Hypertension, and Chronic ischemic heart disease. Interventions: Monitor for altered cardiovascular status and notify physician for example Edema. Review of Resident #47's Physician Orders date 12/2023 revealed an order for Furosemide 20 mg (milligrams) by mouth daily. Review of Resident #47's Medication Administration Record (MAR) and Electronic Treatment Administration Record (ETAR) dated 10/2023 - 12/2023 did not reveal a monitoring tool for edema. On 12/04/2023 at 8:48 a.m., an observation was conducted of Resident #47's sitting in her recliner with her feet dependent on the floor, and her right hand on the arm rest of the recliner. Further observation revealed plus edema was noted to the resident's bilateral feet and right hand. On 12/04/2023 at 11:10 a.m., an observation and interview was conducted with Resident #47. She was observed sitting in her recliner with feet dependent on the floor and right hand on her lap. She reported that she sits in her recliner for most of the day, and she is unable to elevate her feet while in the recliner. She stated that due to her arm fracture, she is unable to reach the button on the recliner. She stated that her feet stay swollen and with her shoulder injury, her right hands swells often as well. On 12/05/23 at 11:10 a.m., an observation and interview was conducted with Resident #47 who was sitting in her recliner inside of her room. The resident stated that her right hand stays swollen and that staff does not prop her hand up on pillows throughout the day. She stated that at night she has to sleep with her legs elevated, to decrease the swelling in her legs. Further observation of the residents recliner revealed on the right lower side was a silver colored button. The resident stated that the button allowed her to raise her feet while sitting in the chair. The resident added that after she fractured her right arm, she has been unable to reach the button. On 12/06/2023 at 9:40 a.m., an observation and interview was conducted with Resident #47, who was observed sitting in her room, in the recliner. An observation was conducted on the resident's bilateral feet and right hand, which revealed two plus edema. The resident stated that her right hand is more swollen today than yesterday. On 12/06/2023 at 10:00 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse) who reported she had not observed Resident #47's edema to her bilateral feet or her right hand. She added that she had not documented on the resident's edema, since 11/08/2023. On 12/06/2023 at 11:55a.m., an interview was conducted with S2ADON (Assistant Director of Nursing), who stated that staff had not documented on Resident #47's edema since 11/04/2023, and it should have been documented daily. She confirmed that the care plan was not being followed for the resident. 47251 Resident #48 Review of Resident #48's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included Essential Hypertension, Obstructive Sleep Apnea, COPD, Heart Failure, Hypothyroidism, and Major Depressive Disorder. Review of physician orders dated 10/10/2019 revealed an order for bilateral knee compression stockings mild to moderate compression 8-15 mm hg (millimeter of mercury). On at 7:00 a.m. and off at 2:00 p.m. daily. Further review of physician orders dated 12/18/2019 revealed an order to make sure resident elevates lower extremities as much as possible. Review of Resident #48's care plan revealed in part an intervention that included compression stockings on am off pm. Further review of Resident #48's care plan revealed it did not include resident elevating lower extremities. On 12/04/2023 at 3:09 p.m., an observation was made of swelling in Resident #48's lower extremities. On 12/06/2023 at 8:36 a.m., an observation was made of Resident #48 in her room sitting in her wheelchair with edema noted to bilateral lower extremities. Resident was not wearing compression stockings and did not have lower extremities elevated. Resident #48 stated that she forgets about her stockings and the facility does not remind or offer her to put them on. She also stated that they do not offer or assist with elevating her lower extremities. On 12/06/23 at 11:11 a.m., another observation was made of Resident #48 sitting in her chair in her room with continued swelling to her lower extremities, no compression stockings and her lower extremities were not elevated. On 12/06/23 at 11:14 a.m., an interview was conducted with S5LPN (Licensed Practical Nurse), she confirmed that resident did have edema to lower extremities and stated that her socks were digging into her skin. She stated that Resident used to have compression stocking, but she has not seen those in a while. On 12/06/23 at 11:23 a.m., an interview was conducted with S8CNA (Certified Nursing Assistant). She stated that she had not placed compression stockings or assisted with elevating her lower extremities on Resident #48. She stated that she was not aware of any edema to her lower extremities. On 12/06/23 at 11:28 a.m., an interview and record review was conducted with S3MDSIP (Minimum Data Set/Infection Preventionist). She confirmed that a care plan was not developed for elevating Resident #48's lower extremities and that her care plan for applying compression stockings was not implemented and both of these should have been performed. On 12/06/23 at 11:56 a.m., an interview and record review was conducted with S2ADON (Assistant Director of Nursing). She confirmed that Resident #48 should have compression stockings applied and that her lower extremities should have been elevated and neither had been done. 49176 Resident #53 Review of Resident #53's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Diabetic Dermatitis. Review of Resident #53's December physician's order revealed an order dated 09/09/2021 for Accucheck to S/S (sliding scale) Regular Insulin: 150-200=4U (units), 201-250=6U, 251-300=8U, 301-350=10U, 351-400=12U, 401-450=14U, >450=Give 16U and Notify MD (Medical Doctor) for Type 2 Diabetes Mellitus with Diabetic Dermatitis. Review of Resident #53's care plan read in part Diabetes .Diabetes Mellitus (Type 2): Receives Metformin and Januvia as ordered. Further review of care plan revealed no interventions for the use of Regular Insulin. On 12/06/2023 at 11:52 a.m., an interview was conducted with S3MDSIP (Minimum Data Set/Infection Preventionist) who stated that she was responsible for completing and updating the care plan for Resident #53. A review of the resident's care plan was conducted with S3MDSIP. S3MDSIP confirmed that Resident #53's care plan did not include that the resident was prescribed Regular Insulin per SS and had no interventions for insulin. S3MDSIP confirmed that the care plan should have been developed to include the medication regular insulin and interventions for SS insulin. Resident #91 Review of Resident #91's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Dementia with agitation, and Unspecified intellectual disabilities. Review of Resident #91's December physician's order revealed an order for dated 12/21/2022 for Exelon 4.6 mg (milligram)/24 hr (hour), apply one patch topically daily and Namenda 5 mg one tablet by mouth daily for Unspecified Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of Resident #91's care plan read in part . Anxiety .has Dx (diagnosis) of Depression .had inpatient stay from 12/9/2022 to 12/21/2022 and returned with Dx of Dementia with behavioral disturbances and new on Cymbalta, Namenda and Exelon. Further review of Resident #91's care plan revealed no interventions for the diagnosis of Dementia. On 12/06/23 at 1:04 p.m., an interview was conducted with S11MDS (Minimum Data Set) who stated that she was responsible for completing and updating the care plan for Resident #91. A review of the resident's care plan was conducted with S11MDS. S11MDS confirmed that the resident's care plan did not have a care plan developed for Dementia and was care planned under the diagnosis of anxiety. She also confirmed that the diagnosis and interventions related to Dementia were not included in Resident #91's care plan and should have been. S11MDS stated the care plan should have been developed to include the Dementia diagnosis and interventions in order to be patient centered.

Based on record review and interview, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center of Medicare And Medicaid Services) in a timely manner for 3 (#17, #24, #59) out of a final sample of 37 residents. Findings: Resident #17 Resident #17 was admitted to the facility on [DATE] with diagnoses including Dysphagia and Generalized Anxiety. Review of Resident #17's electronic health record revealed a quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE]. Section Z of the assessment was not signed by a registered nurse, and the assessment had not been submitted. On [DATE] at 12:00 p.m., an interview was conducted S3MDSIP (Minimum Data Set/ Infection Preventionist ) who stated that she was responsible for signing and submitting Resident #17's MDS assessment. A review of Section Z of Resident #17's MDS assessment with ARD [DATE] was reviewed with S3MDSIP. S3MDSIP confirmed the MDS assessment was not signed, had not been submitted to CMS, and the submission was late. 41419 Resident #24 Resident #24 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, Chronic Obstructive Pulmonary Disease, Heart Failure, Atrial Fibrillation. Review of Resident #24's electronic health record revealed the resident was readmitted from the hospital on [DATE]. Further review of the residents record revealed a Re-entry MDS assessment that not been submitted. On [DATE] at 3:25 p.m., an interview was conducted with S3MDSIP. S3MDSIP confirmed the resident's re-entry MDS assessment should have been complete making it 1 day overdue. Resident #59 Resident #59 was admitted to the facility on [DATE] with a diagnoses including Heart Failure, Chronic Obstructive Pulmonary Disease, Morbid Obesity, and Cardiomegaly. Review of resident #59's electronic health record revealed the resident expired on [DATE]. Further review of the residents MDS assessment revealed a Death MDS assessment had never been opened. On [DATE] at 3:25 p.m., a group interview was conducted with S3MDSIP and S11MDS. Both confirmed the Death in Facility MDS assessment was not complete within the required time frame making it greater than 120 days overdue.

Based on record review and interview, the facility failed to ensure all required members of the IDT (Interdisciplinary Team) attended the care plan meeting for 1 (#60) out of 37 sampled residents. Findings: Review of the facility's policy titled Care Planning - Interdisciplinary Team read in part .2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning/Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietitian; d. The Social Services Worker responsible for the resident; e. The Activity Director/Coordinator; f. Therapists (speech, occupational, recreational, etc. ) g. Consultants (as appropriate) h. The Director of nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. This policy lines up with what the regulation stated. Resident #60 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes, Generalized Anxiety, and Major Depressive Disorder. Review of Resident #60's health record revealed his most recent care plan or care conference meeting was on 10/05/2023. Further review of the care plan meeting documentation revealed the following: IDT members involved in resident's care planning: S3MDSIP (Minimum Data Set/Infection Preventionist) and S11MDS (Minimum Data Set). There were no other IDT members documented as being involved in the resident's care planning. On 12/06/2023 at 2:04 p.m., an interview and record review was conducted with S10SSD (Social Services Director). Resident #60's care conference meeting dated 10/5/2023 was reviewed with S10SSD. She confirmed that S3MDSIP and S11MDS were the only 2 documented members of the IDT in attendance. S10SSD further stated that the Physician or Nurse Practitioner did not attend and were not on conference call during the care plan meeting. S10SSD also stated that the physician did not review the care plan meetings nor the resident's care plan after each quarterly meeting.

Based on observation, record review and interview the facility failed to accurately assess 1 (#76) of 37 sampled residents' oral status. This had the potential to affect the 104 residents that reside in the facility. Findings: Record review revealed Resident #76's was admitted to the facility on [DATE] with Diagnosis of, Nicotine Dependence, Major Depressive disorder Type 2 Diabetes, Anxiety, Chronic Obstructive Pulmonary Disease, Anorexia, Gastroesophageal Reflux Disease, Vitamin D deficiency, Emphysema, Server proteins-Calorie Malnutrition, Dysphagia, Osteoarthritis, Iron Deficiency Anemia, and Dementia. On 12/04/2023 at 9:53 a.m., an observation of Resident #76's oral cavity confirmed she had broken and missing teeth. Record review of Resident #76's dental progress notes dated 04/13/2023 read in part, Oral Assessment, D. Suspect area or broken natural teeth .Tooth #11 is broken down, lingual cusp is broken. Root tips: #15 and #16. Record review of Resident #76's MDS ((Minimum Data Set (Oral Assessment)) dated 08/21/2023 under Section: L-Dental, read in part Cavity or broken natural teeth-Unchecked. (Meaning there was no cavity or broken natural teeth). On 12/05/2023 at 3:58 p.m., S3MDS reviewed Resident #76's MDS dated [DATE]. She stated S11MDS performed Resident #76's dental assessment and it was unchecked meaning there was nothing wrong with the resident's natural teeth. On 12/05/2023 at 4:08 p.m., S11MDS confirmed she does Resident #76's assessments. She stated Resident #76 had seen the dentist this year. She stated when she assessed Resident #76's oral cavity quarterly, the resident has broken and missing teeth. She reviewed Resident #76's MDS oral assessment dated [DATE] and confirmed she did not check the box to indicated the resident had cavity or broken natural teeth. She stated this was an inaccurate assessment.

Based on Interview and Record Review, the facility failed to provide the necessary care and services to attain the highest practicable physical and psychosocial well-being for 1 (#133) of 2 (#133, #100) resident's reviewed for death in stage 2 by failing to: 1.) Attempt non-pharmacological interventions prior to administering the psychoactive medications [MEDICATION NAME] and [MEDICATION NAME]. 2.) Ensure clinically significant adverse consequences of sedation, confusion, and fatigue were minimized. 3.) Recognize the Black Box Warning regarding the use of [MEDICATION NAME] in the elderly with dementia. Findings: Resident #133 On 11/20/13 a review of the clinical record revealed Resident #133 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 11/20/13 a review of the Policy for monitoring Residents who have a new [MEDICAL CONDITION] Medication or a change in [MEDICAL CONDITION] Medications revealed the following: The facility is to monitor and document x 72 hours on all residents who have a change in [MEDICAL CONDITION] medications. The following must be documented in the Nurses Notes every shift. Mood State Behavior Changes Changes in Vital Signs Sleeping and Eating Patterns The physician must be notified of any adverse effects. Purpose is to monitor the effectiveness of [MEDICAL CONDITION] medications and minimize adverse effects A review of the Social Services Notes dated 09/09/13 revealed Resident #133 was a 95 yr. old white male. He was admitted with a [DIAGNOSES REDACTED]. He was alert and oriented to person. He was in a wheel chair and had a power of attorney and was a Do Not Resuscitate. Therapy was to evaluate the resident. The resident's long term plan was to return home. A review of the MDS (Minimum Data Set) dated 09/16/13 revealed in part: Section D Mood: the resident had no depression. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." Section N Medications: Medications received antipsychotic for 2 days. A review of the MDS dated [DATE] revealed in part: Section D Mood: The resident was never depressed. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." Section N Medications: The resident had been on an antipsychotic for 7 days. A review of the MDS dated [DATE] revealed in part: Section D Mood: The resident had no depression. Trouble with sleep was marked as yes with 2-6 days as frequency. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." A review of the resident's care plan revealed in part: A problem dated 09/17/13 of "is on [MEDICATION NAME]. Displays hyper-activity especially at night per staff resident doesn't sleep well, attempts to get out of bed without assistance." Intervention/approaches: Administer meds as ordered. Labs as ordered notify M.D. (medical doctor) with abnormal results. Monitor for and intervene for negative changes in mood or behavior. Observe for side/adverse effects: Tardive dyskinesia A [DIAGNOSES REDACTED]. A review of Resident #133's admission Nursing Assessment and MDS revealed he was alert and oriented to person and place. His decision making was modified independent. He was able to speak and make himself understood. The resident's mood was happy. No behavior problems were documented. He was eating 50% of his food. The resident's long term plan was to return home. The following departmental notes were documented, in part: 09/09/13- Resident #133 was admitted to the facility. 09/09/13 (Admit Physician Order) - P.T. (physical therapy) and O.T. (occupational therapy) weight bearing as tolerated. PT/OT 5xweek to increase strength and endurance post Rt. [MEDICAL CONDITION]. 09/12/13 at 3:15 p.m. (Nurse's Note)- documented the resident attempted to get out of bed at the foot of the bed with side rails up x2 due to being restless in bed. S15MD was notified. Orders were noted for personal alarms in the W/C (wheel chair) and the bed and side rails x1 only and floor pad on door side. 09/12/13 at 3:45 p.m. (New Physician Orders) - [MEDICATION NAME] 0.25mg was ordered to be given at HS (Hour of Sleep). A [DIAGNOSES REDACTED]. The R.P. (resident's representative) was notified of the order and he was informed [MEDICATION NAME] is a chemical restraint and he gave permission for it. 09/17/13 (Nurse's Note) - documented that his appetite was poor for the past few days. He refused breakfast and lunch on 09/17/13. The resident continued to be alert and responsive, but his appetite decreased. 09/18/13 (P.T. Note) - Resident was ambulating 80 feet and on level surfaces requiring moderate assistance with rolling walker. 09/19/13 at 10:35 a.m. (Nurse's Note) Resident refused all food as served, stating it does not appeal to him but he was drinking everything given to him. S15MD was notified. 09/19/13 (new physician's orders [REDACTED].o. (By mouth) H.S.; [MEDICATION NAME] 4mg po every a.m. for poor appetite, hold if drowsy. 09/19/13 at 6:10 p.m. (Nurse's Notes) - Resident up in wheel chair, alert and oriented and verbally responsive. 09/23/13 at 1:00 p.m. (Nurse's Note) - Resident disoriented to place and time. 09/23/13 (P.T. Note) Resident ambulated 20 feet on level surfaces and required moderate assistance x2 with rolling walker. 09/24/13 (Nurse's Note) - Resident has a poor appetite and has not been eating, but does drink Hi Cal after meals. He falls asleep easily and sleeps most of the day. 09/24/13 (P.T. Note) - Resident made no progression nor had the energy to participate. 09/24/13 (new physician's orders [REDACTED]. 09/24/13 (Physician Order) - Pureed food and thickened liquid, speech evaluation. 09/25/13 (Nurse's Note) - S15MD was notified of the resident holding food in his mouth and it taking an increased amount of time to swallow. 09/26/13 at 10:00a.m. (Nurse's note)- Resident difficult to arouse. He was verbally responsive with much effort. A sternal rub was performed and he opened his eyes with difficulty. He was not able to tolerate pureed diet. S15MD was notified and he arrived at 4:00 p.m. to make rounds. 09/26/13 (Physician Order's) the following orders were written: 1- [MEDICATION NAME] gtts (drops) 2 gtts SL every 2 hrs prn increased secretions. 2- [MEDICATION NAME] 20 mg /ml give 0.5ml every 2 hrs. SL for shortness of breath. 3- Discontinue current oral meds. 4-Tylenol supp. (suppository) gr 10 per rectum every 4 hrs. For temp prn (as necessary) 5-Nasal O2 (oxygen) 2-4l/min prn for SOB (shortness of breath) 6- Pureed diet with honey thick liquids R/T (related to) speech recommendations due to holding food and increased time to swallow. 09/27/13 at 9:30 a.m. (Nurse's Note) - Resident was noted to be non- responsive to verbal stimuli. The HOB (Head of Bed) was elevated 30 degrees. 09/28/13 at 9:00 a.m. (Nurse's Note) - Resident continues to be difficult to arouse with no verbal response. O2 (oxygen) was in progress. The HOB was elevated at 20 degrees. His eyes were slightly opened with pupils slightly dilated. He was moaning with facial grimacing during pericare and with positioning. [MEDICATION NAME] 20 mg /ml 0.5ml was given SL. 09/29/13 at 4:00 p.m. (Nurse's Note) - Resident continued to be non-responsive with respiration short and shallow. His blood pressure continued to drop. He responded to tactile stimulations with very little movement. When turned on his left side facial grimacing was observed and he was given [MEDICATION NAME] 0.5ml SL. 09/29/13 at 10:35 p.m. (Nurse's Note) - Staff was unable to auscultate or palpate blood pressure or heartbeat. 09/29/13 at 10:40 p.m. (Nurse's Note) - Resident #133 was pronounced dead by the on-call MD. A review of the adverse reactions related to the use of the medication [MEDICATION NAME] (Mosby's 2013 Nursing Drug Reference) revealed in part common reactions of somnolence, fatigue, urinary incontinence, confusion, and [MEDICAL CONDITION]. When checked for an interaction with the medication of [MEDICATION NAME] it was noted that giving these medications together may increase the side effects such as dizziness, drowsiness and difficulty concentrating. [MEDICATION NAME] has a mean elimination half- life of 20 hrs. In elderly people renal clearance is decreased and the mean elimination half- lives were prolonged to greater than 20 hrs. [MEDICATION NAME] was also noted to have a black box warning in part as follows: Dementia-Related [MEDICAL CONDITION] Not approved for dementia -related [MEDICAL CONDITION]; increase mortality risk in elderly dementia patients on conventional or atypical antipsychotics. On 11/20/13 at 11:35 a.m. the S1DON and S6RNSUP were asked why the resident was started on [MEDICATION NAME]. The S1DON and S6RNSUP reviewed the chart and stated that he was put on it due to restlessness in bed. They were asked what non-pharmacological measures had they used prior to giving [MEDICATION NAME]. They were unable to give any measures that were started. On 11/21/13 at 9:50 a.m. an interview was conducted with S6RNSUP. She was asked if she could show documentation in the chart where the resident was being monitored for behaviors and side effects from the antipsychotic. She stated it is documented in the nurse's notes in the chart. She was asked who follows up with the information after it is documented. She was unable to answer the question. On 11/21/13 at 2:00 p.m. an interview was conducted with S5RN. She was asked to review the chart and explain the behaviors that occurred prior to the order for [MEDICATION NAME] on Resident #133. She stated, "He was restless."She was asked if the resident had displayed any other behaviors prior to this incident on 09/12/13. She stated, "I do not see any other incidents documented on the chart." She was asked if the prescribing MD routinely ordered [MEDICATION NAME] for restlessness and she stated, "I do not know." S5RN stated the MD knew the resident from the hospital. She was asked to provide the documentation of behavior monitoring and monitoring of Side Effects of the psychoactive medications of this resident. She pointed out vital signs each shift on the nurse's notes but was unable to produce any other documentation for monitoring behaviors or side effects of the psychoactive medications. On 11/22/13 at 10:30 a.m. an interview was conducted with S15MD - the resident's physician. He was asked if he started the resident on [MEDICATION NAME] in response to the resident attempting to climb out of the bed on 09/12/13. He stated, "Resident #133 was admitted with End Stage Dementia and I had treated him in the hospital prior to his admission here. During the hospital stay he had problems with [MEDICAL CONDITION] and hallucinations. So I knew him from the hospital and that is why I started the [MEDICATION NAME]." He was asked if he was aware the resident was still on [MEDICATION NAME] when he started the [MEDICATION NAME]? He stated, "I started the [MEDICATION NAME] because in my experience it has been great for improving appetite. I was not aware the resident was still on [MEDICATION NAME] or I would never have put him on both medications at the same time."

Based on Record Review and Staff Interview the facility failed to ensure that the resident's drug regimen remained free from unnecessary medications for 2 (#133, #101) of 6 (# 133, #101, #62, #8, #129, #16) residents who were reviewed for unnecessary medications in stage 2 by failing to : 1.) Attempt behavior modification before starting [MEDICATION NAME] and [MEDICATION NAME] for Resident#133 and before starting [MEDICATION NAME] for Resident #101. 2.) Ensure clinically significant adverse consequences were minimized, such as somnolence, fatigue, confusion and [MEDICAL CONDITION] for Resident #133. 3.) Recognize the Black Box Warnings regarding the use of [MEDICATION NAME] in the elderly with dementia for Resident #133. Findings: Resident #133 On 11/20/13 a review of the clinical record revealed Resident #133 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Social Services Notes dated 09/09/13 revealed Resident #133 was a 95 yr. old white male. He was admitted with a [DIAGNOSES REDACTED]. He was alert and oriented to person. He was in a wheel chair and had a power of attorney and was a Do Not Resuscitate. Therapy was to evaluate the resident. The resident's long term plan was to return home. A review of the MDS (Minimum Data Set) dated 09/16/13 revealed in part: Section D Mood: the resident had no depression. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." Section N Medications: Medications received antipsychotic for 2 days. A review of the MDS dated [DATE] revealed in part: Section D Mood: The resident was never depressed. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." Section N Medications: The resident had been on an antipsychotic for 7 days. A review of the MDS dated [DATE] revealed in part: Section D Mood: The resident had no depression. Trouble with sleep was marked as yes with 2-6 days as frequency. Section E Behavior: The resident was assessed as "[MEDICAL CONDITION] none of the above." A review of the resident's care plan revealed in part: A problem dated 09/17/13 of "is on [MEDICATION NAME]. Displays hyper-activity especially at night per staff resident doesn't sleep well, attempts to get out of bed without assistance." Intervention/approaches: Administer meds as ordered. Labs as ordered notify M.D. (medical doctor) with abnormal results. Monitor for and intervene for negative changes in mood or behavior. Observe for side/adverse effects: Tardive dyskinesia A [DIAGNOSES REDACTED]. On 11/20/13 a review of the Policy for monitoring Residents who have a new [MEDICAL CONDITION] Medication or a change in [MEDICAL CONDITION] Medications revealed the following: The facility is to monitor and document x 72 hours on all residents who have a change in [MEDICAL CONDITION] medications. The following must be documented in the Nurses Notes every shift. Mood State Behavior Changes Changes in Vital Signs Sleeping and Eating Patterns The physician must be notified of any adverse effects. Purpose is to monitor the effectiveness of [MEDICAL CONDITION] medications and minimize adverse effects. A review of Resident #133's admission Nursing Assessment and MDS revealed he was alert and oriented to person and place. His decision making was modified independent. He was able to speak and make himself understood. The resident's mood was happy. No behavior problems were documented. He was eating 50% of his food. The resident's long term plan was to return home. The following departmental notes were documented, in part: 09/09/13- Resident #133 was admitted to the facility. 09/09/13 (Admit Physician Order) - P.T. (physical therapy) and O.T. (occupational therapy) weight bearing as tolerated. PT/OT 5xweek to increase strength and endurance post Rt. [MEDICAL CONDITION]. 09/12/13 at 3:15 p.m. (Nurse's Note)- documented the resident attempted to get out of bed at the foot of the bed with side rails up x2 due to being restless in bed. S15MD was notified. Orders were noted for personal alarms in the W/C (wheel chair) and the bed and side rails x1 only and floor pad on door side. 09/12/13 at 3:45 p.m. (New Physician Orders) - [MEDICATION NAME] 0.25mg was ordered to be given at HS (Hour of Sleep). A [DIAGNOSES REDACTED]. The R.P. (resident's representative) was notified of the order and he was informed [MEDICATION NAME] is a chemical restraint and he gave permission for it. 09/17/13 (Nurse's Note) - documented that his appetite was poor for the past few days. He refused breakfast and lunch on 09/17/13. The resident continued to be alert and responsive, but his appetite decreased. 09/18/13 (P.T. Note) - Resident was ambulating 80 feet and on level surfaces requiring moderate assistance with rolling walker. 09/19/13 at 10:35 a.m. (Nurse's Note) Resident refused all food as served, stating it does not appeal to him but he was drinking everything given to him. S15MD was notified. 09/19/13 (new physician's orders [REDACTED].o. (By mouth) H.S.; [MEDICATION NAME] 4mg po every a.m. for poor appetite, hold if drowsy. 09/19/13 at 6:10 p.m. (Nurse's Notes) - Resident up in wheel chair, alert and oriented and verbally responsive. 09/23/13 at 1p.m. (Nurse's Note) - Resident disoriented to place and time. 09/23/13 (P.T. Note) Resident ambulated 20 feet on level surfaces and required moderate assistance x2 with rolling walker. 09/24/13 (Nurse's Note) - Resident has a poor appetite and has not been eating, but does drink Hi Cal after meals. He falls asleep easily and sleeps most of the day. 09/24/13 (P.T. Note) - Resident made no progression nor had the energy to participate. 09/24/13 (new physician's orders [REDACTED]. 09/25/13 (Nurse's Note) - S15MD was notified of the resident holding food in his mouth and it taking an increased amount of time to swallow. 09/24/13 (Physician Order) - Pureed food and thickened liquid, speech evaluation. 09/26/13 at 10:00a.m. (Nurse's note)- Resident difficult to arouse. He was verbally responsive with much effort. A sternal rub was performed and he opened his eyes with difficulty. He was not able to tolerate pureed diet. S15MD was notified and he arrived at 4:00 p.m. to make rounds. 09/26/13 (Physician Order's) the following orders were written: 1- [MEDICATION NAME] gtts (drops) 2 gtts SL every 2 hrs prn increased secretions. 2- [MEDICATION NAME] 20 mg /ml give 0.5ml every 2 hrs. SL for shortness of breath. 3- Discontinue current oral meds. 4-Tylenol supp. (suppository) gr 10 per rectum every 4 hrs. For temp prn (as necessary) 5-Nasal O2 (oxygen) 2-4l/min prn for SOB (shortness of breath) 6- Pureed diet with honey thick liquids R/T (related to) speech recommendations due to holding food and increased time to swallow. 09/27/13 at 9:30 a.m. (Nurse's Note) - Resident was noted to be non- responsive to verbal stimuli. The HOB (Head of Bed) was elevated 30 degrees. 09/28/13 at 9:00 a.m. (Nurse's Note) - Resident continues to be difficult to arouse with no verbal response. O2 (oxygen) was in progress. The HOB was elevated at 20 degrees. His eyes were slightly opened with pupils slightly dilated. He was moaning with facial grimacing during pericare and with positioning. [MEDICATION NAME] 20 mg /ml 0.5ml was given SL. 09/29/13 at 4:00 p.m. (Nurse's Note) - Resident continued to be non- responsive with respiration short and shallow. His blood pressure continued to drop. He responded to tactile stimulations with very little movement. When turned on his left side facial grimacing was observed and he was given [MEDICATION NAME] 0.5ml SL. 09/29/13 at 10:35 p.m. (Nurse's Note) - Staff was unable to auscultate or palpate blood pressure or heartbeat. 09/29/13 at 10:40 p.m. (Nurse's Note) - Resident #133 was pronounced dead by the on-call MD. A review of the adverse reactions related to the use of the medication [MEDICATION NAME] (Mosby's 2013 Nursing Drug Reference) revealed in part common reactions of somnolence, fatigue, urinary incontinence, confusion, and [MEDICAL CONDITION]. When checked for an interaction with the medication of [MEDICATION NAME] it was noted that giving these medications together may increase the side effects such as dizziness, drowsiness and difficulty concentrating. [MEDICATION NAME] has a mean elimination half-life of 20 hrs. In elderly people renal clearance is decreased and the mean elimination half-lives were prolonged to greater than 20 hrs. [MEDICATION NAME] was also noted to have a black box warning in part as follows: Dementia-Related [MEDICAL CONDITION] Not approved for dementia-related [MEDICAL CONDITION]; increase mortality risk in elderly dementia patients on conventional or atypical antipsychotics.. On 11/20/13 at 11:35 a.m. the S1DON and S6RNSUP were asked why the resident was started on [MEDICATION NAME]. The S1DON and S6RNSUP reviewed the chart and stated that he was put on it due to restlessness in bed. They were asked what non-pharmacological measures they used prior to giving [MEDICATION NAME]. They were unable to give any measures that were started. On 11/21/13 at 9:50 a.m. an interview was conducted with S6RNSUP. She was asked if she could show documentation in the chart where the resident was being monitored for behaviors and side effects from the antipsychotic. She stated it is documented in the nurse's notes in the chart. She was asked who follows up with the information after it is documented. She was unable to answer the question. On 11/21/13 at 2:00 p.m. an interview was conducted with S5RN. She was asked to review the chart and explain the behaviors that occurred prior to the order for [MEDICATION NAME] on Resident #133. She stated," He was restless." She was asked if the resident had displayed any other behaviors prior to this incident on 09/12/13. She stated, "I do not see any other incidents documented on the chart." She was asked if the prescribing MD routinely ordered [MEDICATION NAME] for restlessness and she stated, "I do not know." S5RN stated the MD knew the resident from the hospital. She was asked to provide the documentation of behavior monitoring and monitoring of Side Effects of the psychoactive medications of this resident. She pointed out vital signs each shift on the nurse's notes but was unable to produce any other documentation for monitoring behaviors or side effects of the psychoactive medications. On 11/22/13 at 10:30 a.m. an interview was conducted with S15MD - the resident's physician. He was asked if he started the resident on [MEDICATION NAME] in response to the resident attempting to climb out of the bed on 09/12/13. He stated, "Resident #133 was admitted with End Stage Dementia and I had treated him in the hospital prior to his admission here. During the hospital stay he had problems with [MEDICAL CONDITION] and hallucinations. So I knew him from the hospital and that is why I started the [MEDICATION NAME]." He was asked if he was aware the resident was still on [MEDICATION NAME] when he started the [MEDICATION NAME]? He stated, "I started the [MEDICATION NAME] because in my experience it has been great for improving appetite. I was not aware the resident was still on [MEDICATION NAME] or I would never have put him on both medications at the same time." Resident #101 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 11/7/12, a [DIAGNOSES REDACTED]. A review of the most recent MDS (Minimum Data Set) dated 8/15/13, had a BIMS (Brief Interview of Mental Status) score of 8 indicating that her cognition was moderately impaired. She had " periods of inattention, disorganized thinking and altered level of consciousness. " A review of the care plan on 11/19/13 revealed a problem onset dated 4/26/12 of resident #101 feeling restless and anxious. She called out frequently "hey Miss help me" to staff and visitors. Approaches included: staff to provide one on one activities; sit with ward clerk at the desk for one on one care/attention; let the resident verbalize feelings and listen in a non-judgmental manner; give the resident 1:1 attention when she was anxious and help her to gain control; provide the resident with assurance and support; and observe for changes in resident's mood status; give medication as ordered. The physician's orders [REDACTED]. A review of the October 2013 Medication Administration Report revealed: On 10/3/13 at 11:40 p.m., [MEDICATION NAME] 0.25mg was given. On 10/12/13 at 2:00 p.m., [MEDICATION NAME] 0.25mg was given. On 10/13/13 at 11:15 a.m., [MEDICATION NAME] 0.25mg was given. On 10/15/13 at 2:30 a.m., [MEDICATION NAME] 0.25mg was given. On 10/17/13 at 6:30 p.m., [MEDICATION NAME] 0.25mg was given. On 10/30/13 at 2:30 a.m., [MEDICATION NAME] 0.25mg was given. On 10/31/13 at 11:20 p.m., [MEDICATION NAME] 0.25mg was given. A review of the November 2013 Medication Administration Report revealed: On 11/2/13 at 6:00 p.m., [MEDICATION NAME] 0.25mg was given. On 11/3/13 at 5:00 p.m., [MEDICATION NAME] 0.25mg was given. On 11/16/13 at 8:45 p.m., [MEDICATION NAME] 0.25mg was given. On 11/17/13 at 7:30 p.m., [MEDICATION NAME] 0.25mg was given. On 11/20/13 at 5:30 a.m., [MEDICATION NAME] 0.25mg was given. The Nurse's Notes for October and November 2013 were reviewed. There were no behaviors documented requiring the need for [MEDICATION NAME] and no approaches to relieve anxiety as care planned prior to giving [MEDICATION NAME]. A review of the Chronological Drug Regimen Review for 2013 completed by the facility pharmacist revealed no irregularities or recommendations for [MEDICATION NAME] for October or November 2013. On 11/20/13 at 9:25 a.m., an interview was held with S11LPN. She was unaware of where documentation could be found regarding behaviors for resident #101 that would require the administration of a PRN dose of [MEDICATION NAME]. When asked about how she monitored and documented behaviors, S11LPN stated she did not know. On 11/20/13 at 9:35 am an interview was held with S1DON. She stated that it was normal behavior for resident #101 to call out " mam, mam, mam " and should not be medicated for that behavior. S1DON stated that behavior monitoring and alternative approaches to medication should have been documented in the nurse ' s notes. She stated alternative approaches should have been attempted before each PRN [MEDICATION NAME] administration. S1DON reviewed the nurse ' s notes and MARs for October and November 2013 and was unable to find any documentation of behaviors or alternative approaches for the [MEDICATION NAME] doses given by nursing staff as listed above. She stated that routine monitoring for behaviors and side effects were listed on the MAR (Medication Administration Record). She stated that if a behavior or side effect was present, an X should have been marked on the MAR indicated [REDACTED]. She was unable to find any documentation for behaviors, side effects or behavior modification approaches for the PRN doses of [MEDICATION NAME] listed above for October and November 2013 on the MARs or the nurse ' s notes.

Based on record review and staff interview, the facility failed to maintain acceptable parameters of nutrition for 1 (#8) of 3 residents reviewed for pressure ulcers (#8, #41, #133) by failing to identify and act on a significant weight loss of 53 pounds in a six week period from 5/15/13 until 6/30/13. Resident ' s weight on admit, 3/16/01, was 193 pounds and she remained in the 170-190 range until 5/15/13 when recorded weight was 185 pounds. On 6/30/13 the resident ' s recorded weight was 132 pounds (a 29% weight loss in six weeks. Therapeutic diet measures to increase calories with nutritional supplements was not initiated until 7/31/13, an additional one month after the significant weight loss at which time the resident had lost an additional 7 pounds (125 pounds) . In addition, Resident #8 had no history of pressure ulcers, and by 8/21/13 the resident had developed 2 stage III pressure ulcers. FINDINGS: Resident #8 A review of Resident #8 ' s clinical record revealed that the resident was a [AGE] year old female with the following Diagnoses: [REDACTED]. Further review of the clinical record revealed that Resident #8 required total assistance by staff for all activities of daily living, including bed mobility, and that she had limited movement to her extremities and was incontinent of bowel and bladder. Resident #8 was not interviewable during the survey process due to cognition. A review of Resident #8 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had severely impaired cognitive skills and was totally dependent on staff for activities of daily living including eating. Further review revealed that Resident #8 had a swallowing disorder, but had no weight loss or gain. A review of Resident #8 ' s Nutritional Risk assessments revealed the following; 12/31/12 - score of 12 3/20/13 - score of 7 6/20/13 - score of 7 7/19/13 - score of 14. Further review of the assessments revealed that a score of 7 or more indicated high risk and to follow the facility ' s nutritional protocol. A review of Resident #8 ' s clinical record revealed weights as follows: 1/16/13 - 181 lb 2/13/13 - 178 lb 3/13/13 - 180 lb 4/17/13 - 183 lb 5/15/13 - 185 lb 6/30/13 - 132 lb 7/14/13 - 137 lb 7/30/13 - 125 lb 8/7/13 - 137.4 lb 8/14/13 - 137 lb 8/21/13 - 137 lb 8/28/13 - 135 lb 9/4/13 - 136 lb 9/11/13 - 136 lb 9/18/13 & 9/25/13 - 137 lb 10/2/13 - 135 lb 10/9/13 - 138 lb 10/16 & 10/23/13 - 137 lb 10/30/13 - 133 lb and 11/6/13 - 129 lb A review of the facility ' s Resident Weight Change Status History revealed Resident #8 sustained a 53 pound weight loss between 5/15/13 and 6/30/13. Further review of Resident #8 ' s weights revealed that her weight remained between 129 to 137.8 lb after the weight loss on 6/30/13. Resident #8 was unable to return to her baseline weight of 180s. A review of the Dietary Progress Notes completed by S23, Dietary Manager dated 3/23/13 revealed weight was stable at 180 for the previous 6 months, appetite good and would continue to monitor and that Hospice was discontinued. A review of the following Dietary Progress Note dated 7/3/13 revealed that it was completed with a quarterly assessment for 6/19/13, which included a weight of 185 pounds. Further review revealed that Resident #8 ' s weight was stable at 185 lb as of that date, 7/3/13, that the resident had a 6 pound weight gain in the previous 6 months and that she would continue to monitor. Further reveal also revealed that Resident #8 was consuming 50-100% of her meals and there was no mention of the weight loss that occurred between 5/15/13 and 6/3/13. The weight loss was not addressed in the Dietary Progress Notes until 9/17/13. An interview was conducted with S23, Dietary Manager on 11/22/13 at 11:00 am who confirmed that she competed the Dietary Progress Note on 7/3/13. She stated that she was not aware of the 53 pound weight loss that was identified on 6/30/13 because she was using the weight of 185 pounds on 6/19/13 since she was behind on her work. S23, Dietary Manager stated that she did not go back and check the resident ' s most current weight on 7/3/13 when she completed the assessment, and that if she had, she would have noted the 53 pound weight loss between 5/15/13 and 6/30/13. S23, Dietary Manager stated that if she had noted the 53 pound weight loss on 6/30/13, that she would have notified the Physician and the Dietitian immediately since this was a significant weight loss. A review of Resident #8 ' s Registered Dietitian ' s Progress Notes dated 5/20/13 revealed that the resident ' s weight was 183 lb and that she had a 5 lb weight gain in a month. Further review revealed that her appetite was good and that she would continue to monitor. A review of Resident #8 ' s next Registered Dietitian ' s Progress Note dated 7/22/13 revealed that her weight was 132 lb, stable and that her appetite was good and then a line was drawn through it to indicate an error. Further review of the progress note revealed that she was unsure of the weight on 6/30/13, at 132 lb. Further review also revealed that she requested a reweight which revealed her weight was actually 132 lb even on reweight. S24, Dietitian then spoke with the nursing staff who informed her that the resident had a decreased appetite and was consuming 25-75% of meals. S24, Dietitian ' s recommendation at that time was increase the house supplement to 4 oz three times a day and to begin weekly weights. A review of Resident #8 ' s physician's order [REDACTED]. A review of Resident #8 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of Resident #8 ' s next Registered Dietitian ' s Progress Note dated 7/29/13 revealed that her weight on 7/24/13 continued to decrease and was at 125.4 lb. The Dietitian ' s recommendation at that time was to increase the Hi- Cal to 4 oz four times a day and for labs CMP and CBC to be obtained. An interview was conducted on 11/22/13 at 10:35 am with S,24, Dietitian who stated that she was not aware of Resident #8 ' s 53 pound weight loss until 7/22/13, even though the weight was obtained on 6/30/13. S24, Dietitian stated that a 53 pound weight loss in 1 month would be considered a significant weight loss and that had she known before 7/22/13, that she would have acted on it immediately. S24, Dietitian stated that she made weekly visits to the facility and obtained resident weights from the computer and a binder. S24, Dietitian stated that she would not have gone to the computer to obtain the weight loss on 6/30/13 since the resident was not on weekly weights. An interview was conducted on 11/22/13 at 9:35 am with S2, ADON who stated that resident weights were done by CNA staff who then brought them over to S3, LPN, MDS to input into the computer and that S3, LPN, MDS was responsible for making changes to the care plans. S2, ADON stated that the computer generated weights were available to both the Dietician and the Dietary Manager for review on the computer. S2, ADON stated that she was not aware of Resident #8 ' s 53 pound weight loss, that occurred from 5/15/13 to 6/30/13, and that it must have just been missed until the next Nutritional High Risk meeting on 7/29/13. S2, ADON pointed out that the facility conducted weekly Nutritional High Risk Meetings that were attended by the Dietary Manager, Dietician and herself. She stated that a meeting was conducted on 6/24/13 but there were no meetings between 6/.24/13 and 7/29/13. S2, ADON stated that S24, Dietician went to the facility each week and that she should have noted the weight loss prior to 7/22/13 when she first addressed it in her Dietician ' s Progress Note. S2, ADON also stated that Resident #8 ' s Physician should have been notified immediately of the significant weight loss. S2, ADON denied having any other documentation available for review An interview was conducted on 11/22/13 at 10:13 am with S3, LPN, MDS who stated that she and S4, LPN, MDS Assistant were responsible for imputing resident weights into the computer from the CNA staff, and that it was nursing and dietary ' s responsibility to act on the weight changes at that point. S3, LPN, MDS stated that she was not aware of Resident #8 ' s 53 pound weight loss on 6/30/13. She stated that S4, LPN was responsible for making changes to the care plan when residents experienced significant weight losses. An interview was conducted on 11/22/13 at 10:15 am with S4, LPN, and MDS Assistant who confirmed that she input the weights for Resident #8 on both 5/15/13 and 6/30/13. S4, LPN, MDS Assistant stated that she could not recall if she had noticed the weight loss at the time, but was unable to provide any documentation of her having notified nursing or dietary at that time. S4, LPN, MDS Assistant stated that she should have notified the resident ' s physician and updated the care plan to reflect the weight loss on 6/30/13. S4, LPN, MDS stated that she should have noticed and acted upon the significant weight loss since she entered both weights of 5/15/13 (185 pounds) and 6/30/13 (132 pounds) into the computer. A review of Resident #8 ' s Physician ' s Progress Notes revealed 5/24/13 there were no problems reported. The following Physician ' s Progress Note dated 7/12/13 revealed that the resident had, " no problems reported, " which had a line drawn through it to indicate that it was an error. Further review revealed that the, " nurse reports decreased appetite and weight loss, " but there was no indication that the weight loss was significant and/or 53 pounds in 1 month. Further review of the progress note revealed that the plan for Resident #8 at that time was to add [MEDICATION NAME]. A review of Resident #8 ' s physician's order [REDACTED]. Further review also revealed that on 7/12/13 a handwritten order was written for [MEDICATION NAME] 400 milligrams by mouth daily. On 7/30/13 a Physician ' s order was written for weekly weights and to add Hi Cal 4 ounces by mouth three times a day.

Based on record review and staff interview, the facility failed to administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. Ensure nursing staff assessed, documented, notified the physician, and obtain orders for pain relief for Resident #138's left leg pain on 6/24/12 after the CNA reported the resident's complaints of left leg pain to the LPN on 6/24/12, and 2. Ensure nursing staff assessed, documented, notified the physician, and obtained orders for pain relief for Resident #138's left leg pain on 6/25/12 after the CNA reported to 2 nurses on 6/25/12 there was a yellow green discoloration on the resident's left leg, and that the resident yelled when the CNA picked up her leg to put on her shoe, and 4. Ensure nursing administrative staff assessed, documented, and notified the physician, and/or followed up with LPN on 6/25/12 when the LPN reported to the RN during morning rounds of Resident #138's complaint of left leg pain earlier in the morning of 6/25/12, and when Resident #138 reported pain again to the RN on 6/26/12 during morning rounds, and 5. Ensure RN and LPN staff assessment, documentation and reporting of significant changes in condition to Resident #138's physician when Resident #138's complaints of left leg pain on 6/24/12, 6/25/12, and 6/26/12, and 6. Ensure nursing staff assessment, documentation, and reporting of Resident #138's pain and swelling of the left leg when the CNA reported to the LPN on 6/26/12 at 5:30 a.m., and 7. Ensure that nursing staff follow up in a timely manner when the physician was notified for Resident #138's complaint of pain 6/26/12, after the LPN faxed the resident's physician on 626/12 at 8:45 a.m., and there was no response from the physician until 8 1/2 hours later on 6/26/12 at 5:15 p.m. 8. Ensure nursing staff provide sufficient knowledge of resident status to oncoming staff from shift to shift. The facility failed to assess, identify, document, and/or report, Resident #138's complaints of pain in her left leg with swelling, and discoloration. There was no documented comprehensive nursing assessment or notification of the resident's complaints of pain to the physician by 6 nurses over a period of 3 days (6/24/12, 6/25/12 and 6/26/12), resulting in no nursing and/or medical interventions to treat and relieve Resident #138 ' s pain due to a pathological fracture of her left leg (tibial plateau). Resident #138 experienced unrelieved pain from 6/24/12 through 6/26/12 when staff did not notify the resident's physician to provide interventions to decrease the pain for 1 (#138) of 5 residents reviewed for pain with hospitalization (#8, #66, #104 #109, and #138) out of a total sample of 38 residents Findings: 1. Resident #138. Resident readmitted to the nursing home on 6/24/11 with [DIAGNOSES REDACTED]. Review of Resident #138's MDS (Minimum Data Set) revealed an assessment reference date of 6/11/12. She was assessed at that time to require one person, extensive assistance with transfer, walking in room or corridor, dressing, toilet use, and personal hygiene. She was assessed as limited 1 person assist with bed mobility and locomotion on and off unit. She used a walker and wheelchair. She was assessed as not steady, only able to stabilize with staff assistance to move from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Section J Health conditions revealed she had not received scheduled pain medication regimen, PRN (as needed) pain medications, or other non- medication interventions for pain at any time in during the last 5 days prior to the assessment reference date on the MDS. Review of the facility's report to the state regarding an injury of unknown origin, revealed Resident #138 complained of left leg pain to S7, RN ADON during rounds on 6/25/12 ... ...On 6/25/12 S3, DON also went to the residents room during early morning rounds ...she reports the resident was asleep and resting comfortably .....The resident complained of pain again to her left leg to S7, RN ADON on 6/26/12 during early morning rounds .... Review of the facility ' s Incident /Accident Report dated 6/26/12 at 8:30 a.m., revealed S7, RN ADON documented, " I (S7 RN, ADON) noted resident lying in bed during routine morning rounds. This was unusual for her to be in bed at this time .... Spoke with CNA (Certified Nursing Assistant) on duty (S8, CNA) ....States resident (complained) ... of leg hurting. S7, RN ADON documented on the incident report, " Assessed resident & noted (L) (lower) lateral leg with yellow & red discoloration ...Sensitive to touch. " The Incident/Accident Report revealed Resident #138 ' s physician was notified on 6/26/12 at 8:43 a.m., and was transferred to the emergency roiagnom on [DATE] at 5:40 p.m Review of the ER (emergency room ) records dated 6/26/12 at 1751, revealed Resident #138 presented to the emergency room with " pain and swelling noted over the left calf .... " Review of the X-RAY report dated 6/26/12, revealed 1. Acute displaced fracture involving the lateral tibial plateau. 2. Osteopenia. Resident #138 returned to the nursing home on 6/26/12 at 10:15 p.m. with a brace and orders to follow up with an orthopedic surgeon. Review of the nursing notes, for the days immediately preceding Resident #138 ' s ER visit of 6/26/12, revealed no nursing documentation in the notes since 6/12/12. Review of the nurses notes revealed no documented nursing assessments, interventions, or notification of Resident #138 ' s physician from 6/24/12 through 6/26/12 by nursing staff until 6/26/12 at 8:45 a.m. when S15, LPN documented .... " c/o pain to L leg. Swelling noted to L knee. L Knee warm & tender to touch. Resident vomiting Lg amount of liquids (post) AM meal & (post) meds. Loose stools noted this AM. Faxed info to Dr.___.....monitored per staff. " There was no further documentation of a follow up by S15, LPN with Resident #138 physician. Further review of the nurse ' s notes revealed the next entry regarding Resident #138 was on 6/26/12 at 5:15 p.m. by S14, LPN (8 and ? hours after S15 documented faxing a notice to the physician), which revealed, " Received (order) per Dr. _____ to send to ER for eval " ... ...and, " 5:40 p.m., .....EMS here to transport res to hospital .... " The next entry was " 6/26/12 at 10:15 ..... returned from ...ER ....velcro brace to lt knee ...orders to follow up (with) ....orthopedic ... " There was another nurse ' s noted dated 6/26/12 in which nursing documents ___MD here on rounds, but S7, RN stated on 12/13/12 at 2:40 p.m. that this note was for 6/27/12 because ___MD made rounds at the nursing home on 6/27/12 and not 6/26/12. Review of the physician orders [REDACTED].#138. Further review of the facility ' s investigation and written statements of the Incident/Accident report completed 6/26/12 by S7, RN ADON, revealed Resident #138 began complaining of pain on 6/24/12. The investigation revealed the following staff statements: S10, CNA ' s statement (not dated) revealed she worked the 10-6 shift on 6/24/12. Her statement included, " resident complained of pain to left leg when repositioned in bed ...She reported this to her nurse, S 11, LPN (no time noted). S12, CNA ' s statement (not dated) revealed ... " bather 6/25/12 (no time noted) ....went to give resident a bath ...Picked up resident (L) leg to put shoe on ...resident yelled ...Underneath left lower leg .... noticed yellow green discoloration....reported this to S11, LPN with S10, CNA .....S11, LPN states ' yes it is swollen ' ... instructed S12, CNA not to get her up .....Resident told S11, LPN that her leg was hurting ...S11, LPN stated she would pass it on to the next shift .... " S12, CNA ' s statement also revealed that S12 CNA " also reported resident leg to S13, LPN (treatment) nurse ....told her she would check resident. " S8, CNA ' s statement (not dated) revealed ..... " 6-2 CNA 6/25/12 ....S12 CNA told S8, CNA not to get resident up ....something about her leg ...and she told her to leave her in bed ....has swollen ankle and yellowish discoloration to posterior leg ....S8, CNA said resident told her several times that she was hurting ...did not question about her pain because it had been reported that she had trouble with leg ....Res. (resident) vomited after bkft (breakfast) & lunch - notified S14, LPN because her nurse S15, LPN was not around ... ...6/26/12 continued to complain of leg hurting ...vomited bkft (breakfast) & after receiving medications ....S15, LPN told her she would be calling Dr. " S11, LPN ' s statement (dated 7/13/12) revealed, " On Monday morning June 25, 2012 I was finishing my medicine and treatment pass, and at 5:45 AM I was called to Resident #138 ' s room by S12, CNA ...Upon entering room Resident #138 was lying in her bed and S12, CNA was planning to bring her to take her bath when Resident #138 stated to S12, CNA that her leg hurts ....I assessed her legs and didn ' t noted any swelling but some discolorations to some areas of both legs ....I asked her to show me where she was hurting and she pointed to the inner area of her right knee .....We (me and S12, CNA) laid her back down and I asked her if she could bed bath her for now and she agreed ....I assured Resident #138 I was going in report and I would tell the oncoming nurse. " S13, LPN ' s (Treatment Nurse) statement (not dated) revealed she " was told of an bruise to resident ' s rt (lower) leg on 6/26/12 by S12, CNA ....was also informed that S15, LPN on duty aware & had already been in there. " S17, LPN ' s statement revealed, " On 6/26/12 at 5:30 a.m., I was summoned to Resident #138 ' s room by S18, CNA reporting resident has swelling to the left leg. Res. Noted (with) swelling to LLE. Skin intact (without) breaks or discoloration noted. CNA elevated LLE (with) pillows. Resident denied pain or discomfort. (No signs/symptoms) of distress noted. Findings were reported to oncoming nurse to monitor & (follow up) if needed. " S16, CNA ' s statement (not dated) revealed, " Restorative nursing aid on 6/26/12 (no time) ....resident would not stand. " On 12/13/12 at 2:40 p.m. during an interview and S7, RN and S3, DON, S3 DON reviewed Resident#138 ' s record and the statements of the CNAs and LPNs working with resident #138 from 6/24/12 through 6/26/12. S3, DON stated she could not dispute that Resident #138 did not receive any medication for her complaints of pain from 6/24/12 through the time she went out to the hospital on [DATE]. She confirmed there was no documented evidence of a nursing assessment, and no documented evidence of nursing having reported any finding or Resident #138 ' s complaints of pain to her physician from 6/24/12 until 6/26/12. During an interview with S7, RN ADON on 12/13/12 at 2:45 pm, S7, RN presented evidence of nursing administration ' s disciplinary actions for S11, LPN, S13, LPN, S15, LPN, and S17, LPN. Review of the facility Nurse's Daily Report Sheet revealed no report sheet for 6/24/12. The Nurse's Daily Report Sheet dated 6/25/12 had no documentation of Resident #138's complaints of pain. Review of the Nurse's Daily Report Sheet dated 6/26/12 revealed, "send to ER for eval. Back @ 10:15 P FX to tibia Lt." During an interview with S3DON on 12/14/12 at 2:30 p.m., she confirmed she no longer had copies of the Nurses's Daily Report Sheets prior to 6/25/12.

Based on staff 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 by failing to: 1. Ensure nursing staff assessed, document, notified the physician, and obtain orders for pain relief for Resident #138's left leg pain on 6/24/12 after the CNA reported the resident's complaints of left leg pain to the LPN on 6/24/12. Resident #138. 2. Ensure nursing staff assessed, document,notified the physician, and obtained orders for pain relief for Resident #138's left leg pain on 6/25/12 after the CNA reported to 2 nurses on 6/25/12 there was a yellow green discoloration on the resident's left leg, and that the resident yelled when the CNA picked up her leg to put on her shoe. Resident #138. 4. Ensure nursing administrative staff assessed, document, and notified the physician, and/or followed up with LPN on 6/25/12 when the LPN reported to the RN during morning rounds of Resident #138's complaint of left leg pain earlier in the morning of 6/25/12, and when Resident #138 reported pain again to the RN on 6/26/12 during morning rounds. Resident #138. 5. Ensure RN and LPN staff assessment, documentation and reporting of significant changes in condition to Resident #138's physician when Resident #138's complaints of left leg pain on 6/24/12, 6/25/12, and 6/26/12. Resident #138. 6. Ensure nursing staff assessment, document, and reporting of Resident #138's pain and swelling of the left leg when the CNA reported to the LPN on 6/26/12 at 5:30 a.m. Resident #138. 7. Ensure that nursing staff follow up in a timely manner when the physician was notified for Resident #138's complaint of pain 6/26/12, after the LPN faxed the resident's physician on 626/12 at 8:45 a.m., and there was no response from the physician until 8 1/2 hours later on 6/26/12 at 5:15 p.m. Resident #138. 8. Ensure nursing staff provide sufficient knowledge of resident status to oncoming staff from shift to shift. Resident #138. 9. Failing to ensure the administration of pain medication as ordered by the physician to a resident ( #104) who complained of pain, whose toes were swollen and purple, and who was diagnosed with [REDACTED]. The facility failed to assess, identify, document, and/or report, Resident #138's complaints of pain in her left leg with swelling, and discoloration. There was no documented comprehensive nursing assessment or notification of the resident's complaints of pain to the physician by 6 nurses over a period of 3 days (6/24/12, 6/25/12 and 6/26/12), resulting in no nursing and/or medical interventions to treat and relieve Resident #138 ' s pain due to a pathological fracture of her left leg (tibial plateau). Resident #138 experienced unrelieved pain from 6/24/12 through 6/26/12 when staff did not provide interventions to decrease her pain. For 2 (#138 and #104) of 5 resident review for pain with hospitalization (#8, 66, 104, 109, and 138) out of a total resident sample of 38. Findings: Resident #138. Resident readmitted to the nursing home on 6/24/11 with [DIAGNOSES REDACTED]. Review of Resident #138's MDS (Minimum Data Set) revealed an assessment reference date of 6/11/12. She was assessed at that time to require one person, extensive assistance with transfer, walking in room or corridor, dressing, toilet use, and personal hygiene. She was assessed as limited 1 person assist with bed mobility and locomotion on and off unit. She used a walker and wheelchair. She was assessed as not steady, only able to stabilize with staff assistance to move from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Section J Health conditions revealed she had not received scheduled pain medication regimen, PRN (as needed) pain medications, or other non- medication interventions for pain at any time during the last 5 days prior to the assessment reference date on the MDS. Review of the facility ' s report to the state regarding an injury of unknown origin, revealed Resident #138 complained of left leg pain to S7, RN ADON during rounds on 6/25/12 ... ...On 6/25/12 S3, DON also went to the residents room during early morning rounds ...she reports the resident was asleep and resting comfortably .....The resident complained of pain again to her left leg to S7, RN ADON on 6/26/12 during early morning rounds .... Review of the facility ' s Incident /Accident Report dated 6/26/12 at 8:30 a.m., revealed S7, RN ADON documented, " I (S7 RN, ADON) noted resident lying in bed during routine morning rounds. This was unusual for her to be in bed at this time .... Spoke with CNA (Certified Nursing Assistant) on duty (S8, CNA) ....States resident (complained) ... of leg hurting. S7, RN ADON documented on the incident report, " Assessed resident & noted (L) (lower) lateral leg with yellow & red discoloration ...Sensitive to touch. " The Incident/Accident Report revealed Resident #138 ' s physician was notified on 6/26/12 at 8:43 a.m., and was transferred to the emergency roiagnom on [DATE] at 5:40 p.m Review of the ER (emergency room ) records dated 6/26/12 at 1751, revealed Resident #138 presented to the emergency room with " pain and swelling noted over the left calf .... " Review of the X-RAY report dated 6/26/12, revealed 1. Acute displaced fracture involving the lateral tibial plateau; 2. Osteopenia. Resident #138 returned to the nursing home on 6/26/12 with a brace and orders to follow up with an orthopedic surgeon. Review of the nursing notes, for the days immediately preceding Resident #138 ' s ER visit of 6/26/12, revealed no nursing documentation in the notes since 6/12/12. Review of the nurses notes revealed no documented nursing assessments, interventions, or notification of Resident #138 ' s physician from 6/24/12 through 6/26/12 by nursing staff until 6/26/12 at 8:45 a.m. when S15, LPN documented .... " c/o pain to L leg. Swelling noted to L knee. L Knee warm & tender to touch. Resident vomiting Lg amount of liquids (post) AM meal & (post) meds. Loose stools noted this AM. Faxed info to Dr.___.....monitored per staff. " There was no further documentation of a follow up by S15, LPN with Resident #138 physician. Further review of the nurse ' s notes revealed the next entry regarding Resident #138 was on 6/26/12 at 5:15 p.m. by S14, LPN (8 and ? hours after S15 documented faxing a notice to the physician), which revealed, " Received (order) per Dr. _____ to send to ER for eval " ... ...and, " 5:40 p.m., .....EMS here to transport res to hospital .... " The next entry was " 6/26/12 at 10:15 ..... returned from ...ER ....velcro brace to lt knee ...orders to follow up (with) ....orthopedic ... " There was another nurse ' s noted dated 6/26/12 in which nursing documents ___MD here on rounds, but S7, RN stated on 12/13/12 at 2:40 p.m. that this note was for 6/27/12 because ___MD made rounds at the nursing home on 6/27/12 and not 6/26/12. Review of the physician orders [REDACTED].#138. Further review of the facility ' s investigation and written statements of the Incident/Accident report completed 6/26/12 by S7, RN ADON, revealed Resident #138 began complaining of pain on 6/24/12. The investigation revealed the following staff statements: S10, CNA ' s statement (not dated) revealed she worked the 10-6 shift on 6/24/12. Her statement included, " resident complained of pain to left leg when repositioned in bed ...She reported this to her nurse, S 11, LPN (no time noted) S12, CNA ' s statement (not dated) revealed ... " bather 6/25/12 (no time noted) ....went to give resident a bath ...Picked up resident (L) leg to put shoe on ...resident yelled ...Underneath left lower leg .... noticed yellow green discoloration....reported this to S11, LPN with S10, CNA .....S11, LPN states ' yes it is swollen ' ... instructed S12, CNA not to get her up .....Resident told S11, LPN that her leg was hurting ...S11, LPN stated she would pass it on to the next shift .... " S12, CNA ' s statement also revealed that S12 CNA " also reported resident leg to S13, LPN (treatment) nurse ....told her she would check resident. " S8, CNA ' s statement (not dated) revealed ..... " 6-2 CNA 6/25/12 ....S12 CNA told S8, CNA not to get resident up ....something about her leg ...and she told her to leave her in bed ....has swollen ankle and yellowish discoloration to posterior leg ....S8, CNA said resident told her several times that she was hurting ...did not question about her pain because it had been reported that she had trouble with leg ....Res. (resident) vomited after bkft (breakfast) & lunch - notified S14, LPN because her nurse S15, LPN was not around ... ...6/26/12 continued to complain of leg hurting ...vomited bkft (breakfast) & after receiving medications ....S15, LPN told her she would be calling Dr. " S11, LPN ' s statement (dated 7/13/12) revealed, " On Monday morning June 25, 2012 I was finishing my medicine and treatment pass, and at 5:45 AM I was called to Resident #138 ' s room by S12, CNA ...Upon entering room Resident #138 was lying in her bed and S12, CNA was planning to bring her to take her bath when Resident #138 stated to S12, CNA that her leg hurts ....I assessed her legs and didn ' t noted any swelling but some discolorations to some areas of both legs ....I asked her to show me where she was hurting and she pointed to the inner area of her right knee .....We (me and S12, CNA) laid her back down and I asked her if she could bed bath her for now and she agreed ....I assured Resident #138 I was going in report and I would tell the oncoming nurse. " S13, LPN ' s (Treatment Nurse) statement (not dated) revealed she " was told of an bruise to resident ' s rt (lower) leg on 6/26/12 by S12, CNA ....was also informed that S15, LPN on duty aware & had already been in there. " S17, LPN ' s statement revealed, " On 6/26/12 at 5:30 a.m., I was summoned to Resident #138 ' s room by S18, CNA reporting resident has swelling to the left leg. Res. Noted (with) swelling to LLE. Skin intact (without) breaks or discoloration noted. CNA elevated LLE (with) pillows. Resident denied pain or discomfort. (No signs/symptoms) of distress noted. Findings were reported to oncoming nurse to monitor & (follow up) if needed. " S16, CNA ' s statement (not dated) revealed, " Restorative nursing aid on 6/26/12 (no time) ....resident would not stand. " On 12/13/12 at 2:40 p.m. during an interview and S7, RN and S3, DON, S3 DON reviewed Resident#138 ' s record and the statements of the CNAs and LPNs working with resident #138 from 6/24/12 through 6/26/12. S3, DON stated she could not dispute that Resident #138 did not receive any medication for her complaints of pain from 6/24/12 through the time she went out to the hospital on [DATE]. She confirmed there was no documented evidence of a nursing assessment, and no documented evidence of nursing having reported any finding or Resident #138 ' s complaints of pain to her physician from 6/24/12 until 6/26/12. During an interview with S7, RN ADON on 12/13/12 at 2:45 pm, S7, RN presented evidence of nursing administration ' s disciplinary actions for S11, LPN, S13, LPN, S15, LPN, and S17, LPN. Review of the facility Nurse's Daily Report Sheet revealed no report sheet for 6/24/12. The Nurse's Daily Report Sheet dated 6/25/12 had no documentation of Resident #138's complaints of pain. Review of the Nurse's Daily Report Sheet dated 6/26/12 revealed, "send to ER for eval. Back @ 10:15 P FX to tibia Lt." During an interview with S3DON on 12/14/12 at 2:30 p.m., she confirmed she no longer had copies of the Nurses's Daily Report Sheets prior to 6/25/12. Resident 104: A review of Resident #104 ' s Nurse ' s Notes revealed an entry dated 10/11/12 at 6:15 AM which stated that the resident was found on the bathroom floor lying on her back with both legs stretched out. Resident #104 denied pain or discomfort. Further review of Resident #104 ' s Nurse ' s Notes revealed that on 10/12/12 at 12:30 PM, Resident #104 ' s first two toes on her left foot were swollen and purple, tender to touch, and that she complained of pain. Further review of the entry failed to reveal the administration of pain medication to Resident #104. A review of Nurse ' s Notes dated 10/12/12 at 1:30 PM revealed that new orders were received due to Resident #104 ' s foot swelling and complaints of pain. No documentation of pain medication administration was noted. The resident ' s Nurse ' s Notes dated 10/12/12 at 4:30 PM revealed: Urgent Findings: Fracture great toe. Further review revealed that pain medication was not administered to Resident #104. Further review of Resident #104 ' s Nurse ' s Notes revealed that she was transported via ambulance to the emergency room . No documentation of pain medication administration for Resident #104 ' s complaints of pain was noted in the Nurse ' s Notes. No documentation of Resident #104 refusing pain medication was noted in the Nurse ' s Notes. A review of Resident #104 ' s Physician order [REDACTED]. A review of Physician ' s Telephone Orders dated 10/12/12 at 1:30 PM revealed an order for [REDACTED].#104 to the emergency room for evaluation of a great toe Fracture. A review of Resident #104 ' s October 2012 PRN (As Needed) Medication Sheet revealed an order for [REDACTED]. A review of the backside of the document failed to reveal any administration, or refusal of pain medication, to Resident #104, when she complained of pain. A review of Resident #104 ' s care plan failed to reveal that the resident would refuse pain medication for complaints of pain. On 12/14/12 at 2:50 PM, an interview was conducted with S3 DON. She reviewed Resident #104 ' s chart and confirmed that on 10/12/12 she complained of pain, was diagnosed with [REDACTED]. She further confirmed that there was no documentation that the resident refused pain medication on 10/12/12, when she complained of pain. She stated that the documentation of pain medication would not be anywhere else in Resident #104 ' s chart.

Based on record review and staff interview, the facility failed to meet professional standards of quality according to the Louisiana Administrative Code Title 46 Professional and Occupational Standards Part XLV11. Nurses. Chapter 39 Legal Standards of Nursing Practice ; Sections 3903, 3905,3907, 3909, 3911, and 3913 by failing to 1. Ensure nursing staff assessed, document, notified the physician, and obtain orders for pain relief for Resident #138's left leg pain on 6/24/12 after the CNA reported the resident's complaints of left leg pain to the LPN on 6/24/12. #138. 2. Ensure nursing staff assessed, document,notified the physician, and obtained orders for pain relief for Resident #138's left leg pain on 6/25/12 after the CNA reported to 2 nurses on 6/25/12 there was a yellow green discoloration on the resident's left leg, and that the resident yelled when the CNA picked up her leg to put on her shoe. #138 4. Ensure nursing administrative staff assessed, document, and notified the physician, and/or followed up with LPN on 6/25/12 when the LPN reported to the RN during morning rounds of Resident #138's complaint of left leg pain earlier in the morning of 6/25/12, and when Resident #138 reported pain again to the RN on 6/26/12 during morning rounds. #138 5. Ensure RN and LPN staff assessment, documentation and reporting of significant changes in condition to Resident #138's physician when Resident #138's complaints of left leg pain on 6/24/12, 6/25/12, and 6/26/12. #138 6. Ensure nursing staff assessment, document, and reporting of Resident #138's pain and swelling of the left leg when the CNA reported to the LPN on 6/26/12 at 5:30 a.m. #138 7. Ensure that nursing staff follow up in a timely manner when the physician was notified for Resident #138's complaint of pain 6/26/12, after the LPN faxed the resident's physician on 626/12 at 8:45 a.m., and there was no response from the physician until 8 1/2 hours later on 6/26/12 at 5:15 p.m. #138 8. Ensure nursing staff provide sufficient knowledge of resident status to oncoming staff from shift to shift. Resident # 138. 9. Ensure the effective quality assessment and assurance for the monitoring, tracking and trending of identified quality deficiencies. Resident #138. The facility failed to assess, identify, document, and/or report, Resident #138's complaints of pain in her left leg with swelling, and discoloration. There was no documented comprehensive nursing assessment or notification of the resident's complaints of pain to the physician by 6 nurses over a period of 3 days (6/24/12, 6/25/12 and 6/26/12), resulting in no nursing and/or medical interventions to treat and relieve Resident #138 ' s pain due to a pathological fracture of her left leg (tibial plateau). Resident #138 experienced unrelieved pain from 6/24/12 through 6/26/12 when staff did not provide interventions to decrease her pain. 10. Administer pain medication as ordered by the physician to a resident ( #104) who complained of pain, whose toes were swollen and purple, and who was diagnosed with [REDACTED].#104) of 5 resident review for pain with hospitalization (#8, 66, 104, 109, and 138) out of a total resident sample of 38. Findings: Resident #138. Resident readmitted to the nursing home on 6/24/11 with [DIAGNOSES REDACTED]. Review of Resident #138's MDS (Minimum Data Set) revealed an assessment reference date of 6/11/12. She was assessed at that time to require one person, extensive assistance with transfer, walking in room or corridor, dressing, toilet use, and personal hygiene. She was assessed as limited 1 person assist with bed mobility and locomotion on and off unit. She used a walker and wheelchair. She was assessed as not steady, only able to stabilize with staff assistance to move from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Section J Health conditions revealed she had not received scheduled pain medication regimen, PRN (as needed) pain medications, or other non- medication interventions for pain at any time during the last 5 days prior to the assessment reference date on the MDS. Review of the facility ' s report to the state regarding an injury of unknown origin, revealed Resident #138 complained of left leg pain to S7, RN ADON during rounds on 6/25/12 ... ...On 6/25/12 S3, DON also went to the residents room during early morning rounds ...she reports the resident was asleep and resting comfortably .....The resident complained of pain again to her left leg to S7, RN ADON on 6/26/12 during early morning rounds .... Review of the facility ' s Incident /Accident Report dated 6/26/12 at 8:30 a.m., revealed S7, RN ADON documented, " I (S7 RN, ADON) noted resident lying in bed during routine morning rounds. This was unusual for her to be in bed at this time .... Spoke with CNA (Certified Nursing Assistant) on duty (S8, CNA) ....States resident (complained) ... of leg hurting. S7, RN ADON documented on the incident report, " Assessed resident & noted (L) (lower) lateral leg with yellow & red discoloration ...Sensitive to touch. " The Incident/Accident Report revealed Resident #138 ' s physician was notified on 6/26/12 at 8:43 a.m., and was transferred to the emergency roiagnom on [DATE] at 5:40 p.m. Review of the ER (emergency room ) records dated 6/26/12 at 1751, revealed Resident #138 presented to the emergency room with " pain and swelling noted over the left calf .... " Review of the X-RAY report dated 6/26/12, revealed 1. Acute displaced fracture involving the lateral tibial plateau; 2. Osteopenia. Resident #138 returned to the nursing home on 6/26/12 with a brace and orders to follow up with an orthopedic surgeon. Review of the nursing notes, for the days immediately preceding Resident #138 ' s ER visit of 6/26/12, revealed no nursing documentation in the notes since 6/12/12. Review of the nurses notes revealed no documented nursing assessments, interventions, or notification of Resident #138 ' s physician from 6/24/12 through 6/26/12 by nursing staff until 6/26/12 at 8:45 a.m. when S15, LPN documented .... " c/o pain to L leg. Swelling noted to L knee. L Knee warm & tender to touch. Resident vomiting Lg amount of liquids (post) AM meal & (post) meds. Loose stools noted this AM. Faxed info to Dr.___.....monitored per staff. " There was no further documentation of a follow up by S15, LPN with Resident #138 physician. Further review of the nurse ' s notes revealed the next entry regarding Resident #138 was on 6/26/12 at 5:15 p.m. by S14, LPN (8 and ? hours after S15 documented faxing a notice to the physician), which revealed, " Received (order) per Dr. _____ to send to ER for eval " ... ...and, " 5:40 p.m., .....EMS here to transport res to hospital .... " The next entry was " 6/26/12 at 10:15 ..... returned from ...ER ....velcro brace to lt knee ...orders to follow up (with) ....orthopedic ... " There was another nurse ' s noted dated 6/26/12 in which nursing documents ___MD here on rounds, but S7, RN stated on 12/13/12 at 2:40 p.m. that this note was for 6/27/12 because ___MD made rounds at the nursing home on 6/27/12 and not 6/26/12. Review of the physician orders [REDACTED].#138. Further review of the facility ' s investigation and written statements of the Incident/Accident report completed 6/26/12 by S7, RN ADON, revealed Resident #138 began complaining of pain on 6/24/12. The investigation revealed the following staff statements: S10, CNA ' s statement (not dated) revealed she worked the 10-6 shift on 6/24/12. Her statement included, " resident complained of pain to left leg when repositioned in bed ...She reported this to her nurse, S 11, LPN (no time noted) S12, CNA ' s statement (not dated) revealed ... " bather 6/25/12 (no time noted) ....went to give resident a bath ...Picked up resident (L) leg to put shoe on ...resident yelled ...Underneath left lower leg .... noticed yellow green discoloration....reported this to S11, LPN with S10, CNA .....S11, LPN states ' yes it is swollen ' ... instructed S12, CNA not to get her up .....Resident told S11, LPN that her leg was hurting ...S11, LPN stated she would pass it on to the next shift .... " S12, CNA ' s statement also revealed that S12 CNA " also reported resident leg to S13, LPN (treatment) nurse ....told her she would check resident. " S8, CNA ' s statement (not dated) revealed ..... " 6-2 CNA 6/25/12 ....S12 CNA told S8, CNA not to get resident up ....something about her leg ...and she told her to leave her in bed ....has swollen ankle and yellowish discoloration to posterior leg ....S8, CNA said resident told her several times that she was hurting ...did not question about her pain because it had been reported that she had trouble with leg ....Res. (resident) vomited after bkft (breakfast) & lunch - notified S14, LPN because her nurse S15, LPN was not around ... ...6/26/12 continued to complain of leg hurting ...vomited bkft (breakfast) & after receiving medications ....S15, LPN told her she would be calling Dr. " S11, LPN ' s statement (dated 7/13/12) revealed, " On Monday morning June 25, 2012 I was finishing my medicine and treatment pass, and at 5:45 AM I was called to Resident #138 ' s room by S12, CNA ...Upon entering room Resident #138 was lying in her bed and S12, CNA was planning to bring her to take her bath when Resident #138 stated to S12, CNA that her leg hurts ....I assessed her legs and didn ' t ' noted any swelling but some discolorations to some areas of both legs ....I asked her to show me where she was hurting and she pointed to the inner area of her right knee .....We (me and S12, CNA) laid her back down and I asked her if she could bed bath her for now and she agreed ....I assured Resident #138 I was going in report and I would tell the oncoming nurse. " S13, LPN ' s (Treatment Nurse) statement (not dated) revealed she " was told of an bruise to resident ' s rt (lower) leg on 6/26/12 by S12, CNA ....was also informed that S15, LPN on duty aware & had already been in there. " S17, LPN ' s statement revealed, " On 6/26/12 at 5:30 a.m., I was summoned to Resident #138 ' s room by S18, CNA reporting resident has swelling to the left leg. Res. Noted (with) swelling to LLE. Skin intact (without) breaks or discoloration noted. CNA elevated LLE (with) pillows. Resident denied pain or discomfort. (No signs/symptoms) of distress noted. Findings were reported to oncoming nurse to monitor & (follow up) if needed. " S16, CNA ' s statement (not dated) revealed, " Restorative nursing aid on 6/26/12 (no time) ....resident would not stand. " On 12/13/12 at 2:40 p.m. during an interview and S7, RN and S3, DON, S3 DON reviewed Resident#138 ' s record and the statements of the CNAs and LPNs working with resident #138 from 6/24/12 through 6/26/12. S3, DON stated she could not dispute that Resident #138 did not receive any medication for her complaints of pain from 6/24/12 through the time she went out to the hospital on [DATE]. She confirmed there was no documented evidence of a nursing assessment, and no documented evidence of nursing having reported any finding or Resident #138 ' s complaints of pain to her physician from 6/24/12 until 6/26/12. During an interview with S7, RN ADON on 12/13/12 at 2:45 pm, S7, RN presented evidence of nursing administration ' s disciplinary actions for S11, LPN, S13, LPN, S15, LPN, and S17, LPN. Review of the facility Nurse's Daily Report Sheet revealed no report sheet for 6/24/12. The Nurse's Daily Report Sheet dated 6/25/12 had no documentation of Resident #138's complaints of pain. Review of the Nurse's Daily Report Sheet dated 6/26/12 revealed, "send to ER for eval. Back @ 10:15 P FX to tibia Lt." During an interview with S3 DON on 12/14/12 at 2:30 p.m., she confirmed she no longer had copies of the Nurses's Daily Report Sheets prior to 6/25/12.

Based on staff interview and record review, the facility failed to conduct a comprehensive , accurate, standardized reproducible assessment by failing to: 1. Ensure a comprehensive nursing assessment, document, notify the physician, and obtain orders for pain relief for Resident #138's left leg pain on 6/24/12 after the CNA reported the resident's complaints of left leg pain to the LPN on 6/24/12, and 2. Ensure a comprehensive nursing assessment, document,notify the physician, and obtained orders for pain relief for Resident #138's left leg pain on 6/25/12 after the CNA reported to 2 nurses on 6/25/12 there was a yellow green discoloration on the resident's left leg, and that the resident yelled when the CNA picked up her leg to put on her shoe, and 4. Ensure a comprehensive nursing assessment by administrative nursing staff, documentation, and notified the physician, and/or followed up with LPN on 6/25/12 when the LPN reported to the RN during morning rounds of Resident #138's complaint of left leg pain earlier in the morning of 6/25/12, and when Resident #138 reported pain again to the RN on 6/26/12 during morning rounds, and 5. Ensure RN and LPN staff conducted a comprehensive assessment, documentation and reporting of significant changes in condition to Resident #138's physician when Resident #138's complaints of left leg pain on 6/24/12, 6/25/12, and 6/26/12, and 6. Ensure nursing staff conducted a comprehensive assessment, documentation, and reporting of Resident #138's pain and swelling of the left leg when the CNA reported to the LPN on 6/26/12 at 5:30 a.m., and 7. Ensure that nursing staff reassessed Resident #138 to follow up and report in a timely manner when the physician was notified for Resident #138's complaint of pain 6/26/12, after the LPN faxed the resident's physician on 626/12 at 8:45 a.m., and there was no response from the physician until 8 1/2 hours later on 6/26/12 at 5:15 p.m. 8. Ensure nursing staff provide sufficient knowledge of resident status to oncoming staff from shift to shift The facility failed to comprehensively assess, identify, document, and/or report, Resident #138's complaints of pain in her left leg with swelling, and discoloration. There was no documented comprehensive nursing assessment or notification of the resident's complaints of pain to the physician by 6 nurses over a period of 3 days (6/24/12, 6/25/12 and 6/26/12), resulting in no nursing and/or medical interventions to treat and relieve Resident #138 ' s pain due to a pathological fracture of her left leg (tibial plateau). Resident #138 experienced unrelieved pain from 6/24/12 through 6/26/12 when staff did not comprehensively assess and provide interventions to decrease the pain for 1 (#138) of 5 residents reviewed for pain with hospitalization (#8, #66, #104 #109, and #138) out of a total sample of 38 residents Findings: 1. Resident #138. Resident readmitted to the nursing home on 6/24/11 with [DIAGNOSES REDACTED]. Review of Resident #138's MDS (Minimum Data Set) revealed an assessment reference date of 6/11/12. She was assessed at that time to require one person, extensive assistance with transfer, walking in room or corridor, dressing, toilet use, and personal hygiene. She was assessed as limited 1 person assist with bed mobility and locomotion on and off unit. She used a walker and wheelchair. She was assessed as not steady, only able to stabilize with staff assistance to move from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Section J Health conditions revealed she had not received scheduled pain medication regimen, PRN (as needed) pain medications, or other non- medication interventions for pain at any time in during the last 5 days prior to the assessment reference date on the MDS. Review of the facility's report to the state regarding an injury of unknown origin, revealed Resident #138 complained of left leg pain to S7, RN ADON during rounds on 6/25/12 ... ...On 6/25/12 S3, DON also went to the residents room during early morning rounds ...she reports the resident was asleep and resting comfortably .....The resident complained of pain again to her left leg to S7, RN ADON on 6/26/12 during early morning rounds .... Review of the facility ' s Incident /Accident Report dated 6/26/12 at 8:30 a.m., revealed S7, RN ADON documented, " I (S7 RN, ADON) noted resident lying in bed during routine morning rounds. This was unusual for her to be in bed at this time .... Spoke with CNA (Certified Nursing Assistant) on duty (S8, CNA) ....States resident (complained) ... of leg hurting. S7, RN ADON documented on the incident report, " Assessed resident & noted (L) (lower) lateral leg with yellow & red discoloration ...Sensitive to touch. " The Incident/Accident Report revealed Resident #138 ' s physician was notified on 6/26/12 at 8:43 a.m., and was transferred to the emergency roiagnom on [DATE] at 5:40 p.m Review of the ER (emergency room ) records dated 6/26/12 at 1751, revealed Resident #138 presented to the emergency room with " pain and swelling noted over the left calf .... " Review of the X-RAY report dated 6/26/12, revealed 1. Acute displaced fracture involving the lateral tibial plateau. 2. Osteopenia. Resident #138 returned to the nursing home on 6/26/12 at 10:15 p.m. with a brace and orders to follow up with an orthopedic surgeon. Review of the nursing notes, for the days immediately preceding Resident #138 ' s ER visit of 6/26/12, revealed no nursing documentation in the notes since 6/12/12. Review of the nurses notes revealed no documented nursing assessments, interventions, or notification of Resident #138 ' s physician from 6/24/12 through 6/26/12 by nursing staff until 6/26/12 at 8:45 a.m. when S15, LPN documented .... " c/o pain to L leg. Swelling noted to L knee. L Knee warm & tender to touch. Resident vomiting Lg amount of liquids (post) AM meal & (post) meds. Loose stools noted this AM. Faxed info to Dr.___.....monitored per staff. " There was no further documentation of a follow up by S15, LPN with Resident #138 physician. Further review of the nurse ' s notes revealed the next entry regarding Resident #138 was on 6/26/12 at 5:15 p.m. by S14, LPN (8 and ? hours after S15 documented faxing a notice to the physician), which revealed, " Received (order) per Dr. _____ to send to ER for eval " ... ...and, " 5:40 p.m., .....EMS here to transport res to hospital .... " The next entry was " 6/26/12 at 10:15 ..... returned from ...ER ....velcro brace to lt knee ...orders to follow up (with) ....orthopedic ... " There was another nurse ' s noted dated 6/26/12 in which nursing documents ___MD here on rounds, but S7, RN stated on 12/13/12 at 2:40 p.m. that this note was for 6/27/12 because ___MD made rounds at the nursing home on 6/27/12 and not 6/26/12. Review of the physician orders [REDACTED].#138. Further review of the facility ' s investigation and written statements of the Incident/Accident report completed 6/26/12 by S7, RN ADON, revealed Resident #138 began complaining of pain on 6/24/12. The investigation revealed the following staff statements: S10, CNA ' s statement (not dated) revealed she worked the 10-6 shift on 6/24/12. Her statement included, " resident complained of pain to left leg when repositioned in bed ...She reported this to her nurse, S 11, LPN (no time noted). S12, CNA ' s statement (not dated) revealed ... " bather 6/25/12 (no time noted) ....went to give resident a bath ...Picked up resident (L) leg to put shoe on ...resident yelled ...Underneath left lower leg .... noticed yellow green discoloration....reported this to S11, LPN with S10, CNA .....S11, LPN states ' yes it is swollen ' ... instructed S12, CNA not to get her up .....Resident told S11, LPN that her leg was hurting ...S11, LPN stated she would pass it on to the next shift .... " S12, CNA ' s statement also revealed that S12 CNA " also reported resident leg to S13, LPN (treatment) nurse ....told her she would check resident. " S8, CNA ' s statement (not dated) revealed ..... " 6-2 CNA 6/25/12 ....S12 CNA told S8, CNA not to get resident up ....something about her leg ...and she told her to leave her in bed ....has swollen ankle and yellowish discoloration to posterior leg ....S8, CNA said resident told her several times that she was hurting ...did not question about her pain because it had been reported that she had trouble with leg ....Res. (resident) vomited after bkft (breakfast) & lunch - notified S14, LPN because her nurse S15, LPN was not around ... ...6/26/12 continued to complain of leg hurting ...vomited bkft (breakfast) & after receiving medications ....S15, LPN told her she would be calling Dr. " S11, LPN ' s statement (dated 7/13/12) revealed, " On Monday morning June 25, 2012 I was finishing my medicine and treatment pass, and at 5:45 AM I was called to Resident #138 ' s room by S12, CNA ...Upon entering room Resident #138 was lying in her bed and S12, CNA was planning to bring her to take her bath when Resident #138 stated to S12, CNA that her leg hurts ....I assessed her legs and didn ' t ' noted any swelling but some discolorations to some areas of both legs ....I asked her to show me where she was hurting and she pointed to the inner area of her right knee .....We (me and S12, CNA) laid her back down and I asked her if she could bed bath her for now and she agreed ....I assured Resident #138 I was going in report and I would tell the oncoming nurse. " S13, LPN ' s (Treatment Nurse) statement (not dated) revealed she " was told of an bruise to resident ' s rt (lower) leg on 6/26/12 by S12, CNA ....was also informed that S15, LPN on duty aware & had already been in there. " S17, LPN ' s statement revealed, " On 6/26/12 at 5:30 a.m., I was summoned to Resident #138 ' s room by S18, CNA reporting resident has swelling to the left leg. Res. Noted (with) swelling to LLE. Skin intact (without) breaks or discoloration noted. CNA elevated LLE (with) pillows. Resident denied pain or discomfort. (No signs/symptoms) of distress noted. Findings were reported to oncoming nurse to monitor & (follow up) if needed. " S16, CNA ' s statement (not dated) revealed, " Restorative nursing aid on 6/26/12 (no time) ....resident would not stand. " On 12/13/12 at 2:40 p.m. during an interview and S7, RN and S3, DON, S3 DON reviewed Resident#138 ' s record and the statements of the CNAs and LPNs working with resident #138 from 6/24/12 through 6/26/12. S3, DON stated she could not dispute that Resident #138 did not receive any medication for her complaints of pain from 6/24/12 through the time she went out to the hospital on [DATE]. She confirmed there was no documented evidence of a nursing assessment, and no documented evidence of nursing having reported any finding or Resident #138 ' s complaints of pain to her physician from 6/24/12 until 6/26/12. During an interview with S7, RN ADON on 12/13/12 at 2:45 pm, S7, RN presented evidence of nursing administration ' s disciplinary actions for S11, LPN, S13, LPN, S15, LPN, and S17, LPN. Review of the facility Nurse's Daily Report Sheet revealed no report sheet for 6/24/12. The Nurse's Daily Report Sheet dated 6/25/12 had no documentation of Resident #138's complaints of pain. Review of the Nurse's Daily Report Sheet dated 6/26/12 revealed, "send to ER for eval. Back @ 10:15 P FX to tibia Lt." During an interview with S3DON on 12/14/12 at 2:30 p.m., she confirmed she no longer had copies of the Nurses's Daily Report Sheets prior to 6/25/12.

Based on staff interview and record review, the facility failed to consult with the resident's physician for a significant change in a resident's physical condition by failing to 1. Ensure nursing staff assessed, document, notified the physician, and obtain orders for pain relief for Resident #138's left leg pain on 6/24/12 after the CNA reported the resident's complaints of left leg pain to the LPN on 6/24/12, and 2. Ensure nursing staff assessed, document,notified the physician, and obtained orders for pain relief for Resident #138's left leg pain on 6/25/12 after the CNA reported to 2 nurses on 6/25/12 there was a yellow green discoloration on the resident's left leg, and that the resident yelled when the CNA picked up her leg to put on her shoe, and 4. Ensure nursing administrative staff assessed, document, and notified the physician, and/or followed up with LPN on 6/25/12 when the LPN reported to the RN during morning rounds of Resident #138's complaint of left leg pain earlier in the morning of 6/25/12, and when Resident #138 reported pain again to the RN on 6/26/12 during morning rounds, and 5. Ensure RN and LPN staff assessment, documentation and reporting of significant changes in condition to Resident #138's physician when Resident #138's complaints of left leg pain on 6/24/12, 6/25/12, and 6/26/12, and 6. Ensure nursing staff assessment, document, and reporting of Resident #138's pain and swelling of the left leg when the CNA reported to the LPN on 6/26/12 at 5:30 a.m., and 7. Ensure that nursing staff follow up in a timely manner when the physician was notified for Resident #138's complaint of pain 6/26/12, after the LPN faxed the resident's physician on 626/12 at 8:45 a.m., and there was no response from the physician until 8 1/2 hours later on 6/26/12 at 5:15 p.m. 8. Ensure nursing staff provide sufficient knowledge of resident status to oncoming staff from shift to shift. The facility failed to assess, identify, document, and/or report, Resident #138's complaints of pain in her left leg with swelling, and discoloration. There was no documented comprehensive nursing assessment or notification of the resident's complaints of pain to the physician by 6 nurses over a period of 3 days (6/24/12, 6/25/12 and 6/26/12), resulting in no nursing and/or medical interventions to treat and relieve Resident #138 ' s pain due to a pathological fracture of her left leg (tibial plateau). Resident #138 experienced unrelieved pain from 6/24/12 through 6/26/12 when staff did not notify the resident's physician to provide interventions to decrease the pain for 1 (#138) of 5 residents reviewed for pain with hospitalization (#8, #66, #104 #109, and #138) out of a total sample of 38 residents Findings: 1. Resident #138. Resident readmitted to the nursing home on 6/24/11 with [DIAGNOSES REDACTED]. Review of Resident #138's MDS (Minimum Data Set) revealed an assessment reference date of 6/11/12. She was assessed at that time to require one person, extensive assistance with transfer, walking in room or corridor, dressing, toilet use, and personal hygiene. She was assessed as limited 1 person assist with bed mobility and locomotion on and off unit. She used a walker and wheelchair. She was assessed as not steady, only able to stabilize with staff assistance to move from seated to standing, walking, turning around, moving on and off toilet, and surface to surface transfer. Section J Health conditions revealed she had not received scheduled pain medication regimen, PRN (as needed) pain medications, or other non- medication interventions for pain at any time in during the last 5 days prior to the assessment reference date on the MDS. Review of the facility's report to the state regarding an injury of unknown origin, revealed Resident #138 complained of left leg pain to S7, RN ADON during rounds on 6/25/12 ... ...On 6/25/12 S3, DON also went to the residents room during early morning rounds ...she reports the resident was asleep and resting comfortably .....The resident complained of pain again to her left leg to S7, RN ADON on 6/26/12 during early morning rounds .... Review of the facility ' s Incident /Accident Report dated 6/26/12 at 8:30 a.m., revealed S7, RN ADON documented, " I (S7 RN, ADON) noted resident lying in bed during routine morning rounds. This was unusual for her to be in bed at this time .... Spoke with CNA (Certified Nursing Assistant) on duty (S8, CNA) ....States resident (complained) ... of leg hurting. S7, RN ADON documented on the incident report, " Assessed resident & noted (L) (lower) lateral leg with yellow & red discoloration ...Sensitive to touch. " The Incident/Accident Report revealed Resident #138 ' s physician was notified on 6/26/12 at 8:43 a.m., and was transferred to the emergency roiagnom on [DATE] at 5:40 p.m. Review of the ER (emergency room ) records dated 6/26/12 at 1751, revealed Resident #138 presented to the emergency room with " pain and swelling noted over the left calf .... " Review of the X-RAY report dated 6/26/12, revealed 1. Acute displaced fracture involving the lateral tibial plateau. 2. Osteopenia. Resident #138 returned to the nursing home on 6/26/12 at 10:15 p.m. with a brace and orders to follow up with an orthopedic surgeon. Review of the nursing notes, for the days immediately preceding Resident #138 ' s ER visit of 6/26/12, revealed no nursing documentation in the notes since 6/12/12. Review of the nurses notes revealed no documented nursing assessments, interventions, or notification of Resident #138 ' s physician from 6/24/12 through 6/26/12 by nursing staff until 6/26/12 at 8:45 a.m. when S15, LPN documented .... " c/o pain to L leg. Swelling noted to L knee. L Knee warm & tender to touch. Resident vomiting Lg amount of liquids (post) AM meal & (post) meds. Loose stools noted this AM. Faxed info to Dr.___.....monitored per staff. " There was no further documentation of a follow up by S15, LPN with Resident #138 physician. Further review of the nurse ' s notes revealed the next entry regarding Resident #138 was on 6/26/12 at 5:15 p.m. by S14, LPN (8 and ? hours after S15 documented faxing a notice to the physician), which revealed, " Received (order) per Dr. _____ to send to ER for eval " ... ...and, " 5:40 p.m., .....EMS here to transport res to hospital .... " The next entry was " 6/26/12 at 10:15 ..... returned from ...ER ....velcro brace to lt knee ...orders to follow up (with) ....orthopedic ... " There was another nurse ' s noted dated 6/26/12 in which nursing documents ___MD here on rounds, but S7, RN stated on 12/13/12 at 2:40 p.m. that this note was for 6/27/12 because ___MD made rounds at the nursing home on 6/27/12 and not 6/26/12. Review of the physician orders [REDACTED].#138. Further review of the facility ' s investigation and written statements of the Incident/Accident report completed 6/26/12 by S7, RN ADON, revealed Resident #138 began complaining of pain on 6/24/12. The investigation revealed the following staff statements: S10, CNA ' s statement (not dated) revealed she worked the 10-6 shift on 6/24/12. Her statement included, " resident complained of pain to left leg when repositioned in bed ...She reported this to her nurse, S 11, LPN (no time noted). S12, CNA ' s statement (not dated) revealed ... " bather 6/25/12 (no time noted) ....went to give resident a bath ...Picked up resident (L) leg to put shoe on ...resident yelled ...Underneath left lower leg .... noticed yellow green discoloration....reported this to S11, LPN with S10, CNA .....S11, LPN states ' yes it is swollen ' ... instructed S12, CNA not to get her up .....Resident told S11, LPN that her leg was hurting ...S11, LPN stated she would pass it on to the next shift .... " S12, CNA ' s statement also revealed that S12 CNA " also reported resident leg to S13, LPN (treatment) nurse ....told her she would check resident. " S8, CNA ' s statement (not dated) revealed ..... " 6-2 CNA 6/25/12 ....S12 CNA told S8, CNA not to get resident up ....something about her leg ...and she told her to leave her in bed ....has swollen ankle and yellowish discoloration to posterior leg ....S8, CNA said resident told her several times that she was hurting ...did not question about her pain because it had been reported that she had trouble with leg ....Res. (resident) vomited after bkft (breakfast) & lunch - notified S14, LPN because her nurse S15, LPN was not around ... ...6/26/12 continued to complain of leg hurting ...vomited bkft (breakfast) & after receiving medications ....S15, LPN told her she would be calling Dr. " S11, LPN ' s statement (dated 7/13/12) revealed, " On Monday morning June 25, 2012 I was finishing my medicine and treatment pass, and at 5:45 AM I was called to Resident #138 ' s room by S12, CNA ...Upon entering room Resident #138 was lying in her bed and S12, CNA was planning to bring her to take her bath when Resident #138 stated to S12, CNA that her leg hurts ....I assessed her legs and didn ' t noted any swelling but some discolorations to some areas of both legs ....I asked her to show me where she was hurting and she pointed to the inner area of her right knee .....We (me and S12, CNA) laid her back down and I asked her if she could bed bath her for now and she agreed ....I assured Resident #138 I was going in report and I would tell the oncoming nurse. " S13, LPN ' s (Treatment Nurse) statement (not dated) revealed she " was told of an bruise to resident ' s rt (lower) leg on 6/26/12 by S12, CNA ....was also informed that S15, LPN on duty aware & had already been in there. " S17, LPN ' s statement revealed, " On 6/26/12 at 5:30 a.m., I was summoned to Resident #138 ' s room by S18, CNA reporting resident has swelling to the left leg. Res. Noted (with) swelling to LLE. Skin intact (without) breaks or discoloration noted. CNA elevated LLE (with) pillows. Resident denied pain or discomfort. (No signs/symptoms) of distress noted. Findings were reported to oncoming nurse to monitor & (follow up) if needed. " S16, CNA ' s statement (not dated) revealed, " Restorative nursing aid on 6/26/12 (no time) ....resident would not stand. " On 12/13/12 at 2:40 p.m. during an interview and S7, RN and S3, DON, S3 DON reviewed Resident#138 ' s record and the statements of the CNAs and LPNs working with resident #138 from 6/24/12 through 6/26/12. S3, DON stated she could not dispute that Resident #138 did not receive any medication for her complaints of pain from 6/24/12 through the time she went out to the hospital on [DATE]. She confirmed there was no documented evidence of a nursing assessment, and no documented evidence of nursing having reported any finding or Resident #138 ' s complaints of pain to her physician from 6/24/12 until 6/26/12. During an interview with S7, RN ADON on 12/13/12 at 2:45 pm, S7, RN presented evidence of nursing administration ' s disciplinary actions for S11, LPN, S13, LPN, S15, LPN, and S17, LPN. Review of the facility Nurse's Daily Report Sheet revealed no report sheet for 6/24/12. The Nurse's Daily Report Sheet dated 6/25/12 had no documentation of Resident #138's complaints of pain. Review of the Nurse's Daily Report Sheet dated 6/26/12 revealed, "send to ER for eval. Back @ 10:15 P FX to tibia Lt." During an interview with S3DON on 12/14/12 at 2:30 p.m., she confirmed she no longer had copies of the Nurses's Daily Report Sheets prior to 6/25/12.