Every finding on record at Parkside at Budd Terrace Operating Company LLC

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that Minimum Data Set (MDS) Assessments were completed and transmitted to the Center for Medicare and Medicaid Services (CMS) system within 14 days of completion for seven resident (Resident (R) 56, 204, 248, 425, 426, 457 and 459) out of seven residents reviewed for accuracy of assessments. This failure prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysis. Findings include:Review of the RAI Manual revealed, Policy interpretation and implementation: Omnibus Budget Reconciliation Act (OBRA) required MDS assessments are federally mandated and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include Discharge assessment are mandatory CMS RAI manual tracking records (discharge return anticipated or not anticipated) completed with a resident leaves a facility, required within 14 days of discharge to accurately reflect functional status and close the record. They are crucial for Quality Measures (QMs) and SNF QRP reporting, with specific items like section GG required to track patient outcomes. https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.htmlReview of R56's list of MDS assessment located under the MDS tab in the electronic medical record (EMR) indicated that R56 had a discharge assessment dated [DATE] that was labeled in progress not completed or transmitted as of 03/25/2026.Review of R204's list of MDS assessment located under the MDS tab in the EMR indicated that R204 had a discharge assessment dated [DATE] that was labeled in progress not completed or transmitted as of 03/25/2026.Review of R248's list of MDS assessment located under the MDS tab in the EMR indicated that R248 had a discharge assessment dated [DATE] that was labeled in progress not completed or transmitted as of 03/25/2026.Review of R425's list of MDS assessment located under the MDS tab in the EMR indicated that R425 had a discharge assessment dated [DATE] that was labeled in progress not completed or transmitted as of 03/25/2026.Review of R426's list of MDS assessment located under the MDS tab in the EMR indicated that R426 had a discharge assessment dated [DATE] that was labeled in progress not completed or transmitted as of 03/25/2026.Review of R457's list of MDS assessment located under the MDS tab in the EMR indicated that R457 had a discharge assessment dated [DATE] that was labeled as accepted but with further investigation it was discovered that the MDS was not completed and signed off by the Registered Nurse (RN) until 03/05/2026 and was not transmitted to CMS until 03/05/2026.Review of R459 list of MDS assessment located under the MDS tab in the EMR indicated that R457 had no discharge assessment opened, completed or transmitted as of 03/25/2026. R459 was discharged from the facility to the hospital on [DATE].During an interview on 03/25/2026 at 10:10 AM, MDS Coordinator (MDSC)2 could not state what the RAI manual stated for the timing of completion and transmission of MDS assessments.During an interview on 03/25/2026 at 10:15 AM, MDS1 stated that MDS assessments should be completed and transmitted in the time frame indicated by the RAI manual. MDS1 reviewed the discharge assessments for R56, R204, R248, R425, R426, R457 and R459. MDS1 acknowledged the assessments were not completed and transmitted in the time indicated by the RAI manual. MDS1 also acknowledged that R459 should have had a discharge MDS opened and completed. MDS1 stated that there were no facility policy and procedure for MDS because the facility follows the RAI manual.During an interview on 03/27/2026 at 12:19 PM, the Director of Nursing (DON) stated that all MDS assessments should be done in a timely manner. The DON stated that her expectation was for the MDSC to complete the assessments according to the RAI manual.

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure 32 out of 33 Agency Nurses and 83 out of 83 in-house staff nurses were competent to provide Total Parenteral Nutrition (TPN) related care and services to residents residing in the facility, including one Resident (R) R311 of two residents in the facility receiving TPN. The facility's failure to ensure nursing staff was competent related to the administration of TPN created the potential residents to experience a decline in physical status. Findings include:Review of the facility's policy titled, Competency Evaluation Policy dated April 2025 indicated, It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job; and Competency: is a measurable pattern of knowledge, skills, abilities, behaviors and other characteristics that an individual needs to perform work roles or occupational functions successfully; and 1. The knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process. 2. Evaluating competency of staff is accomplished through the facility's training program. 3. Initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified. 4. Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. 5. A variety of methods may be used to evaluate learning and/or skills competency. Examples include but are not limited to: a. Lecture or demonstration with return demonstration by the employee. b. A pre- and post-test for the learning activity. c. Direct observation of the employee's ability to demonstrate use of tools, devices or equipment. d. Direct observation of the employee's ability to perform specific tasks. e. Review of the employee's documentation. f. Peer review or interviews with other staff, residents, and/or families. g. Review of adverse events or other data. 6. Checklists are used to document training and competency evaluations. 7. Only designated individuals may verify competency: a. Staff Development Coordinator b. Orientation Preceptor c. Department Head/Administrator d. Higher level employee/professional who has demonstrated competency e. Consultant expert f. Physician. 8. Employee competency forms are maintained in the Staff Development Coordinator's office for current training year, then forwarded to the Human Resources Director for placing in the employee's personnel file. Review of R311's Physician's Order Set dated 03/27/2026 in the EMR under the Orders tab revealed an order dated 03/06/2026 for the resident to receive TPN Electrolytes Intravenous Concentrate (Parenteral Electrolytes) Use 2050 milliliter (ml) intravenously at bedtime for Nutrition infuse over 12hrs (hours) with 1hr (hour) taper up and 1hr taper down. The order dated 03/06/2026 for each lumen of the resident's double lumen Peripherally Inserted Central Catheter (PICC) line to be flushed with ten milliliters (ML) of normal saline twice daily before the administration of the resident's TPN and upon discontinuing the resident's TPN.Review of the facility's Facility assessment dated 2025/2026 revealed the facility admitted residents who were receiving TPN. The assessment indicated nursing staff would be appropriately trained and competent to provide TPN related care. Review of the facility's nurse training and competency documentation revealed none of the facility staff nurses currently working in the facility had ever received training or demonstrated competency related to the care of residents receiving TPN.Review of the facility's nurse training documentation (provided to the facility by the Staffing Agency) revealed a document that showed one agency nurse who worked in the facility in the most recent 30 days signed an attestation to indicate she was competent to provide TPN related care. The facility was not able to provide any documentation to show that any of the other agency nursing staff who had worked in the facility in the most recent 30 days had received training or demonstrated competency related to the care of residents receiving TPN. Observation on 03/25/2026 at 9:37 AM, R311 was observed receiving his medications and TPN related care by Registered Nurse (RN7). RN7 stated she was an agency nurse. RN7 stated she had not received training from the facility or the agency for which she worked, however she stated she had skills with working with TPN. RN7 began R311's care by using a 10 ml syringe of normal saline to flush only one line (the line not in use for administering the resident's TPN) with five ml of the saline solution. RN7 did not discontinue R311's TPN while providing care even though the alarm on the pump infusing the TPN repeatedly sounded and the bag of TPN, the resident was receiving was empty. During an interview with RN/Unit Manager (RN1), the Director of Nursing (DON) and the Administrator on 03/27/2026 at 11:01 AM, all three stated their expectation was all nursing staff working in the facility were expected to be competent to provide TPN related care since the facility routinely admitted residents receiving TPN as identified on the most recent Facility Assessment. Cross-reference to F694

Based on record review, staff interview, and review of facility policy, the facility failed to ensure informed consent was obtained for the use of psychotropic medications for one (Resident (R) R49) out of five residents reviewed for unnecessary medication. The deficient practice created the potential for this and other residents to receive medication not necessary or desired related to their psychiatric/mental health care. Findings include:Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives dated April 2025 indicated under Policy, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives.Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of R49's admission Record dated 03/23/2026 and located in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of bipolar disorder, depression, anxiety and obsessive-compulsive disorder. Review of R49's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/2026 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident was receiving antidepressant, antianxiety and antipsychotic medications.Review of R49's Physician's Order Report dated 03/27/2026 in the EMR under the Orders tab revealed an order with an initial order date of 06/02/2018 for the resident to receive Paxil (an antidepressant medication) 20 milligrams (mg) once daily for depression, with an original order date of 10/03/2019; quetiapine (an antipsychotic medication) 75 mg once daily in the morning, 100 mg once daily at 2:00 PM and 300 mg once daily at bedtime for severe bipolar disorder with psychotic features, with an original order date of 09/06/2025; buspirone (an anti-anxiety medication) five mg three times daily for anxiety, with an original order date of 08/07/2025; and Ativan (an anti-anxiety medication) 0.25 mg twice daily in the morning and at bedtime for anxiety. Review of R49's Medication and Treatment Administration Records (MARs/TARS) dated 03/01/2026 through 03/27/2026 in the EMR under the Orders tab revealed the resident received her psychotropic medications per physician's orders. Review of R49's comprehensive record revealed no documentation to indicate informed consent had been obtained for the administration of any of the resident's psychotropic medications. During an interview with the Director of Nursing (DON) and Registered Nurse/Unit Manager (RN6) on 03/27/2026 at 12:43 PM, RN6 confirmed consent for R49's use of psychotropic medications could not be found. The DON stated her expectation was that informed consent was to be received for all psychotropic medication administered to any resident prior to the administration of the medication.

Based on review of facility policy, record review, and resident and staff interviews, the facility failed to ensure the resident record reflected the correct code status for cardiopulmonary resuscitation (CPR) for one (Resident (R) R49) out of five residents reviewed for advance directive in the sample of 63 residents. The facility's failure to ensure R49's record accurately reflected her chosen code status created the potential for CPR to not be performed as requested for this and other residents. Findings include:Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives dated [DATE] indicated under Policy, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives.Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of R49's admission Record dated [DATE] and located in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of bipolar disorder, depression, anxiety and obsessive-compulsive disorder. Review of R49's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R49's Physician's Order Report dated [DATE] in the EMR under the Orders tab revealed an order, with an initial order date of [DATE] for the resident's code status to be Do Not Resuscitate (DNR). Review of R49's Code Status Care Plan dated [DATE] in the EMR under the Care Plan tab revealed, Code Status will be on file.Carry out advance directive as indicated.Review of R49's Physician's Orders for Life-Sustaining Treatment (POLST) form dated [DATE] in the EMR under the Miscellaneous tab and signed by the resident, revealed R49's desired code status was Full Code. During an interview with R49 on [DATE] at 9:19 AM, she confirmed she wanted her code status to be Full Code. During an interview with the Director of Nursing (DON) and Registered Nurse/Unit Manager (RN6) on [DATE] at 12:43 PM, the DON confirmed her expectation was each resident's designated code status was to be accurately reflected in their record to ensure each residents' wishes were honored in the event of a code.

Based on record review and staff interviews, the facility failed to ensure one (Resident (R) R49) out of five residents reviewed for unnecessary medication was free from unnecessary medications. The facility's failure to ensure R49 was free from unnecessary chemical restraints created the potential for this and other residents to receive medication not necessary or desired related to their psychiatric/mental health care. Findings include:Review of R49's admission Record dated 03/23/2026 in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of bipolar disorder, depression, anxiety and obsessive-compulsive disorder. Review of R49's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/22/2026 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS under section N, Medications, indicated the resident was receiving antidepressant, antianxiety and antipsychotic medications.Review of R49's Physician's Order Report dated 03/27/2026 and found in the EMR under the Orders tab revealed an order with an initial order date of 06/02/2018 for the resident to receive Paxil (an antidepressant medication) 20 milligrams (mg) once daily for depression; with an original order date of 10/03/2019, quetiapine (an antipsychotic medication, often used for schizophrenia) 75 mg once daily in the morning, 100 mg once daily at 2:00 PM and 300 mg once daily at bedtime for severe bipolar disorder with psychotic features; with an original order date of 09/06/2025, buspirone (an anti-anxiety medication) five mg three times daily for anxiety; and with an original order date of 08/07/2025, Ativan (an anti-anxiety medication) 0.25 mg twice daily in the morning and at bedtime for anxiety. Review of R49's Medication and Treatment Administration Records (MARs/TARS) dated 03/01/2026 through 03/27/2026 in the EMR under the Orders tab revealed the resident was receiving her psychotropic medications per physician's orders. Review of R49's Psychotropic Medication Care Plan dated 12/22/2026 in the EMR under the Care Plan tab, indicated the resident was receiving psychotropic medications. Interventions included administer medications as ordered and monitor/record side effects and adverse reactions to the medication. Review of R49's EMR revealed no documentation to indicate side effects of any of the resident's psychotropic medications were being monitored or that a recent AIMS Test (a test to determine whether a resident is having unwanted extrapyramidal effects of an antipsychotic medication) had recently been completed. During an interview with the Director of Nursing (DON) and Registered Nurse/Unit Manager (RN6) on 03/27/2026 at 12:43 PM, RN6 confirmed side effect tracking for the resident's use of psychotropic medications and a recent AIMS test could not be found. The DON stated her expectation was that an AIMS test would be performed at least quarterly for any resident receiving antipsychotic medications and side effects related to the administration of all psychotropic medications was to be done at least once per shift and documented on the resident's MAR/TAR.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete quarterly Minimum Data Set (MDS) Assessments not less than once every 3 months, for one resident (Resident (R) 56) out of seven residents reviewed for accuracy of assessments in the sample of 63 residents. This failure prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysisFindings include:Review of the RAI Manual indicated, Policy interpretation and implementation: Omnibus Budget Reconciliation Act (OBRA) required MDS assessments are federally mandated and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include Quarterly Assessments. A quarterly assessment must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessment to ensure critical indicators of gradual change in a resident's status are monitored. https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.htmlReview of R56's list of MDS assessment located under the MDS tab in the electronic medical record (EMR) indicated that the resident had an admission MDS assessment completed on 11/11/2025 and was due for a quarterly assessment on 02/11/2025. Review of R56's list of MDS revealed there was a quarterly assessment in the system, but it had not been completed and was still in progress. Tracking sheet indicates that the quarterly assessment for 02/11/2026 was 27 days overdue. During an interview on 03/25/2026 at 10:10 AM, the MDS Coordinator (MDSC)2 could not state what the RAI manual stated for the timing of completion and transmission of R56's quarterly assessment. During an interview on 03/20/2026 at 10:15 AM, MDSC1 stated that R56's quarterly assessment was not completed or transmitted in the time frame indicated by the RAI manual. She stated that the resident's quarterly assessment should have been completed within 92 days of the resident's admission assessment. During an interview on 03/27/2026 at 12:19 PM, the Director of Nursing (DON) said that all MDS assessments should be done in a timely manner, and her expectation was for the MDSC to complete the assessments according to the RAI manual.

Based on record review, staff interviews, and facility policy review, the facility failed to complete a base line care plan for three (Residents (R)98, R99, and R198) of 63 sampled residents reviewed for base line care plans. The failure had the potential to affect the residents' medical, nursing, mental, and psychosocial needs not being met.Findings include:Review of the facility's policy titled Baseline Care Plan dated December 2024 revealed, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: Be developed within 48 hours of a resident's admission.1. Review of R98's Electronic Medical Record (EMR) admission Record located under the Profile tab revealed an admission date of 12/12/2025. Review of the EMR located under the Evaluation tab revealed no documentation that R98's base line care plan had been completed.2. Review of R99's EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, muscle weakness, dementia, major depressive disorder and hypertension.Review of R99's EMR Baseline Care under the Assessments tab revealed no documentation that the baseline care plan was developed upon admission, or that the baseline care plan was generated, provided or reviewed with R99 or their representative. 3. Review of R198's EMR located under the Profile tab revealed an admission date of 12/29/2025. Review of the EMR located under the Assessments tab revealed no documentation that R198's base line care plan had been completed.Interview on 03/27/2025 at 08:41 AM, the Minimum Data Set Coordinator (MDSC)1 stated that the baseline care plan was conducted by the unit nurse. The MDSC further stated that the baseline care plan for R98, R99, and R189 had not been completed.Interview on 03/27/2025 at 11:00 AM, the Director of Nursing (DON) revealed that when a resident was admitted , the admission assessment was completed by the nurse, and an initial baseline care plan was generated. The DON further stated the baseline care plans for R98, R99, and R198 were not completed.During an interview on 03/27/2026 at 1:15 PM, Licensed Practical Nurse (LPN)4 stated that she did not know about doing a base line care plan at the time of admission.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to develop person-centered, comprehensive care plans with measurable goals and interventions for one resident (Resident (R) 162) of one resident reviewed for care plans out of a sample of 63 residents. The failure placed R162 at risk for skin breakdown due to incomplete and/or inconsistent care to prevent pressure ulcers. Findings include:Review of the RAI Manual dated October 2025 located at www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf, indicated, . The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated. After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes in order to identify problems, causes, contributing factors, and risk factors related to the problems. Subsequently, the IDT [Interdisciplinary Team] must evaluate the information gained to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs . Review of R162's electronic medical record (EMR) admission Record located under the Profile tab indicated the resident was admitted on [DATE].Review of R162's EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/2026 under the MDS tab indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which revealed the resident was cognitively intact. The MDS indicated that the resident was at risk for the development of pressure ulcers and had no pressure ulcers at the time of the assessment. Under the Care Area Assessment (CAA) the resident triggered for pressure ulcers and directed the clinical staff to develop a care plan. Review of R162's EMR Care Plan located under the Care Plan tab failed to indicate that the resident had a care plan that addressed her potential for the development of pressure ulcers. During an interview on 03/27/2026 at 9:36 AM, MDS Coordinator (MDSC)1, MDSC2, and MDSC3 were all present. MDSC1 stated she was the MDS Director and stated that when the CAA was triggered, it directed the clinical staff to develop a care plan. MDSC1 confirmed that there was no care plan developed for R162 on the potential of the development of pressure ulcers.During an interview on 03/27/2026 at 11:11 AM, the Director of Nursing (DON) stated that her expectation was to have a care plan developed with the triggered CAAs so the care plan addressed the care needs of the resident.

Based on observations, record review, and staff interviews, the facility failed to ensure services were provided in accordance with professional standards of practice for one (Resident (R)15) of 63 residents sampled. Specifically, nursing staff failed to follow physician's orders for nephrostomy tube site care. The deficient practices placed the resident at risk for infection and compromised skin integrity.Findings include:1.Review of R15's electronic medical record (EMR admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses of bilateral nephrostomy tubes, and history of urinary tract infections.Review of R15's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2026 with a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R15's cognition was moderately impaired. The MDS indicated that R15 had an indwelling urinary device (nephrostomy tubes).Review of R15'sphysician's orders located under the Orders tab of the EMR revealed an order dated 02/10/2026 for bilateral nephrostomy tube site care, which included cleansing with normal saline, patting dry, and applying a dry dressing twice weekly (Tuesday and Friday day shift) and as needed. Additional orders included flushing the nephrostomy tubes every shift per specified protocol.Review of R15's Medication Administration Record (MAR) and Treatment Administration Record (TAR) located under the MAR/TAR tab indicated the treatments were documented as completed as ordered.Observation on 03/24/2026 at 12:07 PM of R15's nephrostomy tube flush provided by Registered Nurse (RN) 2 and RN3. During the observation, no dressing was present on either nephrostomy tube site. The insertion sites were visible. The left nephrostomy tube site had a small amount of dark, dried, crusted material noted approximately one inch from the insertion site. No redness or swelling was observed at that time. The procedure focused on flushing the tubes; no site care or dressing application was performed.During an interview on 03/24/2026 at 12:23 PM, RN2 stated that she was not aware that a dressing was required for the nephrostomy tube sites and stated she did not recall seeing that order on the MAR. Upon review of the MAR/TAR RN2 confirmed the order for dressing changes twice weekly.During an interview on 03/24/2026 at 12:26 PM, RN3 stated that the resident should have had dressings on the nephrostomy tube sites. She further stated she was unsure why dressings were not in place and acknowledged the presence of dried material around the left nephrostomy site.During an interview on 03/27/2026 at 9:11 AM, the Director of Nursing (DON) confirmed that staff were not aware of the requirement to apply dry dressings to the nephrostomy sites.

Based on staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care, specifically bathing services, in accordance with the residents' needs and the facility's established schedule for three (Residents (R) 306, 76 and 299) of 12 residents reviewed for bathing in the sample of 63 residents, placing the residents at risk for poor hygiene and decreased quality of life.Findings include: 1.Review of R306's electronic medical record (EMR) admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] following a hospitalization related to a rotator cuff tear and diagnoses of right knee pain, quadriplegia, muscle wasting, and chronic pain syndrome. Review of R306's EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2026 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R306 was cognitively intact. Review of R306's Care Plan under the Care Plan tab of the EMR revealed R306 required staff assistance with Activities of Daily Living (ADLs) due to a self-care performance deficit, including bathing. Review of R306'sshower documentation located under the Task tab of the EMR, revealed the resident received assistance with bathing, ranging from physical assistance to total dependence, on the following dates: 02/07/2026, 02/10/2026, 02/25/2026, 03/04/2026, and 03/05/2026. There was no documentation to indicate the resident received showers in accordance with the facility's established schedule on other assigned shower days, and there was no documented refusal or clinical justification for the missed showers. Interview on 03/27/2026 at 8:45 AM, Registered Nurse (RN) 1 stated the facility's practice was to offer showers based on room assignment, with even-numbered rooms scheduled on specific days and odd-numbered rooms on alternate days. RN1 confirmed R306 resided in an even-numbered room and was expected to receive showers in accordance with that schedule. RN1 further stated that Certified Nursing Assistants (CNAs), including agency staff, were responsible for providing showers; however, agency CNAs did not have access to document care in the EMR and were expected to report completed care to the licensed nurse or oncoming shift. RN1 acknowledged this process was not consistently followed, which may have resulted in incomplete documentation and uncertainty as to whether showers were provided as scheduled. 2. Review of R299's admission Record, dated 03/23/2026 in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke and epilepsy. Review of R299's quarterly MDS with an ARD of 02/27/2026 in the EMR under the MDS tab revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident was totally dependent upon staff to complete her bathing/showering. Review of R299's ADL Care Plan dated 02/27/2026 in the EMR under the Care Plan tab indicated, Two staff members provide physical care with personal hygiene, bathing, dressing, and grooming. Review of R299's Point of Care (ADL/bathing documentation) dated 02/25/2026 through 03/25/2026 in the EMR under the POC tab revealed the resident was to be bathed twice weekly on Wednesdays and Saturdays. The documentation indicated R299 had been bathed on 02/25/2026, 02/28/2026, 03/11/2026 and 03/14/2026 (only four times in the past 30 days). 3. Review of R76's admission Record in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy. R76 was discharged from the facility on 03/11/2026. Review of R76's admission MDS with an ARD of 03/04/2026 in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated the resident required moderate assistance from staff to complete his bathing/showering. Review of R76's Care Plan revealed no care plan related to bathing. Review of R76's Point of Care (ADL/bating documentation) dated 02/25/2026 through 03/11/2026 in the EMR under the POC tab, revealed no documentation to indicate when or how often the resident was to be bathed. The record indicated no evidence that R76 had been assisted with bathing during his entire admission to the facility. During an interview on 03/27/2026 at 12:37 PM, the Director of Nursing (DON) stated that her expectation was that residents were to be assisted with bathing according to their preferences and plan of care and bathing (or refusal to bathe) was to be documented in the resident's record. The DON confirmed that documentation was lacking to indicate both residents had been bathed.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for two of two residents (Residents (R) 349 and R299) reviewed for activities out of a total sample of 63 residents. This deficient practice had the potential to negatively affect the quality of life for the affected residents. Findings include: Review of a facility's policy titled Activities dated April 2025 indicated, . It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. 1. Review of R349's electronic medical record (EMR) admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R349's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/2025 located under the MDS tab indicated the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which revealed that the resident was moderately cognitively impaired. Review of R349's EMR Care Plan located under the Care Plan tab dated 10/22/2024 indicated R349 continues to engage in group (Bingo and travel/documentary videos) and self-directed/1:1 (one to one) activities in his room. Interacts with other residents, staff, family and friends daily. Will continue plan of care. Date Initiated: 07/26/2024, Revision on: 10/22/2024. Review of R349's EMR Progress Notes located under the Prog (Progress) Notes tab failed to contain evidence that the activities department conducted 1:1 activities with the resident or if the resident participated in any group activity programs during the assessment period. During an interview on 03/24/2026 at 1:58 PM, the Activity Director (AD) confirmed there was no documentation to support that R349 participated in any activities. The AD confirmed there were no quarterly activity assessments completed for R349. The AD stated it was important to do the assessments for a resident since the facility can determine if the resident should be offered other activity preferences if there was a decline in activity participation. 2. Review of R299's admission Record in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke and epilepsy. Review of R299's quarterly MDS with an ARD of 02/27/2026 in the EMR under the MDS tab revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. Review of R299's Activities Care Plan dated 02/27/2026 in the EMR under the Care Plan tab indicated, I am dependent on staff for assistance with activities, sensory stimulation and social interaction related to impaired cognitive function and physical limitations.I need increased engagement and social interactions with staff, family, and activities as desired in milieu (including) Devotional Service/Music Listening/Videos/Movies.need socialization with peers and/or interests. Interventions included Provide opportunities for socialization with peers as desired by resident; Provide resident with individual music listening gospel and jazz; Provide Resident with opportunities to choose genres she would like to listen to and encourage her to sing/vocalize along; Resident requires assistance using the TV remote to find programs of interest, jazz radio station and with accessing telephone. Face Time Telephone calls as scheduled with mother. Provide opportunities for scheduled Chaplain visits. Review of R299's most recent Activities assessment dated [DATE] in the EMR under the Assessment tab indicated, Resident per annual review involved in 1:1 visits for wellness, reminiscent, orientation, inspirational reading, seasonal decorations and music listening. Resident continues to interact with staff, mother, listen to music and engage in conversations. Scheduled out of room group time not accomplished.Resident continue to respond to 1:1 visits with hello, thank you, I love you, compliments and ask(s) what (is the) date? Resident not calling out as often to staff and others who pass her room door.Recommendations: 1:1 visits for wellness, reminiscent/current event discussions, inspirational reading, sensory activities aroma scents, flowers and Geri-chair rides as tolerated. Review of R299's EMR dated 01/01/2026 through 03/27/2026 revealed no documentation to indicate the resident's participation in any activity program. R299 was observed lying in bed on 03/23/2026 at 12:05 PM, on 03/24/2026 at 10:52 AM, 12:00 PM and 1:42 PM, and on 03/25/2026 at 8:31 AM and 12:07 PM. The resident was not observed to be engaged in any activities (individual, 1:1 or group) during any of the observations. During an interview on 03/24/2026 at 1:58 PM, the AD confirmed she was not able to locate any documentation to indicate R299's participation in facility or 1:1 activity programming. She confirmed R299's most recent Activities Assessment was dated 08/27/2024 and stated the assessment should have been done at least quarterly to ensure activity preferences and abilities were up to date. During an interview with the AD and Activity Assistant (AA1) on 03/24/2026 at 2:21 PM, AA1 confirmed she did not document individual resident's participation in activities. She stated she was unaware she was supposed to be documenting individual activity participation for each resident. The AA1 confirmed she did not know what R299's activity preferences were, nor was she familiar with the resident's activity care plan. During an interview on 03/27/2026 at 11:18 AM, the Administrator stated her expectation was for activities to be provided and documented according to the needs and interests of each resident. She confirmed each resident was to have an activity Assessment upon admission, quarterly and with any significant change in resident status.

Based on observations, resident and staff interviews, record review and review of facility policy, the facility failed to ensure splints were consistently applied for two Residents (R)11 and R299) out of three residents reviewed for positioning and mobility. The facility's failure to ensure splints were applied consistently as ordered for these residents created the potential for the residents to experience a decline in range of motion (ROM). Findings include:Review of the facility's policy titled, Prevention of Decline in Range of Motion dated April 2025 indicated, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. 1. Review of R11's admission Record dated 03/23/2026 and located in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke, hemiplegia and hemiparesis affecting left non-dominant side. Review of R11's quarterly Minimum Data Set (MDS, with an Assessment Reference Date (ARD) of 12/25/2025 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated that the resident had range of motion impairment to his upper and lower extremity on one side of his body. The MDS did not indicate the resident's use of a splint. Review of R11's Physician's Order Report dated 03/27/2026 in the EMR under the Orders tab revealed no orders for the resident's use of a splint.Review of R11's Activities of Daily Living (ADL) Care Plan dated 12/25/2025 in the EMR under the Care Plan tab indicated, Left hand splint and left elbow dynamic splint to be worn at all times (per pt (patient) tolerance). Please remove for skin check, hygiene, monitor for edema, redness, skin breakdown. Review of R11's EMR lacked documentation to indicate the resident's splints were being routinely applied. R11 was observed lying in bed on 03/23/2026 at 12:55 PM, on 03/24/2026 at 9:11 AM, 11:01 AM and 12:43 PM, and on 03/25/2026 at 8:32 AM and 12:07 PM and was not wearing either of his ordered splints during the observations. R11 was observed along with Registered Nurse (RN6) on 03/26/2026 at 12:08 PM. RN6 confirmed the resident was not wearing his ordered splints. R11 was observed with the Director of Rehabilitation on 03/26/2026 at 12:37 PM. He confirmed R11 was supposed to be wearing a dynamic splint to his left elbow and a left-hand splint at all times. The Director of Rehabilitation located the resident's left elbow dynamic splint under a pile of clothing on a chair in the resident's room but was not able to locate the resident's left-hand splint. During an interview on 03/26/2026 at 12:40 PM, R11confirmed his splints had not been applied for a long time and stated he would wear both splints if applied. 2. Review of R299's admission Record, dated 03/23/2026 and located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnosis of history of stroke. Review of R299's quarterly MDs with an ARD of 02/27/2026 in the EMR under the MDS tab, revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident had range of motion impairment to her upper and lower extremities on both sides of her body. The MDS did not indicate the resident's use of a splint. Review of R299's Physician's Order Report, dated 03/27/2026 in the EMR under the Orders tab revealed orders for the use of a left hand palm guard splint to be applied at all times for contracture management.Review of R299's ADL Care Plan dated 02/27/2026 in the EMR under the Care Plan tab indicated, Patient to wear left hand palm guard at all times for contracture management. Review of R299's EMR revealed no documentation to indicate the resident's left palm protector splint was being applied as ordered.R299 was observed lying in bed on 03/23/2026 at 12:05 PM, on 03/24/2026 at 10:52 AM, 12:00 PM and 1:42 PM, and on 03/25/2026 at 8:31 AM and 12:07 PM and was not wearing her left palm splint during any of the observations. Observation of R299 with RN6 on 03/26/2026 at 12:17 PM, RN6 confirmed R299 was not wearing her left palm splint. RN6 stated that the resident was supposed to be wearing the splint.R299 was observed with the Director of Rehabilitation on 03/26/2026 at 12:45 PM. The Director of Rehabilitation confirmed R299 was supposed to be wearing a left palm protector splint at all times. The Director of Rehabilitation was not able to locate the resident's splint. During an interview with the Director of Nursing and RN6 on 03/27/26 at 12:37 PM, the DON stated her expectation was splints were to be applied as ordered. The DON stated either the application of the resident's splint or the resident's refusal to wear an ordered splint was expected to be documented in the resident's record.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure an admission weight was obtained for one resident (Resident (R) 224) out of eight residents reviewed for nutrition. The failure to obtain an initial baseline weight for residents could cause the facility to not accurately determine weight loss or gain during the resident's stay. Findings include:Review of a facility's policy titled Weight Monitoring dated April 2025 indicated, . weight can be a useful indicator of nutritional status. A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status' Assessments should include the following information.Weight. Review of R224's electronic medical record (EMR) titled admission Record indicated the resident was admitted on [DATE] with a diagnosis of chronic kidney disease.Review of R224's EMR titled Weights located under the Wts (Weights) & Vitals tab failed to contain evidence that the resident was weighed upon admission.Review of R224's EMR admission Minimum Data Set with an Assessment Reference Date (ARD) of 03/20/2026 indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The assessment did not have evidence of a weight taken per facility protocol. Review of R224's EMR Dietary Profile located under the Assmts (Assessment) tab dated 03/17/2026 revealed that Registered Dietitian (RD) 1 identified per family interview that the resident was at risk for weight loss due to not eating while in the hospital.Review of R224's EMR Care Plan located under the Care Plan tab dated 03/19/2026 that identified that the resident was at risk for low meal intake. Review of R224's EMR Mini-Nutrition progress note located under the Prog (Progress) Notes tab dated 03/19/2026 failed to indicate that the resident was weighed. The progress note indicated that the resident was malnourished. During an interview on 03/26/2026 at 10:07 AM, Registered Dietician (RD)1 stated that she based her nutritional assessment on what the family shared. RD1 stated she looked at the hospital records, to obtain the resident's initial weight. RD1 stated this was why R224 triggered as malnourished. RD1 stated R224 received nutritional supplements. A subsequent interview was conducted on 03/26/2026 at 12:28 PM with RD1 who stated that obtaining the initial weight was the baseline and could then assess a resident nutritional going forward. During an interview on 03/26/2026 at 12:44 PM, the Assistant Director of Nursing (ADON) stated the clinical staff met weekly to discuss significant weight changes. The ADON stated residents should have their initial weight taken upon admission or the next day. A subsequent interview on 03/26/2026 at 4:08 PM, the ADON verified that there were no weights taken for R224. The ADON stated it was important to obtain the initial weight on a resident since it identified the nutritional care that the resident required. During an interview on 03/27/2026 at 11:11 AM, the Director of Nursing (DON) stated that obtaining the initial weights upon admission were important to create a baseline for the facility and establish a need for care. The DON stated RD1 should not have completed a nutritional assessment without the initial weight.

Based on observations, record review, resident and staff interviews, review of facility policy, the facility failed to ensure two Resident (R) R76 and R311 out of three residents reviewed for Intravenous (IV) Nutrition (i.e., Total Parenteral Nutrition (TPN)) received appropriate care related to the administration of their TPN. The facility's failure to ensure appropriate administration of TPN for R76 and R311 created the potential for these residents to experience a decline in physical status. Findings include: The facility's policy titled, Total Parenteral Nutrition (TPN) dated December 2024 indicated, The facility may administer and monitor residents receiving total parenteral nutrition (TPN) consistent with current standards of practice.Definition: Total Parenteral Nutrition (TPN) is a nutrient solution, including lipids, that is administered through a central venous access device. This solution usually consists of proteins, carbohydrates, electrolytes, vitamins, trace minerals, and lipids (as directed) . Total Parenteral Nutrition (TPN) will be administered under the direction of the ordering practitioner, in collaboration with the pharmacist and other designated individuals. Pharmacy collaboration may be with the facility's participating pharmacy and/or through a contracted infusion service, as per facility policy. Review of R311's admission Record dated 03/27/2026 in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD) and atrial flutter. Review of R311's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/12/2026 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated R311 was receiving more than 50% of his nutrition through an IV line. Review of R311's Physician's Order Set dated 03/27/2026 in the EMR under the Orders tab revealed an order dated 03/06/26 for the resident to receive TPN Electrolytes Intravenous Concentrate (Parenteral Electrolytes) Use 2050 milliliter (ml) intravenously at bedtime for Nutrition infuse over 12hrs (hours) with 1hr (hour) taper up and 1hr taper down. The order dated 03/06/2026 for each lumen of the resident's double lumen Peripherally Inserted Central Catheter (PICC) line to be flushed with ten milliliters (ML) of normal saline twice daily before the administration of the resident's TPN and upon discontinuing the resident's TPN. The order set indicated R311 was to receive nothing to eat or drink by mouth.Review of R311's Nutritional Care Plan dated 03/03/2026 in the EMR under the Care Plan tab indicated that the resident was a nutritional and hydration risk related to TPN dependence. Interventions included, TPN per order. Review of R311's Vital Sign Report dated 03/05/2026 through 03/27/2026 in the EMR under the Vital Signs tab revealed R311 was only weighed once during his admission to the facility on [DATE].Review of R311's daily Skilled Evaluation Notes entered daily from 03/06/2026 through 03/25/2026 in the EMR under the Notes tab revealed nothing to indicate the resident's TPN or PICC line. All of the notes incorrectly indicated R311 was receiving all of his nutrition by mouth. R311 was observed receiving his medications and TPN related care by Registered Nurse (RN7) on 03/25/2026 at 9:37 AM. RN7 stated she was an agency nurse. RN7 began R311's care by using a 10 ml syringe of normal saline to flush only one line (the line not in use for administering the resident's TPN) with five ml of the saline solution. RN7 did not discontinue R311's TPN while providing care even though the alarm on the pump infusing the TPN repeatedly sounded and the bag of TPN, the resident was receiving was empty. During an interview on 03/25/2026 at 9:49 AM, RN7 stated that she did not disconnect R311's TPN while providing care because the resident's TPN was ordered to infuse continuously (24 hours per day/seven days per week). RN7 stated she did not flush both lumens of the resident's PICC line because one of the lumens was being used to infuse TPN and so did not need to be flushed. RN7 stated that her practice was to flush the other unused lumen with five ml of normal saline at the beginning of her shift and then with another five ml of saline sometime later in her shift (for a total of a 10 ml flush during her shift). RN7 stated she never stopped a resident's TPN to flush the lumens of the resident's PICC line. During an interview on 03/25/2026 at 10:05 AM, RN/Unit Manager (RN1) confirmed R311's physicians orders indicated the resident was to have his TPN infused over 12 hours beginning at approximately 9:00 PM each night. She confirmed the resident's TPN did not run continuously (24 hours per day/seven days per week) and confirmed RN7 should have discontinued the resident's TPN while providing care and then flushed each of the lumens on the resident's PICC line with 10 ml of normal saline according to the resident's physician's orders. RN1 stated she did not know if RN7 was competent to provide TPN related care as that was not something she was responsible for verifying.2. Review of R76's admission Record dated 03/27/2026 and located in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of noninfective gastroenteritis and colitis, Crohn's disease and short bowel syndrome. The record indicated the resident was discharged from the facility on 03/11/2026. Review of R76's admission MDS with an ARD of 03/04/2026 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The record indicated R76 was receiving more than 50% of his nutrition through an IV line. Review of R76's Physician's Order Set dated 03/27/2026 in the EMR under the Orders tab revealed an order dated 02/25/2026, for the resident to receive TPN Electrolytes Intravenous Concentrate use 2000 ml intravenously at bedtime for Nutrition infuse over 14hrs with 1hr taper up and 1hr taper down. The order set did not indicate orders for the resident's double lumen IV PICC line, orders for changing the resident's PICC line dressing or orders for the maintenance or flushing of the PICC line utilized to administer the resident's TPN. Review of R76's Medication Administration Record (MAR) dated 02/25/2026 through 03/27/2026 in the EMR under the Orders tab revealed the resident did not receive his ordered TPN on 03/10/2026 and revealed the resident's PICC line dressing was not changed until one day prior to his discharge from the facility on 03/10/2026.Review of R76's Orders/Administration Notes dated 03/10/2026 in the EMR under the Notes tab revealed R76's TPN was not administered on that dates due to the TPN not being available from pharmacy. Review of R76's Nutritional Care Plan dated 03/03/2026 in the EMR under the Care Plan tab indicate the resident was at nutritional and hydration risk related to TPN dependence in the presence of Crohn's disease. Interventions included TPN per order. Review of R76's Vital Sign Report, dated 02/25/2026 through 03/11/2026 in the EMR under the Vital Signs tab revealed R76 was never weighed during his admission to the facility.Review of R76's daily Skilled Evaluation Notes dated 02/28/2026, 03/06/2025 and 03/09/2026 in the EMR under the Notes tab revealed nothing to indicate the resident's TPN or PICC line. Daily skilled evaluation notes were absent from the resident's record for all other days of the resident's admission to the facility. During an interview with the Administrator and Director of Nursing (DON) on 03/25/2026 at 2:15 PM, the DON stated her expectation was that all orders related to the care and maintenance of a resident's PICC line and TPN administration were expected to be entered into the resident's record immediately upon admission the facility or initiation of treatment. Nurses caring for resident's receiving TPN and/or with a PICC line in place were expected to accurately document route of nutritional intake, the presence of the PICC line and administration of TPN in their daily progress notes. Nursing staff responsible for providing care to residents receiving TPN were expected to follow physician's orders and provide competent care related to the resident's TPN and IV/PICC line. The DON further stated monitoring of resident's weights while receiving TPN was expected to be completed upon admission, and then weekly for four weeks after admission to ensure adequate caloric intake. Cross reference to F726

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure bed rails were necessary and a consent was obtained prior to the use of bed rails for two (Residents (R)11 and R299) out of eight residents reviewed for accident hazards in the sample of 63 residents. The facility's failure to ensure bed rails were necessary for these residents created the potential for these and other residents to experience potential negative outcomes such as becoming entrapped in bed rails.Findings include:Review of the facility's policy titled, Proper Use of Bed Rails or Enabler Bar dated April 2025 indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails and/or the use of an enabler bar. Appropriate alternative approached are attempted prior to installing or using bed rails or an enabler bar.Informed consent from the resident or resident representative must be obtained (prior to use of the bed rails) .Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom or functional reason for the use of the bed rail.1. Review of R11's admission Record dated 03/23/2026 in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke, hemiplegia and hemiparesis affecting left non-dominant side.Review of R11's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/25/2025 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS indicated the resident was completely dependent upon staff for rolling back and forth in bed and for transferring in and out of bed. The MDS indicated bed rails were not in use for the resident.Review of R11's Physician's Order Report dated 03/27/2026 in the EMR under the Orders tab revealed no orders for the use of bed rails.Review of R11's EMR Care Plan dated 03/25/2026 in the EMR under the Care Plan tab did not indicate the resident's use of bed rails. Review of R11's EMR revealed no documentation that an assessment had been completed or that informed consent had been obtained related to the resident's use of bed rails.Observations on 03/23/2026 at 12:55 PM, on 03/24/2026 at 9:11 AM, 11:01 AM and 12:43 PM, and on 03/25/2026 at 8:32 AM and 12:07 PM of R11 lying in his bed with bilateral 1/2 bed rails raised on the resident's bed during all of the observations. Interview and observation of R11 with Registered Nurse (RN6) on 03/26/2026 at 12:08 PM, RN6 confirmed bilateral bed rails were raised on the resident's bed and stated she thought maybe the resident could use the rails to assist staff with turning in bed. 2. Review of R299's admission Record dated 03/23/2026 in the EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of history of stroke and epilepsy. Review of R299's quarterly MDS with an ARD of 02/27/2026 in the EMR under the MDS tab revealed a BIMS score of four out of 15, which indicated the resident was severely cognitively impaired. The MDS indicated the resident was completely dependent upon staff for rolling back and forth in bed and for transferring in and out of bed. The MDS indicated bed rails were not in use for the resident.Review of R299's Physician's Order Report dated 03/27/2026 in the EMR under the Orders tab revealed no orders for the use of bed rails.Review of R299's Care Plan dated 02/27/0226 in the EMR under the Care Plan tab did not indicate the resident's use of bed rails. Review of R11's EMR revealed no documentation of an assessment had been completed or that informed consent had been obtained related to the resident's use of bed rails.Observations of R299 lying in bed on 03/23/2026 at 12:05 PM, on 03/24/2026 at 10:52 AM, 12:00 PM and 1:42 PM, and on 03/25/2026 at 8:31 AM and 12:07 PM with bilateral 1/2 bed rails raised on the resident's bed during all of the observations. Interview and observation of R299 with RN6 on 03/26/2026 at 12:17 PM, RN6 confirmed bilateral bed rails were raised on the resident's bed. RN6 thought the resident might use one of the rails to assist staff with turning in bed. During an interview with the Director of Nursing (DON) and RN6 on 03/27/2026 at 12:37 PM, RN6 confirmed orders, a care plan, a recent assessment and informed consent for R11 and R299's use of bed rails could not be located by the facility. The DON stated her expectation was any resident using bed rails was expected to have a current assessment for use of the rails, physicians' orders, a care plan in place for use of the rails, and informed consent should be obtained for the use of the rails.

Based on observations, record reviews, staff interviews, and facility policy reviews, the facility failed to ensure a medication error rate of less than five percent. There were four errors from 26 opportunities for one of eight residents (R) (R311) observed, for a medication error rate of 15.38 percent. The facility's failure to ensure a medication error rate of less than five percent created the potential for R311 to experience negative physical effects related to medication errors. Findings include:Review of the facility's policy titled, Medication Administration dated January 2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Ensure the six rights of medication administration are followed: a. Right Resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation.Review of the facility's policy titled, Administration of Metered Dose Inhaler, dated December 2024, indicated, It is the policy of this facility to ensure medications are administered as prescribed, in accordance with professional standards of practice and only by persons legally authorized to do so.Repeat puffs (of inhaled medication) as directed waiting at least one minute between puffs.If the resident is using a corticosteroid and a bronchodilator, administer the bronchodilator first then wait five minutes before administering the corticosteroid. Review of R311's admission Record, dated 03/27/2026, in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD).Review of R311's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2026, in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R311's Physician's Order Set, dated 02/27/2026, in the EMR under the Orders tab, revealed an order, dated 03/05/26 for Incruse Ellipta (an inhaled bronchodilator medication used to relax airways for patients with COPD) one puff inhaled once daily for COPD; an order dated 03/05/2026 for Advair (an inhaled corticosteroid medication used to prevent airway inflammation) one puff inhaled once daily for COPD; and an order dated 03/05/2026 for resident to have both lumens of his Peripherally Inserted Central Catheter (PICC) line flushed with 10 milliliters (ml) of normal saline solution twice daily before beginning his Total Parenteral Nutrition (TPN) and after discontinuing his TPN.Observation on 03/25/2026 at 9:41 AM, revealed:1. Registered Nurse (RN)7 administered the resident's Advair (steroid) medication first, and then the resident's Incruse Ellipta.2. RN7 did not direct R311 to rinse his mouth after the administration of his inhaled medications; 3. RN7 then flushed only one of R311's PICC line lumens with approximately five ml of normal saline solution rather than the 10 ml.4. RN7 failed to flush the other lumen with the 10 ml of normal saline. During an interview on 03/25/2026 at 9:49 AM, RN7 stated she was not aware that inhaled medication had to be administered in any certain order or with any wait time between puffs of the medication. RN7 confirmed she forgot to have R311 rinse his mouth after administering the inhaled steroid medication. RN7 stated she always flushed only the PICC line lumen not being utilized to administer TPN and only with five ml of normal saline each time. RN7stated that she would use the other five ml of the ordered saline flush later in the shift to flush R311's PICC line lumen again. During an interview on 03/25/2026 at 10:05 AM, with RN/Unit Manager (RN1) confirmed inhaled bronchodilator medication was to be administered first and then inhaled corticosteroid medication was to be administered after a wait time of approximately three minutes. She stated nursing staff was expected to direct residents to rinse their mouth with water after the administration of inhaled steroid medication to prevent thrush. RN1 stated normal saline PICC line flushes were expected to be delivered as ordered by the resident's physician. (in R311's case 10 ml of normal saline to each lumen of the resident's PICC line twice daily before beginning TPN and after discontinuing TPN.During an interview on 03/27/2026 at 1:00 PM, the Director of Nursing (DON) confirmed her expectation was that all medication were to be administered according to physician's orders. The DON stated that inhaled bronchodilator medication was to be given before inhaled corticosteroid medication, and the resident's mouth was to be rinsed after the administration of an inhaled corticosteroid medication.

Based on staff interviews, record review, and review of facility policy, the facility failed to ensure one resident (R) (R311) out of eight residents reviewed for medication errors was free from a significant medication error. The facility's failure to ensure that R311 was free from significant medication errors created the potential for the resident to experience negative physical effects related to the medication errors. Findings include:Review of the facility's policy titled Medication Administration dated 01/2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Ensure the six rights of medication administration are followed: a. Right Resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation. Review of R311's admission Record dated 03/27/2026 in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of atrial flutter. Review of R311's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2026, in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R311's Physician's Order Set dated 02/27/2026 in the EMR under the Orders tab revealed an order dated 03/05/26 for the resident to receive Xarelto (a blood-thinning medication) 15 milligrams (mg) once daily, related to his diagnosis of atrial flutter. Review of R311's Medication Administration Record (MAR) dated 03/05/2026 through 03/27/2026 in the EMR under the Orders tab revealed the resident did not receive his ordered Xarelto on 03/06/2026 or on 03/25/2026.Review of R311's Orders/Administration Notes dated 03/06/2026 and 03/25/26 in the EMR under the Notes tab revealed R311's Xarelto was not administered on those dates because the medication was not available from the pharmacy. During an interview with the Director of Nursing (DON) and the Administrator on 03/25/2026 at 2:15 PM, the DON confirmed her expectation that all ordered medications should be available at the facility for administration to residents as ordered.

Based on observations and staff interviews, record review, and review of facility policy, the facility failed to ensure infection control practices were followed for one (Resident (R)311) of eight residents observed during medication administration. Specifically, the nurse administering the resident's medications failed to sanitize her hands and change her gloves after administering oral and inhaled medications, and before administering medication through a Peripherally Inserted Central Catheter (PICC) line. The facility's failure to ensure proper infection control during medication administration created the potential for cross-contamination and infection. Findings include:Review of the facility's policy titled, Medication Administration dated 01/2025 indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection:.Wash hands using facility protocol and product.Review of R311's admission Record dated 03/27/2026 and located in the Electronic Medical Record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses of muscle wasting and atrophy and chronic obstructive pulmonary disease (COPD). Review of R311's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/2026 in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R311's Physician's Order Set dated 02/27/2026 in the EMR under the Orders tab revealed an order, dated 03/05/2026, for Incruse Ellipta (an inhaled bronchodilator medication used to relax airways for patients with COPD) one puff inhaled once daily; an order dated 03/05/2026 for Advair (an inhaled corticosteroid medication used to prevent airway inflammation) one puff inhaled once daily for COPD; and an order dated 03/05/2026 for both lumens of his PICC line flushed with 10 milliliters (ml) of normal saline solution twice daily before beginning his Total Parenteral Nutrition (TPN) and after discontinuing his TPN.Observation on 03/25/2026 at 9:41 AM, Registered Nurse (RN)7 administered the resident's inhaled medication and then administered 5 ml normal saline flush to one lumen of the resident's PICC line without washing/sanitizing her hands or changing her gloves in between medication administration. During an interview on 03/25/2026 at 9:49 AM, RN7 stated she only washed her hands and donned gloves one time when administering each resident's medication. She stated she never washed/sanitized her hands or changed her gloves between administering oral and/or inhaled medication and administering IV (intravenous) medication to a resident. During an interview with RN/Unit Manager (RN1) on 03/25/2026 at 10:05 AM, she confirmed nursing staff were expected to wash/sanitize their hands and change their gloves between administration of each different route of medication. She stated RN7 should have sanitized/washed her hands and changed her gloves after administering R311's oral/inhaled medication and prior to administering his normal saline flush through his PICC line. During an interview on 03/27/2026 at 1:00 PM, the Director of Nursing (DON) confirmed her expectation was that hand hygiene was to be performed between the administration of oral/inhaled medication and the administration of IV medication of any kind.

Based on observations, resident and staff interviews, and the facility's policy titled, Safe and Homelike Environment, the facility failed to ensure the residents' living area was safe, clean, and comfortable in four of 165 rooms (Rm 515, Rm 624, Rm 702, and Rm 703). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit filters were free of buildup and debris and failed to ensure that a broken mirror was not stored on the floor in one of six Central bath areas. Findings include: Review of the facility's undated policy titled, Safe and Homelike Environment, revealed under Policy Explanation and Compliance Guidelines: 1. The facility will create and maintain, to the extent possible, a homelike environment that emphasizes the institutional character of the setting. 3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Initial screening observation on 5/27/2025 at 8:10 am in room [ROOM NUMBER] revealed a small black oscillating fan blowing on bed A near window with fuzzy grayish substance on its fan vents. Initial screening observations on 5/27/2025 at 11:44 am and 1:04 pm in rooms 624, 702, 703 revealed PTAC unit front spongy filters dirty with thick gray fluffy substances. Observations on 5/28/2025 at 12:55 pm in room [ROOM NUMBER] revealed a small black oscillating fan blowing on bed A with fuzzy grayish substance on its fan vents. Observations on 5/28/2025 at 1:19 pm in rooms 624, 702, 703 revealed PTAC unit front spongy filters dirty with thick gray fluffy substances. Observation on 5/28/2025 at 3:30 pm revealed third floor shower room with a shattered broken wall mirror lying on the floor and wheelchair's leg rests lying on top of the PTAC unit. Observation on 5/29/2025 at 9:55 am revealed third floor shower room with a shattered broken wall mirror lying on the floor and wheelchair's leg rests lying on top of the PTAC unit. Interview walking rounds on 5/29/2025 at 10:25 am with Regional Maintenance Director (RMD) OO confirmed dirty personal fans, broken shattered wall mirror lying on the floor and wheelchair's leg rests on top of PTAC unit in the shower room, and dirty damaged PTAC units. Staff member stated his expectation was for environmental issues to be taken care of as soon as possible.

Based on resident and staff interviews, record review, and review of the facility's policy titled Coordination with PASAAR Program, the facility failed to provide Preadmission Screening and Resident Review (PASARR) Level II for two of six residents (R) (R54 and R75) with qualifying diagnoses. Findings include: Review of the facility undated policy titled, Coordination with PASAAR Program revealed under Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serios mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 5b. The Level II resident review must be completed within 40 calendar days of admission. Record Review revealed R54 was admitted to the facility with a diagnosis of but not limited to bipolar disorder current episode, aphasia, major depressive disorder, epilepsy, anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R54 has Brief Interview for Mental Status (BIMS) score of five indicated the resident has severe cognitive impairment. Record review of the care plan revealed R54 has focus to use anti-psychotic medication to manage bipolar disorder. R54 goals are to remain free of drug related complication through the review date. Interventions are to use medication as ordered and monitor for side effects and effectiveness. Interview on 5/29/2025 at 11:46 am with Social Worker WW described the process used to identify potential mental health concerns prior to admission. Continued interview revealed that the PASARR level I screening is reviewed to determine if a referral for PASARR Level II is required. If a resident is triggered a referral for a PASARR Level II will be submitted. SW WW expressed that the hospital makes a referral to the agency if a resident has a mental health diagnosis prior to admission. During the interview it was disclosed that if a resident has a diagnosis in the facility, then the social workers will do the referral. She confirmed a PASSAR Level II was not submitted for the R54 until 5/27/2025. 50943 2. Record review revealed R75 was admitted to the facility with diagnosis of but not limited to paranoid schizophrenia, mood disorder due to known physiological condition with mixed features, and major depressive disorder, recurrent. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section C that R75 had a BIMS score of ten indicating the resident has moderate cognitive impairment. Section O revealed R75 has not received psychological therapy. Review of R75's care plan with revision date of 7/23/2020 revealed resident has past medical history of schizophrenia. Interventions to care include administer medications as ordered, assist and provide resident with a program of activities that are meaningful, and behavioral health consults as needed. Interview on 5/28/2025 at 2:47 pm with the Licensed Practical Nurse (LPN) VV revealed the process for identifying residents with possible mental disorders is checking the chart to see if they have any diagnoses of mental disorders. It was revealed the psychiatric doctor comes in to check for mental disorders. LPN VV stated the social worker is responsible for sending a PASARR referral to the appropriate agency. LPN VV confirmed R75 had a diagnosis of mental disorders without a PASARR II in the system. Interview on 5/29/2025 at 11:46 am with Social Worker WW revealed the facility's process for identifying residents with possible mental disorders prior to admission is to look at the PASARR Level I to identify if a resident is triggered for a PASARR Level II. It was revealed if a resident is triggered, a referral for PASARR Level II will be submitted. The social workers are responsible for making the referral if diagnoses occur in the facility. The Social Worker confirmed that R75 did not have a Level II on file and it was submitted for approval on 5/28/2025 during the survey. Interview on 5/29/2025 at 2:00 pm with the Administrator revealed her expectation is for the facility to be in compliance with the PASARR Level II audits and screenings. Interview on 5/29/2025 at 2:00 pm with the Administrator revealed her expectation is for the facility to be in compliance with the PASARR Level II audits and screenings.

Based on observation, clinical record review, review of the State of Georgia Rule 410-10-.01 Standards of Practice for Registered Professional Nurses and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, and staff interviews, the facility failed to maintain professional nursing standards of quality and nursing standards of practice as evidenced by not assessing a resident for pain during wound care. This resulted in actual harm for one resident (R) #331, who had frequent and repetitive verbalizations of pain during one of two wound care observations. A total of five residents were reviewed for pain during wound care, and the sample size was 36 residents. Findings include: Review of the Georgia Standards of Practice for Registered Professional Nurses revealed that the Board recognizes that assessment, nursing diagnosis, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The Standards of Practice for Registered Professional Nurses delineate the quality of nursing care which a patient/client should receive regardless of whether it is provided solely by a registered nurse or by a registered nurse in collaboration with other licensed or unlicensed personnel. The Standards are based on the premise that the registered nurse is responsible for and accountable to the patient/client for the quality of nursing care rendered. The Standards of Practice for Registered Professional Nurses shall establish a baseline for quality nursing care; be derived from the Georgia Nurse Practice Act; apply to the registered nurse [MEDICATION NAME] in any setting; and, govern the practice of the licensee at all levels of competency. (a) Standards related to the registered nurse's responsibility to apply the nursing process (adapted from American Nurses' Association Code for Nurses and Standards of Practice). The registered nurse shall: 1. Assess the patient/client in a systematic, organized manner; 6. Evaluate with the patient/client the status of goal achievement as a basis for reassessment, reordering of priorities, new goal-setting and revision of the plan of nursing care; Review of the Georgia Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice; (c) Performing comfort and safety measures. Review of the facility's Pain Management policy revealed the following: Each resident of Budd Terrace has the right to have pain assessed and managed. Pain is whatever the experiencing person says it is. Assess the resident for pain (origin, location, severity, alleviating and exacerbating factors, impact on functional ability, prior methods of pain management and current treatment and response to treatment). Accept and act on a patient's report of pain. No evidence exists that the cognitively impaired elderly experience less pain or that their reports of pain are less valid than individuals with intact cognitive function. Assess cognitively impaired residents by observing behaviors such as facial grimaces, restlessness, behaviors, or guarding. Review of R#331's care plan for chronic back pain and [MEDICAL CONDITION] AEB (as evidenced by) alteration in discomfort, she is on routine and as needed pain medications with an initiated date of 4/3/17 revealed a goal of will indicate verbally or non-verbally adequate pain management/relief, and had the following interventions: -Assess for non-verbal S&S (signs and symptoms) of pain (grimace, frown, withdrawal, disinterest, clenched jaw, quivering chin, irritability). -Assess pain using a pain scale rating of 1-10 or other verbal indicators. -Assess resident's response to medication through pain scale rating, non-verbal, and verbal feedback. Report ineffective relief to practitioner. -Encourage resident to report pain at onset and not to wait until pain is severe. -If appropriate, administer pain medication prior to treatments. -May try non-pharmacological approaches for pain control: repositioning, use of pillows. Review of a Wound Care Specialist Evaluation report dated 3/31/17 revealed that R#331 had a total of eight pressure ulcer or vascular wounds to her sacrum, ankles, and feet. During observation of R#331's wound care done by the Registered Nurse (RN) Wound Care Nurse CC on 4/13/17 at 9:40 a.m., and assisted by the third floor Licensed Practical Nurse (LPN) Unit Manager, the resident had frequent and repetitive verbalizations of discomfort. At no time during this wound observation, which lasted for 43 minutes, did the RN or LPN stop and reassess the resident for the effectiveness of the prn (as needed) pain medication that she had been given at 8:10 a.m. that morning. During interview with the third floor LPN Unit Manager on 4/14/17 at 10:37 a.m., and with RN Wound Care nurse CC on 4/14/17 at 10:55 a.m., they verified that they did not stop to assess and evaluate why R#331 was yelling out so often during wound care on 4/13/17. Cross-refer to F 309.

Based on observation, record review, and staff interview, the facility failed to follow the care plan related to assessing for pain, and assessing response to a pain medication for one resident (R) #331. This resulted in actual harm for R#331, who had frequent and repetitive verbalizations of discomfort during one of two wound care observations made. In addition, the facility failed to follow the care plan related to administering blood pressure medications as ordered for one resident (#48). A total of five residents were reviewed for pain during wound care, and the sample size was 36 residents. Findings include: 1. Review of a Wound Care Specialist Evaluation report dated 3/31/17 revealed that R#331 had seven arterial and pressure ulcer wounds to her ankles and feet, and one pressure ulcer to her sacrum. Review of her clinical record revealed [DIAGNOSES REDACTED]. Review of her Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status score of 5 (a score of 0 to 7 indicates severe cognitive impairment), was on a scheduled pain medication regimen, and received prn (as needed) pain medications. Review of R#331's care plan for chronic back pain and [MEDICAL CONDITION] AEB (as evidenced by) alteration in discomfort, on routine and as needed pain medications with an initiated date of 4/3/17 revealed a goal of will indicate verbally or non-verbally adequate pain management/relief, and interventions included the following: -Assess for non-verbal S&S (signs and symptoms) of pain (grimace, frown, withdrawal, disinterest, clenched jaw, quivering chin, irritability). -Assess pain using a pain scale rating of 1-10 or other verbal indicators. -Assess resident's response to medication through pain scale rating, non-verbal, and verbal feedback. Report ineffective relief to practitioner. During wound care performed by Registered Nurse (RN) Wound Care Nurse CC and assisted by the third floor Licensed Practical Nurse (LPN) Unit Manager on 4/13/17 at 9:40 a.m., R#331 was observed to have frequent, loud, and repetitive verbalizations including ow ow ow, Lord Lord, Jesus, oh Lord, Lord Lord Lord, oh Lord, and ow. During the entire wound care observation, which was completed at 10:23 a.m., at no point did either the treatment nurse or the unit manager ask the resident if she wanted them to stop when she was having these repetitive verbalizations of discomfort. Review of a pharmacy Transactions by Patient report revealed that R#331 received a prn (as needed) dose of [MEDICATION NAME] (a narcotic pain medication) 2.5 mg (milligrams) on 4/13/17 at 8:10 a.m., prior to the wound care. During an interview with the third floor Unit Manager on 4/14/17 at 10:37 a.m., she was asked why the wound care wasn't stopped to evaluate the resident's repetitive and frequent verbalizations of discomfort during wound care on 4/13/17, and she verified that neither she or the wound care nurse stopped to ask the resident if she was having pain. During an interview with Wound Care RN CC on 4/14/17 at 10:55 a.m., she stated that she always asked the medication nurse to pre-medicate the resident and then waited for about 30 minutes before doing wound care. She further stated that R#331 screamed out yesterday more than usual during the treatment. During further interview when asked why she did not stop the wound care on 4/13/17 when the resident was verbalizing so much discomfort, she stated that she was just focused on doing the wound care, that the amount of verbalizations of pain was not typical for the resident, and that she did not know why she didn't stop. Cross-refer to F 309. 2. Review of the medical record for R#48 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 11/22/16 and reviewed 2/22/17 revealed that the resident had a potential for fluctuations in blood pressure with an intervention for licensed/registered nursing staff to administer his antihypertensive medications as ordered. Continued review of his medical record revealed a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. Review of the Medication Administration Records (MAR's) revealed that licensed/registered nursing staff failed to hold the [MEDICATION NAME] for a SBP less than 130 as ordered by the physician 11 times in February 2017, 11 times in March 2017 and 10 times in April 2017. Continued review revealed that licensed/registered nursing staff failed to hold the [MEDICATION NAME] for a HR less than 60 for five times in February 2017, six times in March 2017 and for four times in April 2017. Interview with the Director of Nursing (DON) on 04/14/2017 at 9:17 a.m. revealed that she expected the nurses to administer medications as ordered by the physician and as care planned. Cross refer to F309.

Based on observation, record review, physician, family, and staff interviews, the facility failed to stop and assess one resident's (R) (#331) repeated expressions of discomfort during one of two wound care observations. This resulted in actual harm for R #331. In addition, the facility failed to follow the physician's orders [REDACTED].#48 and #468). A total of five residents were reviewed for pain during wound care, and the sample size was 36 residents. Findings include: 1. Review of the facility's Pain Management policy revealed the following: Each resident of Budd Terrace has the right to have pain assessed and managed. Pain is whatever the experiencing person says it is. Assess the resident for pain (origin, location, severity, alleviating and exacerbating factors, impact on functional ability, prior methods of pain management and current treatment and response to treatment). Accept and act on a patient's report of pain. No evidence exists that the cognitively impaired elderly experience less pain or that their reports of pain are less valid than individuals with intact cognitive function. Assess cognitively impaired residents by observing behaviors such as facial grimaces, restlessness, behaviors, or guarding. Notify the physician: If all prescribed treatment measures have been exhausted and the resident is experiencing unacceptable, uncontrolled pain. Review of R#331's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a bilateral duplex lower extremity arterial study dated 11/3/16 suggested stenosis from the left femoral artery to the popliteal artery, as well as from the right popliteal to the DPA (dorsalis pedis artery), with slow flow from right PTA (posterior tibial artery) and left DPA. Review of a Weekly Pain assessment dated [DATE] revealed that the staff assessed R#331 as having no signs or symptoms of pain. Review of her Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status score of 5 (a score of 0 to 7 indicates severe cognitive impairment); she had no behaviors; was on a scheduled pain medication regimen; received prn (as needed) pain medications; had occasional pain in the past five days that had not made it hard for her to sleep nor limited her day-to-day activities and had a numeric rating of 3 on a scale of 0 to 10. Review of the Care Area Assessment Summary (CAAS) for this MDS revealed that pain did not trigger as an area of concern. Review of R#331's care plan for chronic back pain and [MEDICAL CONDITION] AEB (as evidenced by) alteration in discomfort, she is on routine and as needed pain medications with an initiated date of 4/3/17 revealed a goal of will indicate verbally or non-verbally adequate pain management/relief, and had the following interventions: -Assess for non-verbal S&S (signs and symptoms) of pain (grimace, frown, withdrawal, disinterest, clenched jaw, quivering chin, irritability). -Assess pain using a pain scale rating of 1-10 or other verbal indicators. -Assess resident's response to medication through pain scale rating, non-verbal, and verbal feedback. Report ineffective relief to practitioner. -Encourage resident to report pain at onset and not to wait until pain is severe. -If appropriate, administer pain medication prior to treatments. -May try non-pharmacological approaches for pain control: repositioning, use of pillows. Review of a care plan updated on 3/29/17 revealed that R#331 had noted resistance during care provided by nursing staff and combative behaviors. She also has noted yelling out behaviors and at times intrudes on the privacy of others. Review of the interventions for this care plan included to intervene as necessary to protect the rights and safety of others during yelling out episodes. Approach/speak in a calm manner. Remove from situation and take to alternate location as needed. Monitor and document observed behavior and attempted interventions. Review of a Wound Care Specialist Evaluation report dated 3/31/17 revealed that R#331 had the following wounds: Site 1. Arterial wound of the right lateral ankle that measured 6.5 X 2.4 X 0.2 cm (centimeters). Site 2. Unstageable pressure ulcer to the right medial heel that measured 2.0 X 2.0 cm, with 100% thick adherent black necrotic tissue (eschar). Site 3: Arterial wound of the left posterior heel that measured 3.5 X 4 cm, with 100% thick adherent black necrotic tissue (eschar). Site 4: Stage 3 pressure ulcer to the sacrum that measured 1.8 X 2.0 X 0.1 cm. Site 7: Wound (unclassified) of the left dorsal second toe that measured 0.4 X 0.4 cm. Site 8: Wound (unclassified) of the right distal first toe that measured 0.4 X 1.2 cm. Site 9: Arterial wound of the left lateral ankle that measured 0.5 X 0.5 cm. Site 10: Arterial wound of the right medial foot that measured 4.0 X 1.0 cm. Review of the Clinical physician's orders [REDACTED]. Review of completed Clinical physician's orders [REDACTED]. Further review of the Clinical physician's orders [REDACTED]. In addition, the resident was also receiving [MEDICATION NAME] (a muscle relaxant) 5 mg at bedtime for muscle spasms, aspirin 81 mg daily for [MEDICAL CONDITION]([MEDICAL CONDITION] -stroke), and [MEDICATION NAME] 650 mg every six hours as needed for pain. Just prior to observation of R#331's wound care done by the Registered Nurse (RN) Wound Care Nurse CC on 4/13/17 at 9:40 a.m., the nurse stated that the resident had been medicated earlier for pain. Observation at this time revealed that the sacral treatment was done first, and R #331 did not exhibit any outward signs or verbalizations of pain. Observation of wound care to the right heel revealed that the resident loudly said ow ow ow, Lord Lord, ow ow ow repetitively when the right leg was lifted off the bed and the area of eschar on the heel cleansed. Observation of the right lateral ankle treatment revealed that the resident said Jesus, oh Lord repetitively when the wound care was done, and she stopped moaning and crying out when the treatment to this area was completed. The resident was next observed to be turned to her right side, and her left leg was lifted to place a pillow under it, at which time she loudly stated ow ow ow, Lord Lord Lord. When the left leg was lifted to provide treatment to the left heel, R#331 stated oh Lord. When the left ankle was being wrapped after treatment to the area, the resident stated ow, and the third floor Licensed Practical Nurse (LPN) Unit Manager, who was assisting with the treatment, told the resident to wait just a minute. When the resident's left leg was repositioned, she verbalized a loud ow. During the entire wound care observation, which was completed at 10:23 a.m., at no point did either the treatment nurse or the unit manager ask the resident if she wanted them to stop when she was having the repetitive verbalizations of pain. During interview with the RN Wound Care Nurse CC after the wound care on 4/13/17 at 10:23 a.m., she stated that the amount of pain R#331 exhibited during treatments varied from day to day, and that the resident did not yell out at all during the treatment yesterday. Review of a Comprehensive Pain assessment dated [DATE] at 11:58 a.m. revealed that R#331 had daily indicators of pain, and that wound changes made the pain worse. Review of the Clinical Physician order [REDACTED]. During interview with Certified Nursing Assistant (CNA) DD on 4/13/17 at 2:21 p.m., she stated that R#331 did seem to have pain during moving or turning, but that she would stop hollering out and would be OK afterwards. During an interview with the Director of Nursing (DON) on 4/13/17 at 5:01 p.m., she stated that the wound care nurse had told her that R#331 was yelling out during wound care, and that there was a difference between yelling out as a behavior and yelling out due to pain, and referred to the resident's care plan that noted yelling out behaviors. Review of a Medical Progress Note dated 4/13/17 at 21:50 (9:50 p.m.) noted that R#331 had significant pain during wound care despite [MEDICATION NAME] and [MEDICATION NAME] 2.5 prn use. During the exam the resident stated no pain as long as you don't touch my legs. On 4/14/17 at 9:08 a.m., the facility's contracted wound care physician and the RN Wound Care Coordinator (WCC) were observed performing wound assessments and treatments to all of R#331's wounds. The third floor LPN Unit Manager was observed to assist with positioning as well as talk to R#331. The only verbalizations of pain observed was when her right foot was wrapped with a roll of gauze (the resident said ow), but no verbalizations of pain when wound care was completed to the sacrum, left foot (including surgical removal of necrotic tissue to the left heel), and left ankle. The resident was observed to say ow-ow-ow when the head of the bed was lowered and the incontinent brief unfastened, and she said ow-ow-ow, when pulled up in bed by the nurses by use of a draw sheet, but the resident shook her head no when the unit manager asked her if that hurt. The resident was observed to be comfortable throughout the entire procedure which lasted until 9:45 a.m., and any verbalizations of discomfort were not nearly as loud or repetitive as the wound care observation on 4/13/17. Review of the pharmacy Transactions by Patient report revealed that R #331 had received the increased dose of [MEDICATION NAME] 5 mg at 8:13 a.m. prior to the wound care. During an interview with the facility's contracted wound care physician on 4/14/17 at 9:45 a.m., he stated that the arterial wounds could be painful, but the verbalizations of ow that she had might not necessarily be from the wounds as she had dementia and might be scared. He further stated that if the resident was saying ow or having other verbalizations frequently during wound care, that it would be prudent to stop the treatment and medicate her with something stronger for pain. During an observation of a bedbath and incontinent care performed by CNA's DD and EE on 4/14/17 at 9:52 a.m., the only time R#331 expressed discomfort was once when her arms were lifted, but she stopped as soon as her arms were lowered. However, when the resident's legs were maneuvered to replace the protective padded boots on her legs, the resident stated hurts so bad, oh Lord briefly until the boots were on. During an interview with LPN FF on 4/14/17 at 10:33 a.m., she stated that she gave [MEDICATION NAME] 30 to 45 minutes before wound care was done, and Tylenol only if the resident complained of a headache. Review of pharmacy Transactions by Patient reports for R#331 from February to April 2017 revealed that she received the prn [MEDICATION NAME] three times in April, including at 8:10 a.m. prior to the wound care on 4/13/17; five doses in March; and 12 doses in February. During interview with the third floor Unit Manager on 4/14/17 at 10:37 a.m., she stated that during any care, R#331 hollered out, and that it wasn't just during wound care. During further interview when asked why the wound care wasn't stopped to evaluate the resident's repetitive and frequent verbalizations of discomfort during wound care on 4/13/17, she verified that neither she or the wound care nurse stopped to ask the resident if she was having pain. During interview with Wound Care RN CC on 4/14/17 at 10:55 a.m., she stated that she always asked the medication nurse to pre-medicate the resident and then waited for about 30 minutes before doing wound care. She further stated that R#331 screamed out yesterday more than usual during the treatment. Continued interview with RN CC revealed that the attending physician was contacted after the wound care on 4/13/17, and orders were obtained to increase the [MEDICATION NAME] dosage, and to apply [MEDICATION NAME] (an anesthetic) gel to the wounds. During further interview when asked why she did not stop the wound care on 4/13/17 when the resident was verbalizing so much discomfort, she stated that she was just focused on doing the wound care, that the amount of verbalizations of pain was not typical for the resident, and that she did not know why she didn't stop. During an interview with three family members of R#331 on 4/14/17 at 12:56 p.m., they stated that the resident had hollered out for years, but felt that the sores on her legs caused the pain whenever the resident was turned causing her to yell out. During an interview with R#331's attending physician on 4/14/17 at 1:31 p.m., he stated that ever since the resident had a stroke, she was not able to verbalize very well. He further stated that the resident had neuropathic and musculoskeletal pain, and that her wounds themselves would be painful, as would a change in position. During further interview, he stated that the staff should give the resident a pain medication before wound care, and that they should stop and get an order for [REDACTED]. During an interview with the facility's LPN Education Specialist on 4/14/17 at 1:47 p.m., he stated that if a resident experienced pain during a treatment, his expectation would be for the staff to stop and assess the situation, ask the resident the severity of their pain, and if the resident wanted them to continue. He further stated that if the resident had impaired cognition, that the staff should stop and assess to determine if the treatment was causing the pain, and call the physician for additional orders if needed. Review of a wound care policy Alginate dressing application provided by the Education Specialist at this time revealed to perform a comprehensive pain assessment. Administer pain medication to the patient at least 20 minutes before performing the dressing change, as needed and ordered, because dressing changes can be painful. Encourage the patient to request a time-out during the procedure if he experiences pain. 2. Review of the medical record for R#48 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 11/22/16 and reviewed 2/22/17 revealed that the resident had a potential for fluctuations in blood pressure with an intervention for licensed/registered nursing staff to administer his antihypertensive medications as ordered. Continued review of his medical record revealed a physician's orders [REDACTED]. The resident also had a physician's orders [REDACTED]. However, review of the February 2017 Medication Administration Record [REDACTED].m for a SBP of 120, at 2:00 p.m. for a SBP of 120 and at 10:00 p.m. for a SBP of 118; and on 2/28/17 at 6:00 a.m. for a SBP of 120. Continued review of the MAR indicated [REDACTED]. Review of the March 2017 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Review of the April 2017 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. review of the resident's medical record revealed [REDACTED]. Interview with Licensed Practical Nurse (LPN) PP on 4/14/17 at 2:40 p.m. revealed that nurses should administer medications as ordered by the physician and per the physician's parameters. LPN PP reviewed the April 2017 MAR's at that time and stated that she had administered the [MEDICATION NAME] to the resident on 4/5/17 although his HR was 50 because his BP was high at 179/81. Continued interview with LPN PP revealed that she had not notified the physician that she had failed to hold the [MEDICATION NAME] for a HR less than 60 at that time. 3. Review of the clinical record revealed R#468 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. Review of the MAR for R#468 revealed on 3/24/17 at 2:00 p.m., [MEDICATION NAME] HCL was administered with a blood pressure (BP) of 90/52. On 4/2/17 at 6:00 a.m., [MEDICATION NAME] HCL was administered with a BP of 98/60; and on 4/11/17 at 2:00 p.m., [MEDICATION NAME] HCL was administered with a BP of 95/51. Review of the Nurses Notes for 3/24/17, 4/2/17, and 4/11/17 revealed no documentation related to withholding [MEDICATION NAME] HCL for BP outside of parameters ordered by the physician. Further review of the Nurses Notes revealed no adverse reactions related to the medication not being withheld per physician orders. Interview with LPN BB at 8:20 a.m. revealed that the CNA's check the vital signs and document them on the flowsheet. LPN confirmed that the nurses must check the flow sheet and enter the BP on the MAR prior to administration on the medication. LPN stated that the medication parameters should be verified at that time and medication should be held if appropriate. Interview with the DON on 04/14/2017 at 9:17 a.m. revealed there was no facility policy regarding medication administration and she expects the nurses to always give medications according to the physician order; and to notify the physician with any concerns related to the medications.

Based on record review, observation and interviews, the facility failed to provide breakthrough pain medication for one (1) resident ("A"). This resulted in actual harm. The sample included twenty-nine (29)residents. The findings included: During a resident interview on 2/22/11 at 10:48 a.m. resident "A" was observed rubbing his right knee. Resident "A" revealed his right leg hurts most of the time and added the nurse was aware. The resident described the pain in the right knee and leg as sharp and aching. He rated his pain (from 0-10) as a number "4" most of the time but at night the pain can be a "10" and can wake him from sleep. The right leg hurts in the daytime too but at night there is nothing he can take or they can give him. The resident stated he was told by the night nurse that he has to make an appointment to see the doctor about his pain medications. He stated he had asked the nurse to change his pain medication to as needed (prn) basis and was told he would have to talk to his doctor. The resident asked for Tylenol and was told he could not have anything because it was not time. The nurse told the resident to let his doctor know if the medication was not working. A review of the current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review revealed multiple documentation in the Nursing Notes (at varied times of day) (1/24/11, 2/08/11, 2/10/11, 2/12/11, 2/14/11, 2/17/11 and 2/20/11) of the resident complaining of right knee or leg pain. On 2/23/11 at 1:10 p.m. a telephone interview with Nurse Practitioner "JJ" revealed the plan was to get the resident off pain medications. The resident's wound was not recent and the resident should not be having that much pain. Review of the Pain Management Protocol documented: each resident has a right to have pain assessed and managed, and that pain is whatever the experiencing person says it is. Nursing interventions for pain includes that nursing collaborates with the physician to modify the pain management plan as needed, based on information obtained from the resident, ongoing assessment findings and notifies the physician. On 2/24/11 at 8:55 am during an interview with the DON she indicated if a resident complains of pain and their medication is not due, she expects the nurse to notify the physician. If the resident did not have any medication ordered for break-through pain the DON said the physician should be notified. She did not expect staff to tell the resident to make an appointment to discuss his pain medications with the physician. On 2/24/11 at 10:40 p.m. interview with the physician revealed when a resident complains of pain not being relieved he would expect staff to notify the Nurse Practitioner. The physician said there is a communication book on the unit and used as a communication tool to notify the physician and Nurse Practitioner. A review of the communication book did not reveal any communications to the Nurse Practitioner until 2/23/11 about pain medication adjustment.