Every finding on record at Parkway Hills Nursing & Rehabilitation

Based on interview and record review, the facility failed to ensure treatment orders were obtained and followed for a surgical foot wound on one of two residents reviewed for wound care (Resident 1). This failure had the potential to result in infection or other wound complications.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses to include fracture of the lateral malleolus (the prominent bony bump on the outer side of the ankle), according to the undated admission Record.A record review was conducted.According to the physician's History and Physical note (H&P), dated 12/5/25, Resident 1 was admitted to the facility following a fall and ankle fracture with surgical repair.According to a Nurses Note, dated 12/4/25, Resident 1 had surgical wounds with staples on his right foot and ankle.The physician's orders for Resident 1 were reviewed. No treatment orders for the surgical wounds were identified for Resident 1's admission date of 12/3/25 through 12/26/25.According to the December Treatment Administration Record (TAR, a record of all treatments ordered and provided to heal the wounds), no treatments were done to Resident 1's surgical wounds from 12/3/25 through 12/28/25.According to a wound care physician's note, dated 12/25/25, the primary care physician (PCP) had consulted the specialist physician to evaluate and treat Resident 1's surgical wounds.According to the physician's orders, dated 12/27/25, Resident 1 was to receive wound care treatments to the surgical wounds.According to the December TAR, Resident 1's surgical wounds were treated as ordered by the physician on 12/28/25 through 12/31/25. According to a wound care physician's note, dated 1/1/26, surgical staples had been removed from Resident 1's foot and ankle, and four of the six surgical wounds had resolved. The physician indicated wound care treatment was to continue for the resolved wounds and the remaining wounds.Resident 1 was not available for an interview.An interview was conducted with Licensed Nurse (LN) 1 on 4/28/26 at 2:11 P.M. LN 1 stated she was the wound care nurse for the facility. LN 1 stated she had assessed Resident 1 on 12/4/25 when he was admitted to the facility. LN 1 stated her responsibility was to assess new resident's skin and wounds, then contact the physician for treatment orders. LN 1 stated once treatment orders were obtained, the orders would be available in the TAR so nursing staff could sign their initials when the prescribed treatment was completed. LN 1 stated she did not remember calling the physician for Resident 1's surgical wound treatment orders. LN 1 stated she assessed Resident 1's surgical wounds five days a week, and other nurses would assess on her days off. LN 1 stated Resident 1's surgical wounds healed well, and the wound care physician was brought in to remove surgical staples and assess the wound status. LN 1 stated she should have called the physician to obtain clinical orders to ensure the documentation was completed. LN 1 stated, I should have obtained the treatment orders so nurses knew to watch for signs of infection or other problems.An interview was conducted with the Director of Nursing (DON) on 4/28/26 at 2:20 P.M. The DON stated her expectation was for the wound care nurse to call the physician and obtain orders to monitor and treat wounds. The DON stated most of Resident 1's surgical wounds had healed well, but the written physician's orders should have been in the medical record as evidence the treatments had been provided.Per a facility document, revised April 2019 and titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, .the nurse shall describe and document/report the following: Current treatments, including support surfaces.

Based on interview and record review, the facility failed to permit a resident to return to the facility after a hospitalization for one of two sampled residents (1). As a result, Resident 1 had a delayed stay in the hospital while waiting for alternate placement. Findings: Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include paraplegia (inability to move the lower limbs), and was discharged to a General Acute Care Hospital (GACH) on 3/28/26. Per the GACH's Case Manager Interdisciplinary Note, dated 3/30/26 (two days after admitting to the GACH) at 11:39 A.M., Resident 1 was calm and cooperative, and was medically cleared to discharge back to his skilled nursing facility. Resident 1 stated that he wanted to return to the skilled nursing facility. Resident 1 had an active bedhold at the skilled nursing facility, but they were not accepting him back. Per the GACH's Nursing Note, dated 4/3/26 at 6:46 P.M., Resident 1 discharged to a different skilled nursing facility on 4/3/26 (Four days after he was initially cleared for discharge back to his initial skilled nursing facility). On 4/9/26 at 12:08 P.M., an interview was conducted with the Admissions Director (AD). The AD stated, the GACH attempted to send Resident 1 back to the facility, but the facility made the decision not to readmit him. On 4/14/26 at 2:52 P.M., a telephone interview was conducted with the Administrator. The Administrator stated, the facility decided not to readmit Resident 1 from the GACH. Per the facility's policy titled, Bed-Holds and Returns, revised October 2022, 5. The requirement that residents be permitted to return to the facility following hospitalization.6. Residents who seek to return to the facility within the bed-hold period.are allowed to return to their previous room.11. Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred.

Based on observation, interview and record review, the facility failed to ensure the Dietary Manager (DM) had the required education or experience to effectively manage the Food Service department. This failure had the potential to place 52 residents at risk for foodborne illness. Cross reference: F806, F812, F813Findings: An interview was conducted with the DM on 9/22/25 at 9:45 A.M. The DM stated she had been employed as the DM for approximately 18 months. The DM stated she did not have a degree in food service management, or a Certified Dietary Manager (CDM) credential. The DM stated she did not have experience as a food service manager from any other facility. The DM stated she had been promoted into her current job by a previous manager. A record review of the DM's employee file was conducted on 9/22/25. An undated, unsigned job description, titled Certified Dietary Manager, was in the file. Per the job description, The primary purpose of this position is to plan, organize, develop and direct the operations of the food and nutrition services department in accordance with current federal, state and local standards .Education: Must possess, as a minimum, a bachelor's degree in nutrition, dietary management or related field .Specific Requirements: Must be a Certified Dietary Manager . An undated, unsigned document, titled License or Certification Verification Form, was in the HR file. The document was blank and did not include a license or certification number. A resume for the DM listed her education as a high school graduate, currently enrolled in college courses as of February 2022. No course of study or graduation date for college was listed. No credential or license was listed on the resume or within the employee file. An interview was conducted with the Administrator (Admin) on 9/22/25 at 1 P.M. The Admin stated the DM reported to her. Per the Admin, the DM had been promoted by her predecessor. The Admin stated she was unaware the DM did not have a license or certificate to fulfill the job qualifications. The Admin stated the lack of training and education had the potential to impact the quality of the food service provided to the residents.

Based on observation, interview, and record review, the facility failed to ensure two of three residents reviewed for oxygen therapy had:Oxygen saturation levels (the amount of oxygen in the blood) routinely monitored and documented (Resident 3), and,A physician's order for oxygen therapy was obtained prior to administration (Resident 7). These failures had the potential for Residents 3 and 7 to receive oxygen when it was not required, resulting in the possibility of dependency. Findings: 1. Resident 3 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-permanent damage to the lungs which affects airflow and gas exchange), per the facility's admission Record. An observation and interview was conducted with Resident 3 on 9/21/25 at 8:51 A.M. Resident 3 was sitting up in bed with a nasal cannula (a plastic tube that delivers oxygen to the nose) inserted in his nares. Resident 3 stated he had trouble breathing sometimes and normally gets 2 liters of oxygen. An oxygen condenser (a machine that delivered oxygen) was on the floor next to the bed. On 9/22/25, Resident 3's clinical record was reviewed. According to the physician's order, dated 9/8/25, oxygen two liters per minute via nasal cannula to keep oxygen saturation rate above 90%, (normal 97% - 99%) as needed. The facility's Weights and Vital Summary Task sheet for documenting oxygen saturation rates from 8/4/25 through 9/23/25 were reviewed. Oxygen saturations were documented 22 times out of 51 opportunities (if completed 1 time a day). Resident 3's oxygen saturation was recorded on room air 17 times out of 22 opportunities and was 95% or above with the exception of once. The facility's Medication (MAR) and Treatment Administration Records (TAR) from 8/4/25 through 9/23/25 were reviewed with no indication if oxygen was being administered or not. Observations were conducted of Resident 3 in bed, receiving two liters of oxygen on 9/22/25 at 2:44 P.M., and 3:14 P.M, with no documented evidence of oxygen saturation levels for 9/22/25. An observation and interview was conducted with Resident 3 in his room on 9/23/25 at 8:15 A.M. Resident 3 was sitting up in bed receiving two liters of oxygen via nasal cannula. Resident 3 had a portable pulse oximetry (an external device used to check oxygen saturations) on his bedside table. Resident 3 stated he liked to check his own oxygen saturation and demonstrated how the device was used. Resident 3 applied the finger device, which displayed an oxygen saturation rate of 89% after being off oxygen for three minutes. Resident 3 reapplied the nasal cannula to his nose afterwards. There was no documented evidence of oxygen saturation levels for 9/23/25. An interview was conducted with Licensed Nurse 16 (LN 16) on 9/23/25 at 8:48 A.M. LN 16 stated oxygen saturation levels should be checked every shift, to determine if prn (as needed) oxygen was required. LN 16 stated oxygen saturations levels should be documented in the Task section and also in the Pulmonary (lung) section of the electronic record. LN 16 stated staff who provided respiratory treatments documented all of their assessments in the Pulmonary section. An interview and record review was conducted with LN 17 on 9/23/25 at 8:53 A.M. of Resident 3's Pulmonary assessments. LN 17 stated he checked oxygen saturation levels and lung sounds during his Pulmonary assessments of residents. LN 17 stated certified nursing assistants (CNAs) also check oxygen saturation levels every shift and document their results in the Task section of the resident's electronic record. LN 17 stated since Resident 3 was on prn oxygen, if the saturations were 90% or below, they should be documenting the saturation levels every shift (three times a day). LN 17 stated during his pulmonary treatments he also checked the saturations levels and documented the level before applying oxygen, if needed. LN 17 reviewed Resident 3's saturation levels in the Pulmonary section of the electronic record and stated the saturation levels were not there, and they should be. LN 17 stated the saturations levels were important to determine if Resident 3 required oxygen or not. LN 17 stated if Resident 3 received oxygen when it was not required, he could become more dependent on oxygen. LN 17 stated if the physician reviewed Resident 3's electronic record for oxygen saturation levels, it would not provide an accurate picture of the resident's current pulmonary status. An interview and record review was conducted with the Director of Nursing (DON) of Resident 3's pulmonary documentation on 9/23/25 at 9:06 A.M. The DON stated since Resident 3 was on prn oxygen to keep saturation levels above 90%, his oxygen saturation level should be checked on room air every shift and documented. The DON stated if Resident 3's oxygen saturation levels were above 90% and he was still receiving oxygen, there was the potential for Resident 3 to become dependent on the oxygen. The DON stated oxygen saturation levels and when oxygen was applied, should be documented in the Pulmonary section of the electronic record. The DON reviewed the Pulmonary section for Resident 3 and stated the oxygen saturation levels should be documented, but she could not see that they were. A follow up interview was conducted with LN 17 at 9/23/25 at 9:30 A.M. LN 17 stated he realized the Pulmonary section of Resident 3's electronic record was not saving the documented oxygen saturation levels, and they just realized there was a glitch in the system that needed to be corrected. LN 17 stated it as important to have documented oxygen saturation levels so the physician could analyze Resident 3's pulmonary status and change orders as needed. According to the facility's policy, titled Pulse Oximetry (Assessing Oxygen Saturation), dated October 2010, .1. Review the physician's orders.Documentation: The SaO2 (oxygen saturation) flow sheet should be placed in the medical record. In addition, the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. Any unusual findings and the action taken. According to the facility's policy titled Oxygen Administration, dated October 2010, .1. Verify that there is a physician's order.Documentation: 1. The date and time that the procedure was performed.5. The reason for the prn (as needed) administration. 2. Resident 7 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease, per the facility's admission Record. On 9/21/25 at 9:24 A.M., an observation during the initial tour was conducted. Resident 7 had the oxygen nasal cannula delivered at three liters per minute (LPM) via oxygen concentrator. Resident 7 did not respond when her name was called. On 9/22/25, a record review was conducted. There was no physician's order of oxygen for Resident 7. A form, titled Pulmonary Functioning/Monitoring dated 9/21/25, indicated Resident 7 was on continuous flow of three liters of oxygen per minute for COPD. On 9/22/25 at 9:27 A.M. and 1:42 P.M., a follow-up observation of Resident 7 was conducted. Resident 7 laid in bed, with her eyes closed and did not respond when her name was called. Resident 7 had the oxygen set at three LPM via nasal cannula. On 9/22/25 at 1:59 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 12. CNA 12 stated Resident 7 was always on oxygen. On 9/23/25 at 9:32 A.M., a joint observation of Resident 7, a review of Resident 7's clinical record and an interview was conducted with LN 11. Resident 7 was in bed with the oxygen cannula on top of the oxygen concentrator. LN 11 stated Resident 7 had a prn for oxygen. LN 11 stated Resident 7 had a change in condition (a medical complication) and was placed on oxygen. LN 11 stated there was no physician's order for oxygen in Resident 7's clinical record. LN 11 stated whatever was administered to the resident, must be a physician's order because oxygen was considered a medication. On 9/24/25 at 9:16 A.M., an interview was conducted with the DON. The DON stated the expectation was when the resident had a change in condition and needed oxygen, the LNs should have obtained an order from the physician because oxygen was considered a medication and LNs should not administer any medications without physician's order. A review of the facility's policy on Oxygen Administration revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders.for oxygen administration.

Based on observation, interview and record review, the facility failed to ensure alternate food items were of equal nutritive value. This failure had the potential to place residents at risk for nutritional deficits. Findings:An observation of the kitchen tray line was conducted on 9/23/25 starting at 11:20 A.M. Trays were being prepared for 52 residents for lunch. The following items were served or prepared during the tray line: 1. [NAME] (CK 2) removed a plastic-covered chef salad from the refrigerator, and placed the salad on a resident tray. The chef salad contained a hard boiled egg, lettuce, cheese, turkey and ham. 2. CK 2 prepared a sandwich from two pieces of white bread and two slices of what appeared to be American cheese. CK 2 then grilled the sandwich in butter until browned, then placed the sandwich on a resident tray. 3. CK 2 prepared a quesadilla from a medium sized flour tortilla and a handful of shredded cheese. CK 2 browned the quesadilla in an oiled pan, then plated the quesadilla and placed it on a resident tray. No recipes or measuring utensils were visible or in use by CK 2. An interview was conducted with CK 2 on 9/23/25 at 11:50 A.M. Per CK 2, the alternative food items were offered daily in case the residents did not like the foods offered on the main menu. CK 2 stated she had not used a recipe, and had not measured or weighed the items. CK 2 stated she should have measured or weighed the cheese and meat for the salads and the sandwiches, but she did not have a scale. A concurrent observation and interview was conducted with the Registered Dietitian (RD) on 9/23/25 at 12 P.M. Per the RD, it was important to measure and weigh the ingredients for all recipes to ensure the residents were getting protein and calories equal to that provided by the main entree. The RD pulled a food scale out of a drawer to demonstrate for CK 2. A record review was conducted on 9/23/25. A facility recipe for chef's salad indicated each salad was to have one ounce of cooked turkey, a half ounce of ham, a half ounce of cheese, and a hard cooked egg. A facility recipe for grilled cheese indicated each sandwich was to have two ounces of cheese, and contained the note, Be sure to weigh cheese .Sliced cheese may not weigh one ounce per slice, make sure to weigh cheese to know how many slices equal two ounces .If using shredded cheese, a half cup equals two ounces of cheese - Do not use American Cheese . A facility recipe for cheese quesadilla indicated to use a half cup of shredded cheese per serving. Per a facility policy, dated 2023 and titled Portion Control, To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used .A diet scale should be used .

Based on observation, interview and record review, the facility failed to ensure kitchen sanitation and proper food storage was implemented in a manner that lessened the risk for foodborne illness when: 1. Food preparation areas, food storage containers and a tabletop can opener were visibly dirty, 2. Food in the kitchen was not labeled with opened date, use by date, or dispose date,3. Foods in the storeroom were not labeled with opened date or use by date, and4. Overhead light fixtures in the kitchen were rusted and dirty. These failures had the potential to cause foodborne illness to a population of 52 residents who received food from the kitchen. Findings: A kitchen tour was conducted on 9/21/25 at 8:39 A.M. with [NAME] (CK) 1. 1. The tile ledge near the hand wash sink, as well as a chemical dispenser box were covered with a thick, dark greasy layer of what appeared to be dirt. A window ledge over a utility sink had a thick dark layer of the same substance. A table top can opener had food debris embedded into the grooves of the can opener, as well as the tabletop can opener holder. A plastic food storage container with salt in it, located on a shelf over the food preparation area, had visible dried food debris on the outside of the container. CK 1 stated the area should be clean so the food would not become contaminated. CK 1 stated the can opener and salt container should have been removed from the service area and cleaned. 2. A large metal bowl on the countertop, containing approximately 25 dinner rolls was covered with plastic wrap. No label was on the container indicating the date prepared. Per CK 1, the dinner rolls should have a label indicating the date the rolls were prepared, and when to discard them. 3. In the storage room, a large bag of oatmeal was observed, placed on a metal rack. The bag contained approximately 20 pounds of oatmeal. The top of the bag was rolled down and not sealed. No label was evident, no date indicated when the oatmeal had been opened or when it should be discarded. Two large plastic buckets containing chicken and beef base were on the same rack, with the manufacturers' product label but no other indication of opened date or dispose date. The lids on the soup bases were not fully closed, leaving the contents partially exposed. Per CK 1, the oatmeal and the soup bases should have been transferred to a covered, sealed container with all important dates on a label. CK 1 stated it was important to keep foods in airtight containers to prevent bugs and other pests. 4. A kitchen observation and RD interview was conducted on 9/23/25 at 11 A.M. Ceiling light fixtures over the food prep areas had what appeared to be rust or dark, solid debris on the metal ends. The light fixtures were suspended over the food carts, where trays were being prepared for the residents' lunch meal. The RD stated maintenance staff should have noticed the rust or debris and either repaired or replaced the light fixture. The RD stated it was the DM's role, as well as her own, to follow up on the light fixtures, and to report the concerns to the Administrator. The RD stated she had not previously identified the light fixtures as a food safety issue, and she should have notified the Admin. An interview was conducted on 9/24/25 at 1:30 P.M. with the DM and the RD. Per the DM, she was responsible for the sanitation and food storage in the kitchen. The DM stated the kitchen tile and can opener should have been cleaned but had been missed by staff. The DM stated all foods should be labeled and dated with a received date and as appropriate, an opened date and discard date. The DM stated kitchen staff currently only wrote a received date on the product labels, which could lead to miscommunication about food safety. The RD stated she did monthly audits of sanitation and product labeling with the last audit done approximately three weeks earlier. The RD stated she provided oversight of the kitchen and was responsible for reporting any concerns to the Admin. The RD stated she had not identified any problems with sanitation, labeling or food safety during her recent kitchen audit. An interview was conducted with the Admin on 9/24/25 at 2 P.M. The Admin stated the DM and the RD reported to her. The Admin stated neither the DM nor the RD had informed her of any sanitation issues or maintenance concerns within the kitchen. The Admin stated her expectation was for managers to report their concerns to her so that they could be resolved promptly. Per a facility policy, dated 2023 and titled Sanitation, .The FNS Director [DM] is responsible for.sanitation in food service.The FNS Director will report any equipment needing repair to maintenance.all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. According to a facility policy, dated 2023 and titled Labeling and Dating of Foods, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines.All prepared foods need to be covered, labeled and dated. Per a facility policy, dated 2023 and titled Storage of Food and Supplies, Food and supplies will be stored properly and in a safe manner.Dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized .Bins/containers are to be labeled, covered and dated.All foods will be dated - month, day, year.Dry food items which have been opened, such as pudding, gelatin, biscuit mix.will be tightly closed, labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT, a group of healthcare professionals from different disciplines involved in providing care to the residents) assessed and documented self-administration of medications kept at bedside was clinically appropriate for one of 15 sampled residents (Resident 29). This failure had the potential for Resident 29 to experience negative health outcomes, including increased risk of infections and not to receive the full therapeutic benefits of his medications.Findings:A review of Resident 29's clinical record indicated he was admitted to the facility with diagnoses such as burn of second degree [a burn that causes injury, blistering, pain and swelling to the outer and middle layers of the skin]. including the right eye.During a concurrent observation and interview with Resident 29 on 9/23/25 at 9:29 A.M., Resident 29 stated he sometimes.[ran] out of Tegaderm [a transparent dressing used to cover and shield wounds], which he wore underneath his eyepatch. Resident 29 stated he also ran out of his lubricating eye ointment and eye drops at times. Resident 29 stated without his lubricating eye drops and eye ointment, the Tegaderm dressing would stick to his right eyeball because he did not have an eyelid. Resident 29 stated when that occurred, the Tegaderm would rip the top layer of his eye leading to pain and bleeding. Resident 29 reached for a bin in his room full of medications and supplies. Resident 29 laid out his medications and explained how he self-administered his eye treatment. Resident 29 stated he irrigates (to wash or remove debris) film on his eye using a saline (salt water) flush and sponge(s). Resident 29 stated the saline flush stung his eye, so he used Refresh Tears lubricating eye drops to relieve the burning sensation. Resident 29 stated he followed that with moxifloxacin (an antibiotic) eye drops. Resident 29 said he had bacterial conjunctivitis (or pink eye, an infection on the outer layer of the eye) on and off for two years. Resident 29 stated he instilled GenTeal Tears lubricating eye ointment after the moxifloxacin eye drops and then applied Tegaderm. Asked if he waits between instilling any of the eye drops, Resident 29 stated, I don't have to wait because I don't have any other antibiotics to put on. I only have [moxifloxacin]. Resident 29 stated he had been self-administering his eye treatment four times daily for about a year. During an interview with the Treatment Nurse (TN) on 9/24/25 at 9:59 A.M., the TN stated she no longer provides Resident 29 with treatments as he prefers to self-administer his ointment and wound care for [his] right eye. The TN stated Resident 29 informed staff when he was low on medications and supplies for his right eye treatment. The TN stated Resident 29 was particular about Tegaderm, he wants 3M [brand] Tegaderm. If it's not 3M, he'll refuse. The TN stated Resident 29 may have done his eye treatment more frequently than prescribed. The TN stated, I think he does it more than four times [a day]. In the computer, it's four times. The order is every six hours. I believe he does his wound care more often.A review of Resident 29's clinical record indicated he had a form titled, Self-Administration of Medications, dated 10/6/22, which indicated, Does the resident want to self-administer medications? The option c. No. was selected.During an interview with the Director of Nursing (DON) on 9/24/25 at 1:21 P.M., the DON stated Resident 29 wasn't supposed to self-administer. We don't have an order for it. It may have come from his eye appointment. I don't know. He shouldn't be self-administering. The DON stated, he shouldn't have [medications] at bedside. The DON stated, he shouldn't be self-administering without appropriate documentation and assessment because if he's not assessed, we don't know if he's doing it the right way, following physician orders, for safety.A review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, revised 2/2021, indicated, .1.the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.A review of the facility's P&P titled, Administering of Medications, revised 4/2019, indicated, .26. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.A review of the facility's P&P titled, Instillation [method used to put a liquid into the body slowly] of Eye Drops, revised 1/2014, indicated, .General Guidelines.4. When administering two or more different eye drops allow three to five minutes between each application.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive resident-centered care plan (detailed plan with information about a patient's treatment, goal, and interventions) was implemented for one of two sampled residents (Resident 8) reviewed for pain management. This failure had the potential to affect resident's care needs. Cross Reference F 697.Findings: Resident 8 was readmitted to the facility on [DATE] with diagnoses which included cancerous tumor of the right breast and chronic pain, per the facility's admission Record. On 9//21/25 at 8:22 A.M., an observation and an interview with Resident 8 was conducted in her room. Resident 8 laid in bed and was watching a television show. Resident 8 stated she had missed four doses of her pain medication because staff had informed her the facility ran out. Resident 8 stated she was upset because she was in pain. On 9/22/25, a record review was conducted. Resident 8's History and Physical (H & P), dated 7/17/25, indicated she had the capacity to understand and make decisions. A physician's order, dated 8/22/25, indicated Resident 8 was to receive oxycodone (a controlled medication for pain) every six hours for pain management. A care plan, dated 8/4/24, indicated Resident 8 had chronic pain, and interventions were to administer oxycodone (a pain medication) as ordered. On 9/22/25 at 2:15 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated he was taking care of and was familiar of Resident 8. CNA 11 stated Resident 8 was alert, oriented and knew what was going on. CNA 11 stated Resident 8 talked about her pain a lot and talked about not feeling good. CNA 11 stated Resident knew when her pain medication was due. CNA 11 stated Resident 8 mentioned she missed some doses of her pain medications. On 9/22/25 at 2:51 P.M., an interview and record review for Resident 8 was conducted with Licensed Nurse (LN) 1. LN 1 stated she was familiar with Resident 8. LN 1 stated Resident 8 had scheduled pain medication to be given every six hours and usually had pain. LN 1 reviewed Resident 8's Pain care plan, and stated the interventions to administer pain medications were not implemented. On 9/24/25 at 9:16 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was to implement Resident 8's care plan to manage her pain. A review of the facility's policy titled, Care Plan, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measurable objectives.to meet the resident's physical, psychosocial.needs is developed and implemented for each resident.

Based on observation, interview and record review, the facility failed to ensure a pain medication was available for one of two residents reviewed for pain management (Resident 8). This failure had the potential to cause the resident unnecessary pain, negatively affecting the resident's quality of life. Cross Reference to F 656.Findings: Resident 8 was readmitted to the facility on [DATE] with diagnoses which included cancerous tumor of the right breast and chronic pain, per the facility's admission Record. On 9//21/25 at 8:22 A.M., an observation and an interview with Resident 8 was conducted in her room. Resident 8 laid in bed and was watching a television show. Resident 8 stated she had missed four doses of her pain medication because staff had informed her the facility ran out. Resident 8 stated she was upset because she was in pain. On 9/22/25, a record review was conducted. Resident 8's History and Physical (H & P), dated 7/17/25, indicated she had the capacity to understand and make decisions. A physician's order, dated 8/22/25, indicated Resident 8 was to receive oxycodone (a controlled medication for pain) every six hours for pain management. On 9/22/25 at 2:15 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11. CNA 11 stated he was taking care of and was familiar of Resident 8. CNA 11 stated Resident 8 was alert, oriented and knew what was going on. CNA 11 stated Resident 8 talked about her pain a lot and talked about not feeling good. CNA 11 stated Resident knew when her pain medication was due. CNA 11 stated Resident 8 mentioned she missed some doses of her pain medications. On 9/22/25 at 2:51 P.M., an interview and record review for Resident 8 was conducted with Licensed Nurse (LN) 1. LN 1 stated she was familiar with Resident 8. LN 1 stated Resident 8 had scheduled pain medication to be given every six hours and usually had pain. Resident 8's Medication Administration Record (MAR) for September 2025 was reviewed. LN 1 stated Resident 8 did not receive three doses of scheduled pain medications on 9/19/25 at 11 P.M., 9/20/25 at 5 A.M. and 9/20/25 at 11 A.M. LN 1 stated the pain medication was not available. LN 1 stated Resident 8 had mentioned to her she wanted to go out on a pass but was in pain so she would just stay at the facility. LN 1 stated Resident 8 was in hospice and the hospice facility supplied Resident 8's medications. LN 1 stated it was important to have good communication with the hospice to ensure pain medications were ordered and available. On 9/22/25 at 3:13 P.M., a telephone interview was conducted with the hospice LN (HLN). The HLN stated the facility should have informed hospice when pain medication were running low to ensure the medications were delivered and available. On 9/24/25 at 9:16 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the expectation was to make sure pain medications were available for Resident 8 for pain control and management. A review of the facility's policy titled, Pain Assessment and Management, revised April 2025, indicated, .The medication regimen is implemented as ordered .

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. Random controlled medication (medications with a high abuse potential) use audit for five of six sampled residents (Residents 6, 19, 26, 27 and 52) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR - section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. This failure had the potential for diversion (unlawful distribution or use), mismanagement of controlled medications and inadequate narcotic accountability, healthcare professional clinical decision-making based on an incomplete medical record which could result in adverse resident outcomes, and the potential to not meet the needs of the residents in the facility. 2. Expired medications were not removed from stock in one of one Medication Rooms for two residents (Residents 7 and 29). This failure had the potential for Residents 7 and 29 to receive deteriorated (reduced quality) and ineffective medications. Findings:1. During an inspection of the Long Hall Medication Cart conducted with Licensed Nurse (LN) 6 on 9/21/25 at 3:06 P.M., the CDRs for three random residents receiving PRN (as needed) controlled medications were requested for review. Additionally, three other CDRs from the Short Hall Medication Cart were requested for review on 9/22/25 at 10:31 A.M. from LN 1. a) A review of Resident 27's medical record indicated an order for hydrocodone-acetaminophen (a controlled medication used to manage pain) 5/325 milligram (mg, unit of measurement) tablet - give one tablet by mouth every 4 hours as needed for moderate to severe pain, dated 8/15/25. During a concurrent interview and record review with the Director of Nursing (DON) on 9/22/25 at 1:47 P.M., a review of Resident 27's CDR for hydrocodone-acetaminophen 5/325 mg and September 2025 MAR indicated the nursing staff signed out of the CDR, but did not document the medication administration on one occasion: 9/18/25 at 8:30 A.M. The DON confirmed there was no documentation on the MAR on 9/18/25 at 8:30 A.M. and stated, I've already looked for this one and couldn't find it. b) A review of Resident 6's medical record indicated an order for hydrocodone-acetaminophen 5/325 mg tablet - give one tablet by mouth every 6 hours as needed for moderate to severe pain, dated 1/2/25. During a concurrent interview and record review with the DON on 9/22/25 at 1:51 P.M., Resident 6's CDR for hydrocodone-acetaminophen 5/325 mg, and MARs dated May 2025 and July 2025 were reviewed. The CDR indicated the nursing staff signed out one tablet of hydrocodone-acetaminophen 5/325 mg, but did not document the medication administration on the following days: 5/31/25 at 6 A.M. 7/12/25 at 9 A.M. 7/23/25 at 2:48 P.M. The DON confirmed the lack of documentation in the medical record. The DON stated, I'm not seeing May 31st [2025]. The DON stated, I'm not finding it.neither one of those, regarding the 7/12/25 and 7/23/25 entries. c) A review of Resident 52's medical record indicated an order for oxycodone (a controlled medication used to manage pain) 5 mg tablet - give one tablet by mouth every 6 hours as needed for moderate pain (breakthrough dose), dated 9/13/25.During a concurrent interview and record review with the DON on 9/22/25 at 1:54 P.M., Resident 52's CDR for oxycodone 5 mg and September 2025 MAR were reviewed. Resident 52's CDR indicated nursing staff signed out one tablet of oxycodone 5 mg for administration, but did not document the medication administration on four occasions: 9/19/25 at 5 A.M.9/19/25 at 12 P.M.9/20/25 at 12 A.M.9/21/25 at 12 A.M. The DON confirmed she could not find any documentation of administration on Resident 52's September 2025 MAR for the above dates and times. The DON stated, I looked for those yesterday [9/21/25] and I couldn't find it.d) A review of Resident 26's medical record indicated orders for oxycodone 5 mg tablet, give one tablet by mouth every 4 hours as needed for moderate pain (5-6 level pain out of 10, 0 being no pain and 10 being the worst pain imaginable), dated 9/14/25. Resident 26 also had an order for oxycodone 5 mg tablet - give two tablets by mouth every 4 hours as needed for severe pain (7-10 level pain out of 10), dated 9/14/25.During a concurrent interview and record review with the DON on 9/22/25 at 1:54 P.M., Resident 26's CDR for oxycodone 5 mg and September 2025 MAR were reviewed. Resident 26's CDR indicated nursing staff signed out two tablets of oxycodone 5 mg for administration, but did not document the medication administration on one occasion: 9/20/25 at 5 A.M.The DON confirmed the lack of documentation in the medical record and stated, No, I can't find it either.e) A review of Resident 19's clinical record indicated orders for morphine (a controlled medication used to manage pain), including morphine 100 mg/5 mL (milliliters, a unit of measurement) - give 0.25 mL every 4 hours as needed for mild pain or dyspnea (difficulty breathing), dated 2/20/25 and discontinued on 9/10/25. During a concurrent interview and record review with the DON on 9/22/25 at 2:02 P.M., Resident 19's CDR for morphine 100 mg/5 mL and MARs dated May 2025 and September 2025 were reviewed. Resident 19's CDR indicated nursing staff signed out 0.25 mL of morphine for administration, but did not document the medication administration on three occasions: 5/26/25 at 3:09 P.M.5/27/25 at 9:30 A.M.9/9/25 at 2 P.M. The DON stated, There's nothing documented under the May [2025] MAR at all.I can't find 9/9 [2025] . The DON stated nursing staff were expected to document on the MAR first to ensure the order is correct. The DON stated nursing staff were to document on the CDR after documenting on the MAR and administering the medication. The DON stated the CDR and MAR documentation should match. The DON stated proper documentation was important to avoid drug diversion and to ensure med errors are not occurring and to make sure efficacy of the medication pre and post [administration]. You can't do that if you don't document on the MAR. A review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised 11/22, indicated, .Handling Controlled Substances.4.an individual.controlled substance record is made for each resident who will be receiving a controlled substance.This record contains.h. date received; i. time of administration. 2. During a concurrent observation and interview on 9/21/25, 10:05 A.M., an inspection of the Medication Room was conducted with Licensed Nurse (LN) 17. Multiple expired medications were observed in the medication refrigerator. a) Four boxes of regular insulin (a diabetes medication used to lower blood sugar) prefilled pens (a newer form of packaging the medication as opposed to the traditional vial) for Resident 7. Two boxes had a manufacturer expiration date of 3/18/25 and the other two boxes had a manufacturer expiration date of 7/1/25. LN 17 confirmed the manufacturer expiration dates. LN 17 stated, that's no good.that's something we must've missed. During an interview with LN 17 on 9/21/25 at 11:31 A.M., LN 17 stated Resident 7's family brought in [the four boxes of insulin] last Friday [9/19/25]. LN 17 stated the risks of expired medications include adverse [negative] effects to the resident if meds are expired.[medications] should be checked prior to administration by nurses.too. During an interview with the DON on 9/22/25 at 1:38 P.M., the DON stated, we don't use [residents'] medications from home, but we store them. The DON stated Resident 7's caregiver.will bring in her.insulin. She's not even on that insulin. The DON stated the facility had nowhere else to store the expired boxes of insulin. The DON stated, we have to keep insulin in the fridge and [there's] no other place to put it aside from the med room. A review of the facility's P&P, titled, Medications Brought to the Facility by the Resident/Family, revised 4/07, indicated, The facility shall ordinarily not permit residents and families to bring medications into the facility. b) Two bottles of compounded (customized preparation of a medication) vancomycin (an antibiotic) eye drops for Resident 29 were labeled with an expiration date of 8/28/25. LN 17 verified the expiration date. During an interview with the DON on 9/22/25 at 1:44 P.M., the DON stated nursing staff were expected to immediately destroy expired medications or remove discontinued medications from the refrigerator. The DON stated this process was important because you don't want to have a medication error by giving a drug [medication] that's expired.A review of the facility's P&P titled, Medication Labeling and Storage, revised 2/23, indicated, .Medication Storage.3. If the facility has discontinued, outdated.medications.the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 10.71% when three medication errors occurred out of 28 opportunities during the medication administration for one of seven randomly observed residents (Resident 26). This failure had the potential for Resident 26 not to get the full therapeutic benefit of his medications or to experience negative health outcomes. Findings:During a medication administration observation on 9/21/25 at 9:03 A.M., Licensed Nurse (LN) 1 was observed preparing and administering eleven medications for Resident 26. LN 1 stated Resident 26 received his medications crushed and mixed with applesauce. LN 1 crushed all of Resident 26's tablets individually and mixed each one with applesauce in separate medicine cups, including the following tablet: methadone (a strong painkiller) oral tablet 5 milligrams (mg, unit of measurement) - give 1 tablet by mouth every 8 hours for pain management, dated 9/14/25.LN 1 opened all of Resident 26's capsules (medications that are enclosed in a shell), poured the granules (medicine that is inside capsules) into separate medicine cups and mixed the contents of each medicine cup with applesauce, including the following capsules: duloxetine (a medication used for various psychiatric and neurological conditions) oral capsule Delayed Release (DR, designed to release slowly) Sprinkle 30 mg - give 1 capsule by mouth one time a day for depression (a condition characterized by persistent sadness) AEB (as evidenced by) irritability, dated 9/14/25, and lansoprazole (a medication used to treat heartburn) oral capsule DR 30 mg - give 1 capsule by mouth two times a day for GERD (gastroesophageal reflux disease, acid reflux), dated 9/14/25.During an interview with LN 1 on 9/21/25 at 2:47 P.M., LN 1 verified she opened the duloxetine capsule and mixed the granules with applesauce. LN 1 verified she crushed Resident 26's methadone tablet prior to administration. LN 1 stated lansoprazole was typically given before [a] meal because it's for the stomach. LN 1 confirmed she administered Resident 26's lansoprazole dose in the 9 o'clock hour, which was after breakfast. LN 1 stated breakfast was served around 7:20-7:30 A.M.A review of duloxetine DR capsule drug information, provided by the facility, indicated, Swallow capsule whole; do not crush or chew.A review of the duloxetine DR capsule package insert (PI, document from the drug manufacturer on how to safely and effectively use medications), provided by the facility, indicated, .swallow whole. Do not chew or crush, and do not open the delayed-release capsule and sprinkle its contents on food or mix with liquids because these actions might affect the enteric coating [designed to dissolve in the small intestine instead of the stomach]. A review of methadone tablet drug information, provided by the facility, indicated, Tablets for oral suspension [drug particles in a liquid]: For oral administration only.Do not chew.A review of the methadone PI and medication guide (product labeling information for patients), provided by the facility, indicated, Do not crush, dissolve (the incorporation of a solid into a liquid), snort or inject methadone.tablets because this may cause you to overdose and die.A review of lansoprazole capsule drug information, provided by the facility, indicated, Administer 30-60 minutes before a meal.During a telephone interview with the Consultant Pharmacist (CP) on 9/24/25 at 1:58 P.M., the CP stated duloxetine capsules shouldn't be opened. It should've been given whole. The CP stated that due to the delayed release design, not swallowing it whole can cause increased side effects.reduce[d] effectiveness. Regarding methadone tablets, the CP stated, the manufacturer says you shouldn't crush it because it could lead to.uncontrolled delivery [medication going throughout the body] of methadone. The CP stated, some people crush [methadone] and snort it. They want that extreme high really fast. [Nursing] should not be crushing methadone. When asked about lansoprazole, the CP stated it should be given before breakfast or the first meal [of the day], generally. The CP stated administering lansoprazole that way prevents [stomach] acids from forming. The CP stated he was available to look up meds and tell nurses if a med is crushable or not.A review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed.

Based on observation, interview, and record review, the facility failed to ensure a medication was stored under proper temperature controls in one of one Medication Rooms. This failure had the potential to negatively alter the drug's stability, physical properties (such as consistency) and effectiveness, which could result in adverse resident outcomes.Findings:During a concurrent observation and interview on 9/21/25, 10:05 A.M., an inspection of the Medication Room was conducted with Licensed Nurse (LN) 17. A tube of erythromycin (an antibiotic) ophthalmic (for the eye) ointment for Resident 29 was found in the medication refrigerator, which was 37 F (degrees Fahrenheit, a measurement of temperature). The drug manufacturer's labeling on the medication instructed, store between.59 F to 77 F . LN 17 confirmed the manufacturer's labeling and stated, it would have to be stored outside. During an interview with the Director of Nursing (DON) on 9/22/25 at 1:44 P.M., the DON stated medications have to be stored how [the drug manufacturer] says. The DON stated it was important to follow the drug manufacturer's storage instructions because otherwise, improper storage can mess with the medication.During a telephone interview with the Consultant Pharmacist (CP) on 9/24/25 at 1:58 P.M., the CP stated erythromycin ophthalmic ointment should be stored at room temperature. The CP stated, do not freeze [it] because it makes the ointment too thick or hard to apply. Most likely do not refrigerate.A review of erythromycin ophthalmic ointment package insert (document from the drug manufacturer on how to safely and effectively use medications), provided by the facility, indicated, store between.59 F to 77 F.A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised 2/2023, indicated, The facility stores all medications.under proper temperature.controls.

Based on observation, interview and record review, the facility failed to ensure resident food brought into the facility from outside sources was stored appropriately, and procedures were in place for safe reheating of foods.This failure had the potential to result in pest control concerns, as well as foodborne illnesses.Findings:An observation and interview was conducted on 9/21/25 at 9 A.M. with Resident 24. Resident 24 was sitting in a wheelchair next to her bed. The bedside table was covered with large bags of candy, cookies and other opened food items. A blanket was folded at the foot of the bed, and on top of the blanket was a bunch of ripe bananas and a small brown bag from a fast food restaurant. None of the foods were in plastic bags, and none had labels attached with dates or the resident name and room number. Resident 24 stated the food from the kitchen was sometimes cold, so she had friends and family bring her food from outside to keep in her room. Resident 24 stated the facility had not offered her bins or containers to store her food items. An observation and interview was conducted on 9/24/25 at 12:30 P.M. with Certified Nursing Assistant (CNA) 21. CNA 21 stated if residents wanted to reheat food they had obtained from outside of the facility, the CNA could reheat the food in the microwave. CNA 21 stated she would heat the food for 30 seconds, no matter the food item. CNA 21 stated she did not have instructions for reheating food, and a thermometer was not available to check the temperature of the food. Per CNA 21, she would just heat for 30 seconds then bring the food to the resident to consume. An interview was conducted on 9/24/25 at 12:45 P.M. with CNA 22. CNA 22 stated if residents brought in food from outside, staff should tape a piece of paper on the food item and write the residents' name and room number on it. CNA 22 stated she would also write the date she received the food. An interview with the Registered Dietitian (RD) was conducted on 9/24/25 at 1 P.M. The RD stated instructions for reheating foods should be posted on the resident refrigerator and microwave, and a thermometer should be available to check food temperatures. The RD stated this was important to prevent food related illness, and for food safety. The RD stated she had spoken to Resident 24 and others many times about storing foods safely in the rooms but the residents did not want to let staff touch their belongings. The RD stated there was a risk to the residents from eating spoiled foods, and the facility was responsible for the residents' food safety. An interview was conducted on 9/24/25 at 2 P.M. with the Administrator (Admin). The Admin stated she was not aware foods brought in from home were being reheated without instructions or checking of temperatures. The Admin stated her expectation was for the Dietary Manager (DM) and RD to have established guidance so CNAs could safely reheat foods. The Admin stated she was aware residents stored foods in their rooms, and that this posed a food safety issue and potentially a pest management issue. Per the Admin, no solution had yet been identified. Per a facility policy, dated 2023 and titled Food For Residents From Outside Sources, Food brought in from outside the facility kitchen.will be monitored.Prepared food brought in for the resident must be consumed within one hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter.non-perishable foods such as cookies, cake, crackers, fruit, etc. can be stored in the residents room.with the resident's name and date of storage.If opened, the food must be sealed, dated to the date opened and disposed by the best buy date or 30 days, whichever comes first.Per an undated facility policy, titled Foods Brought by Family/Visitors, .All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices.Food brought by family/visitors that is left with the resident to consume later will labeled and stored.Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded.Per a facility policy, dated 2023 and titled Reheating Food Brought In For A Resident, Resident food brought in from outside the facility will be reheated, if necessary, to 165 degrees for 15 seconds, one time only.

Based on interview and record review, the facility failed to maintain accurately documented records when the wrong blood pressure (BP) reading was recorded on the Medication Administration Record (MAR, an official legal document that has a complete and accurate record of all medications administered to a resident to ensure patient safety) of one out of five sampled residents (Resident 9). This failure resulted in inaccurate documentation in Resident 9's medical records.Findings:During a concurrent interview and record review with Licensed Nurse (LN) 16 on 9/24/25 at 10:53 A.M., a review of Resident 9's clinical records was conducted. Resident 9's clinical records indicated she had active orders for medications, including the following: losartan (a medication for high blood pressure) 25 milligrams (mg, unit of measurement for dose) - give one tablet by mouth one time a day for HTN (hypertension, high blood pressure). Hold if SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110, started 10/1/24, and metoprolol (a medication for high blood pressure) 25 mg - give one tablet by mouth two times a day (9 A.M. and 9:30 P.M.) for HTN. Hold if SBP less than 110 or HR (heart rate) less than 60 ., started 10/1/24.A review of Resident 9's clinical records indicated her BP was 103/59 on 9/18/25, but received her losartan dose and her 9 A.M. metoprolol dose, despite the blood pressure hold parameter in the physician's orders. LN 16 stated nurses measured BP before administering BP medications. LN 16 stated Certified Nursing Assistants (CNAs) also measured BP throughout the day. LN 16 stated, I accidentally inputted the CNAs vital signs (VS, important measurements such as BP, HR, temperature and respiratory rate [breaths per minute]) rather than the one I took. LN 16 stated he took Resident 9's BP before administering her BP medications on 9/18/25. LN 16 handwrote Resident 9's BP on a sheet of paper on 9/18/25. LN 16 read from that sheet and stated Resident 9's BP was 118/68 on 9/18/25 at 9 A.M.During a concurrent interview and record review of Resident 9's clinical records with the Director of Nursing (DON) on 9/24/25 at 1:13 P.M., the DON stated LN 16 took Resident 9's BP before administering her BP medications at 9 A.M. on 9/18/25 and hand wrote the BP. The DON stated the BP recorded electronically on 9/18/25 was taken by the CNA at 11:25 A.M. The DON stated LN 16 did not enter his own BP reading on Resident 9's MAR on 9/18/25, but entered the CNA's BP reading.A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, revised 7/2017, indicated, .3. Documentation in the medical record will be objective.complete, and accurate.

Based on observation, interview and record review, the facility failed to implement proper infection control practices in one of 15 sampled residents (Resident 26). This occurred when Certified Nursing Assistant (CNA) 1 and CNA 2 did not wear proper personal protective equipment (PPE, clothing or equipment, such as gowns, gloves and masks, designed to prevent the spread of infections) while caring for Resident 26, who was on enhanced barrier precautions (EBP, infection control practices designed to prevent the spread of multidrug resistant organisms [MDROs, germs that cannot be killed or inactivated by medications] in nursing homes). This failure had the potential to put residents, staff, and visitors at risk for infections due to cross-contamination.Findings:During a medication administration observation on 9/21/25 at 9:28 A.M., immediately outside Resident 26's room, Licensed Nurse (LN) 1 stated Certified Nursing Assistants (CNAs) were changing Resident 26. LN 1 stated she would give Resident 26 medications after the CNAs were done providing him with care. A sign was observed posted outside Resident 26's door, which read, Enhanced Barrier Precautions [EBP].staff must.wear gloves and a gown for the following high-contact resident care activities.transferring[,] changing linens[,] providing hygiene[,]. CNA 2 and CNA 3 were observed repositioning Resident 26 in a wheelchair. Both CNAs had gloves on, CNA 3 had a mask on, but neither wore a gown. CNA 2 was observed brushing Resident 26's hair and putting a baseball cap on him, while CNA 3 was observed changing linens from Resident 26's bed. CNA 2 was observed without gloves. Resident 26 was observed being transferred out of his room; CNA 2 pushed Resident 26's wheelchair with her bare hands as CNA 3 walked alongside them.During an interview with LN 1 on 9/21/25 at 9:49 A.M., LN 1 stated the EBP sign was for Resident 26 because he has a catheter [a tube used to remove urine from the bladder]. LN 1 stated CNA 2 and CNA 3 should have worn gowns before changing Resident 26's linens and while transferring him. LN 1 stated, they were supposed to gown up.to prevent bacteria from entering him or [CNA 2 and CNA 3] because he has a catheter.During an interview with CNA 2 and CNA 3 on 9/21/25 at 10:01 A.M., CNA 2 stated that because Resident 26 had a catheter, he was on EBP. CNA 2 stated caring for residents on EBP requires staff to gown up usually. That's where we went wrong. CNA 2 stated gowning [wearing gowns] was important to protect ourselves.to protect the patient also.During an interview with the Infection Preventionist (IP) on 9/22/25 at 2:23 P.M., the IP stated staff were expected to wear gloves, gown and a mask when changing linens because there's a chance for things to splash back because there's crumbs and all sorts of things in the bed. The IP stated staff were expected to wear gloves, gown and a mask when transferring a resident on EBP because of the direct contact with the patient. The IP stated PPE was important to wear because without it .infections could.spread throughout the facility.A review of the Centers for Disease Control and Prevention's (CDC, a national agency that provides guidance on public health issues) resource on EBP, titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, indicated, .PPE .refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.A review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, revised 12/2024, indicated, .7. EBPs employ targeted gown and glove use.during high contact resident care activities.c. Face protection may be used if there is a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.c. providing hygiene or grooming.e. transferring.g. changing linens.

Based on observation and review of the Client Accommodations Analysis (document with measurements of the square footage of the useable living space of individual resident rooms and approved capacities), the facility failed to provide the minimum of 80 square feet (sq. ft.) per resident in 4 of 28 resident rooms.This failure had the potential for residents in rooms 2, 4, 6, and 21 to feel cramped and uncomfortable. Findings:The facility's Analysis of Accommodations was reviewed.Resident rooms [ROOM NUMBERS] each accommodated two resident occupancy providing 143 total square feet of space per room. Each room provided 71.5 sq. ft. per resident.Interviews were conducted with the residents of rooms [ROOM NUMBERS] on 9/23/25 at 11:06 A.M. All residents stated their rooms were comfortable and they had no concerns. Resident room [ROOM NUMBER] accommodated three residents, providing a total of 221 sq. ft. of room, with 73.66 sq. ft. of room space per resident.Interviews were conducted with the residents of Rooms 6 on 9/23/25 at 11:09 A.M. All residents stated their rooms were comfortable and they had no concerns. Resident room [ROOM NUMBER] accommodated four resident occupancy providing a total of 304 sq. ft. per room, with 76 sq. ft. per resident.Interviews were conducted with the residents of Rooms 6 on 9/23/25 at 11:14 A.M. All residents stated their rooms were comfortable and they had no concerns. Variations in room size requirements were not observed to adversely affect the resident's health, safety, quality of care or quality of life during the survey.The Department recommends continuing the room size variance/waiver for Rooms 2, 4, 6 and 21.

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for residents residing in the facility when: 1. Hallway floors were taped and with missing floorings, 2. A handrail was observed loose and wobbly. This failure had the potential for residents to trip, fall and sustain injury. Findings: 1. During the initial tour of the facility on 8/20/24 at 8:26 A.M., the hallway floors were observed to have gray duct tape (tape used for general sealing, patching holes, and repairs) to secure the flooring. Multiple duct tapes extended from the flooring in the front nursing station to both hallways of the facility. One hallway had missing flooring in front of room [ROOM NUMBER] which created an uneven surface. a. Resident 30 was admitted to the facility on [DATE] with diagnoses including muscle weakness according to the facility's Admission Record. On 8/21/24 at 9:52 A.M. Resident 30 was observed walking into room [ROOM NUMBER] using a cane. During an interview on 8/22/24 at 7:53 A.M. with Resident 30, Resident 30 stated the tape on the floors was bothersome. Resident 30 stated there was no glue to keep the flooring stable. Resident 30 stated he walked with a cane and made sure he had shoes on to prevent injury. Resident 30 further stated he can get hurt while walking down the hallways. During a review of Resident 30's care plan date initiated on 9/18/23, the care plan indicated, At risk for accidents, FALLS r/t (related to) .unsteady gait . b. Resident 32 was admitted to the facility on [DATE] with diagnoses including history of falling and muscle weakness according to the facility's Admission Record. During an interview and observation on 8/23/24 at 8:25 A.M. with Resident 32, Resident 32 was observed walking in the halls without an assistive device (cane or walker). Resident 32 stated his room was in 21C, just past the area with missing flooring. Resident 32 stated the missing flooring Could be a problem. I get scared. An interview and joint observation was conducted on 8/22/24 at 8:25 A.M. with the maintenance director (MT). The MT observed the missing flooring in front of room [ROOM NUMBER] and the hallway flooring with duct tape. The MT stated the flooring was already taped up when he started in April 2024. An interview was conducted on 8/23/24 at 11:23 A.M., with the Director of Nurses (DON). The DON stated she was aware of the condition of the floors in the hallways and the flooring was a tripping hazard. 2. On 8/22/24 at 7:55 A.M., the handrail outside room [ROOM NUMBER] was observed to be wobbly and with a loose screw to secure the handrail. During an interview and joint observation on 8/22/24 at 8:14 A.M. with CNA 21, CNA 21 stated the handrail outside room [ROOM NUMBER] was loose. CNA 21 stated the handrail could be harmful for residents and staff. CNA 21 also observed the missing flooring outside of room [ROOM NUMBER] and stated the area with the missing flooring was dangerous for staff and residents because of the uneven surface. CNA 21 further stated usually there was a caution sign in the hallway, but none was observed today, 8/22/24. An interview and joint observation was conducted on 8/22/24 at 8:25 A.M. with the MT. The MT observed the handrail outside room [ROOM NUMBER] with a loose screw. The MT stated he did not have a routine schedule to check handrails and was just notified about the broken handrail. The MT stated he should have a schedule to check handrails to prevent injury. During a review of the facility's policy and procedure titled Homelike Environment dated February 2021, the policy indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .

Based on interview and record review the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for 18 days from January 1, 2024 through March 31 of 2024. This failure had the potential for residents and staff to receive inadequate supervision and for residents to not receive an appropriate quality of care. Findings: Review of PBJ Staffing Data Report, CASPER Report 1705 (a report that can helped Skilled Nursing Facilities identify areas for improvement in care and operations) for January 1st through March 31, 2024 indicated ,No RN (Registered Nurse) hours was triggered for 19 days. On 8/23/24 at 9:15 A.M., a concurrent interview with the Staffing Coordinator (SC) and record review of staffing log for January 1st through March 31, 2024 was conducted. SC stated her records indicated the following days did not have an RN scheduled for at 8 least hours: January 1, 6, 7, 8, 20, 28 February 2, 3, 9 10, 11, 24, 25 March 2, 3, 9,10,17 SC stated that staffing numbers for Licensed Nurses (LN) and Certified Nursing Assistants (CNAs) were within limit those days, but they were unable to retain the services of an RN. SC stated facility had no waivers for staffing. SC stated that when they do not have a RN on schedule they have tried to accommodate with more LN's. SC stated they have tried in past to use registry for RNs, but registry can be undependable. SC stated the expectation is the facility should have RN at least 8 hours a day. SC stated the importance of having an RN at least 8 hours a day is to give Intravenous medication (IV-within the vein) and to oversee patient care and safety. On 8/23/24 at 10 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that the facility should have an RN at least 8 hours a day, 7 days a week. The DON stated the importance of having an RN for at least 8 hours a day was for the RN to manage other staff, oversee resident care, insert IV's and give IV medication to residents. Review of the undated facility policy titled Staffing indicated, .Facility provides sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment .4. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by Centers for Medicare and Medicaid Services (CMS- government agency) but no less than once a quarter .

Based on observations, interviews, and record review, the facility failed to prevent medication errors of less than 5% for three of eight sampled residents (Resident 37, Resident 31, and Resident 33) during medication pass observation with three licensed nurses (LN 1, LN 2 and LN 3) when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered (eight medication errors) . 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than three hours (nine medication errors). 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart (one medication error). As a result, there were 18 medication errors and 36 total opportunities during a medication pass observation. The facility's medication error rate was 50%. Cross Reference F760 Findings: 1. A review of Resident 37's admission record indicated Resident 37 was readmitted to the facility on [DATE] with diagnoses which included a history of epilepsy (also known as seizures - uncontrolled jerking, blank stares, loss of consciousness)who required nutritional and medication administration through a G-tube. A record review of Resident 37's MDS (Minimum data set: nursing facility assessment tool) dated 7/29/24 indicated that Resident 37 was unable to participate with a cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) brief interview for mental status and indicated that his cognitive skills for daily decision making was severely impaired (never/rarely made decisions). On 8/21/24 at 8:45 A.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 1, in Resident 37's room. LN 1 administered the following medications to Resident 37 via G-tube: - Benztropine is a medication for extrapyramidal symptoms (EPS- side effects of long-term use of psychotropic [medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior medications] that exhibit a drug induced movement disorder). LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml (milliliters) medication cup and diluted (adding water to help administer medication through a G-tube) with 10 ml of water. Prior to administration LN 1 was unsure which medication she was administrating to Resident 37 because of similar white diluted unlabeled medication cups she had taken to Resident 37's room then mixed all the medication cups with the same G-tube syringe to the other remaining medications to be administered. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10ml of water for the next medication to be administered. The medication cup contained white remnants (undissolved crushed medication particles not administered) remaining in the medication cup. LN 1 stated there were still remnants in the medication cup. - Calcium is a supplement for nutrition. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10mL's of water for the next medication to be administered. The medication cup contained white remnants remaining in the medication cup. LN 1 stated there were still remnants still in the medication cup. - Vitamin D (a supplement for nutrition). LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10ml of water for the next medication to be administered. The medication cup contained light orange remnants remaining in the medication cup. LN 1 stated there were still remnants in the medication cup. - Clonazepam is a medication used to treat anxiety (uneasy feeling), stop seizures or relax tense muscles. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10mL's of water for the next medication to be administered. The medication cup contained white with a light orange eraser tip sized remnants remaining in the medication cup. - MVI (multivitamin) is a supplement for nutrition. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and with 10 ml of water then re-diluted the medication cup with an additional 20 ml of water and re-administered the medication. After administrating the medication, LN 1 continued to flush Resident 37's G-tube site with an additional 10 ml of water for the next medication to be administered. The medication cup contained a golden brown thickened undissolved remnant remaining in the medication cup. - Levetiracetam is a medication for epilepsy management. LN 1 missed medication administration of medication until it was pointed out that medication was not given. LN 1 stated she had forgotten to administer medication because it had clear liquid that she thought had already been administered. LN 1 stated it was important Resident 37 received this medication to prevent seizures. On 8/21/24 at 9:00 A.M., an observation, interview and medication reconciliation record review was conducted with LN 1, in Resident 37's room. LN 1 administered the following medications to Resident 37 via G-tube: - Irbesartan is a medication to manage high blood pressure (BP) and prevent heart complications. Prior to medication administration LN 1 took Resident 37's BP on Resident 37's left wrist with the result of 110/78. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 continued to flush Resident 37's G-tube site with an additional 10 mL's of water for the next medication to be administered. The medication cup contained white remnants remaining in the medication cup. LN 1 stated there were still remnants still in the medication cup. On 8/21/24 at 9:20 A.M., an observation, interview and medication reconciliation record review was conducted with LN 1, in Resident 37's room. LN 1 administered the following medications to Resident 37 via G-tube: - Divalproex a medication for mood stability associated with depression (a constant feeling of sadness and loss of interest). LN 1 opened the capsule (is a small tube that contains powdered or liquid medication) and removed the medication granules and transferred the granules in a clear unlabeled medication cup then added 10 ml's of water then took the medication to Resident 37 to administer the medication. LN 1 used a small plastic spoon to mix the contents of the granules then transferred to the 60 ml syringe for administration. LN 1 stated that the granules in the syringe was getting clogged at the tip and that she was having problems getting the granules down in Resident 37's feeding tube so she removed the syringe and diluted the syringe with an additional 40 ml's of water then attempted to administer again in Resident 37's G-tube. LN 1 stated that there was still resistance to Resident 37's tube and removed the syringe with the medication granules still intact. LN 1 stated she should have used warm water to try and dissolve the granules prior to administration. LN 1 stated the medication cup and the syringe cup still had white undissolved granules along with the 60 ml syringe. On 8/21/24 at 10:00 A.M., an interview was conducted with LN 1. LN 1 stated the medications she administered to Resident 37's G-tube all still had remnants in them. LN 1 stated because the medications were not fully dissolved prior to administering all of Resident 37's medications, Resident 37 did not get the full dosage of his medications. LN 1 stated it was important that Resident 37 get the full dosage of all his medications to manage Resident 37's health complications to prevent seizures, hypertension (high blood pressure), stabilize his anxiety/mood and for nutritional support because Resident 37 relied on the G-tube for medication and nutritional management. On 8/22/24 at 2:04 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that her expectations for medication administration for all residents in the facility is that the medication nurses give medications according to their medication administration policy (right resident, right medication, right dosage, right time, and right route/method). The DON stated it was important to administer medications according to the five rights per policy to prevent complications for example a resident with hypertension to have their BP medications given per Physician's order to manage BP and prevent a hypertensive crisis, stroke, dizziness, anything cardiac related. For depression/psychotropic medications to have the intended therapeutic effects and levels, and seizure medications to prevent seizures. The DON stated prior to administering medications to Resident 37's G-tube, medications should be fully dissolved without remnants to get the complete dosage for the medication's intended therapeutic effects and safety. A review of the facility's policy and procedure titled ADMINISTRATING MEDICATIONS THROUGH AN ENTERAL TUBE undated, indicated, .General Guidelines . 1. Request liquid forms of medications from the pharmacy, if possible. 8. This procedure is contraindicated if the tube is obstructed .9. Dilute Medication . 2. A review of Resident 31's Admission Record indicated Resident 31 was readmitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure (is a long-term condition that occurs when the heart is not able to pump enough blood to meet the body's needs. This can happen when the heart is too weak or stiff to pump properly, or if it can't fill up with enough blood. As a result, blood backs up in the heart, or becomes congested). A record review of Resident 31's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 5/21/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 31 was cognitively (pertaining to memory, judgement and reasoning ability) intact. On 8/21/24 at 9:47 A.M., an observation was conducted in Resident 31's room. Resident 31 was asleep wearing a hospital gown laying in his bariatric (an oversized bed) bed. On 8/21/24 at 12:32 P.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 2, outside of Resident 31's room. LN 2 stated that she missed all of Resident 31's morning medications because Resident 31 was with the rehabilitation (rehab) therapy team. LN 2 stated the following medications were not administered at the scheduled 9 A.M., medication rounds which included: - Metformin an oral medication for diabetes (when the body is unable to control blood sugar in the blood stream leading to circulatory problems that can affect the heart, nerves, kidneys, eyes and cause multi-system complications) management. - Diltiazem a medication to prevent high blood pressure (BP). - Metoprolol Tartrate a medication that helps control BP. - Duloxetine a medication that treats depression (a constant feeling of sadness and loss of interest). - Senna a medication that helps prevent constipation. - Theragram multivitamin a supplement that supports nutrition. - Folic Acid (Vitamin B9) a supplement for nutritional health that can help the body make red blood cells. - Pregabalin medication to help with pain associated to neuropathy (nerve pain). - Magnesium Oxide is a supplement that can help with digestive problems heart burn (burning sensation in the chest associated with gas reflux). On 8/21/24 at 12:41 P.M., an observation and interview was conducted with Resident 31 and LN 2, in Resident 31's room. Resident 31 stated he did not go to rehab in the morning and stated I get rehab at 1 P.M. and complained of a chronic 8 out of 10 shoulder pain but denied a headache. LN 2 stated I must have missed him in the morning then showed Resident 31's electronic medication administration record (MAR) that highlighted resident with the color red. Per LN 2 that Resident 31's MAR showed red to indicate medications were late. LN 2 stated all of Resident 31's 9 A.M., medications were three hours late and was not given on time. LN 2 stated it was important that Resident 31 get all his medications in a timely manner and that three hours was not an acceptable time frame. LN 2 stated Resident 31 was on hypertensive medications with a BP of 177/100 heart rate (HR) 89 and stated Resident 31 had two medications (Diltiazem and Metoprolol) to help control his BP and stated complications could include a hypertensive crisis (a rapid spike in BP that can result in a stroke). LN 2 stated Resident 31 was also on medications for diabetes (Metformin) and stated complications could include hyperglycemia (high blood sugar if left untreated can lead to a decreased level of consciousness). LN 2 stated Resident 31 was also on medication for depression (Duloxetine) and it was important that resident 31 to receive medication to continue the therapeutic effects to manage depressive symptoms. Lastly, LN 2 stated all of Resident 31's ordered medications should have been given timely to prevent complications with nutrition and health. On 8/22/24 at 2:08 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON) on Resident 31's clinical chart. Resident 31's progress note indicated that on 8/21/24 of a BP of 177/100 with a HR of 89 was observed on 8/21/24 during a medication pass observation with LN 1 at 12:41 P.M. The DON stated Resident 31 should have gotten his medications on time and that administering medications three hours late was not acceptable. The DON stated complications from Resident 31 not taking his BP medications on time to include uncontrolled blood pressure and a hypertensive crisis along with diabetic medications were important for the intent of keeping blood sugars stable. The DON stated it was important that meds are administered timely for the medications to continue its intended level of efficacy (effectiveness), safety, and therapeutic effects for health management for any resident's health diagnosis. A review of the facility's policy and procedure titled ADMINISTERING MEDICATIONS undated, indicated, .General Guidelines .7. Medications are administered within (1) hour of their prescribed time . 3. A review of Resident 33's Admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses which included a history of type two diabetes mellitus (when the body is unable to control blood sugar in the blood stream leading to circulatory problems that can affect the heart, nerves, kidneys, eyes and cause multi-system complications). A record review of Resident 33's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 6/18/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 31 was cognitively (pertaining to memory, judgement and reasoning ability) intact. On 8/22/24 at 8:21 A.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 3, in front of Resident 33's room. LN 3 stated Resident 33's Januvia (oral medication to control blood sugar) was not in the medication cart during the reconciliation of medications. LN 3 stated that he would not be able to administer Resident 33's Januvia because it was unavailable. LN 3 stated he was unaware if the medication had been ordered and needed to notify pharmacy to get the medication delivered. LN 3 stated it was important for Resident 33 to receive her Januvia medication for diabetes management and complications could include hyperglycemia (high blood sugar if left untreated can lead to a decreased level of consciousness). On 8/22/24 at 2:04 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that her expectations for medication administration for all residents in the facility is that the medication nurses give medications according to their medication administration policy (right resident, right medication, right dosage, right time, and right route/method). The DON stated it was important to administer medications according to the five rights per policy to prevent complications and for residents safety. The DON stated Resident 33's diabetic medication (Januvia) should be administered to continue the efficacy of the medication and it's intended use to control hyperglycemia and prevent further complications associated with diabetes. A review of the facility's policy and procedure titled ADMINISTERING MEDICATIONS undated, indicated, .General Guidelines .7. Medications are administered within (1) hour of their prescribed time .

Based on observation, interview, and record review, the facility failed to ensure three of eight sampled residents (Resident 37, Resident 31, and Resident 33) were free from significant medication errors when: 1. LN 1 administered medications to Resident 37's gastronomy tube (G-tube: a surgical opening on the abdomen for nutritional and/or medication administration) omitting one medication to be administered and the full dose of medications administered. 2. LN 2 did not administer Resident 31's morning medications (9:00 A.M.) as scheduled for more than 3 hours. 3. LN 3 did not administer Resident 33's Januvia (oral medication that lowers blood sugar) as scheduled due to medication not available in medication cart. As a result, Resident 37, Resident 31 and Resident 33 had the potential for serious health complications to cause discomfort and/or jeopardizes his or her health and safety. Cross Reference 759 Findings: 1. A review of Resident 37's admission record indicated Resident 37 was readmitted to the facility on [DATE] with diagnoses which included a history of epilepsy (also known as seizures - uncontrolled jerking, blank stares, loss of consciousness) who required nutritional and medication administration through a G-tube(gastronomy tube: a surgical opening on the abdomen for nutritional and/or medication administration). A record review of Resident 37's MDS (Minimum data set: nursing facility assessment tool) dated 7/29/24 indicated that Resident 37 was unable to participate with a cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) brief interview for mental status and indicated that his cognitive skills for daily decision making was severely impaired (never/rarely made decisions). On 8/21/24 at 8:45 A.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 1, in Resident 37's room. LN 1 administered the following significant medications to Resident 37 via G-tube: - Benztropine is a medication for extrapyramidal symptoms (EPS-side effects of long-term use of psychotropic [medications that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior medications] that exhibit a drug induced movement disorder). LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml (milliliters) medication cup and diluted (adding water to help administer medication through a G-tube) with 10 ml of water. Prior to administration LN 1 was unsure which medication she was administrating to Resident 37 because of similar white diluted unlabeled medication cups she had taken to Resident 37's room then mixed all the medication cups with the same G-tube syringe to the other remaining medications to be administered. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10 ml of water for the next medication to be administered. The medication cup contained white remnants (undissolved crushed medication particles not administered) remaining in the medication cup. LN 1 stated there were still remnants still in the medication cup. - Clonazepam is a medication used to treat anxiety, stop seizures or relax tense muscles. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 flushed Resident 37's G-tube site with 10mL's of water for the next medication to be administered. The medication cup contained white with a light orange eraser tip sized remnants remaining in the medication cup. - Levetiracetam is a medication for epilepsy management. LN 1 missed medication administration of medication until it was pointed out that medication was not given. LN 1 stated she had forgotten to administer medication because it had clear liquid that she thought that the medication had already been administered. LN 1 stated it was important Resident 37 received this medication to prevent seizures. On 8/21/24 at 9 A.M., an observation, interview and medication reconciliation record review was conducted with LN 1, in Resident 37's room. LN 1 administered the following significant medications to Resident 37 via G-tube: - Irbesartan is a medication to manage high blood pressure (BP) and prevent heart complications. Prior to medication administration LN 1 took Resident 37's BP on Resident 37's left wrist with the result of 110/78. LN 1 crushed the medication in a plastic pill bag than transferred the contents into a clear unlabeled 30 ml medication cup and diluted with 10 ml of water. After administrating the medication, LN 1 continued to flush Resident 37's G-tube site with an additional 10 mL's of water for the next medication to be administered. The medication cup contained white remnants remaining in the medication cup. LN 1 stated there were still remnants in the medication cup. On 8/21/24 at 9:20 A.M., an observation, interview and medication reconciliation record review was conducted with LN 1, in Resident 37's room. LN 1 administered the following significant medications to Resident 37 via G-tube: - Divalproex a medication for mood stability associated with depression (a constant feeling of sadness and loss of interest). LN 1 opened the capsule (is a small tube that contains powdered or liquid medication) and removed the medication granules and transferred the granules in a clear unlabeled medication cup then added 10 ml's of water then took the medication to Resident 37 to administer the medication. LN 1 used a small plastic spoon to mix the contents of the granules then transferred to the 60 ml syringe for administration. LN 1 stated that the granules in the syringe was getting clogged at the tip and that she was having problems getting the granules down in Resident 37's feeding tube so she removed the syringe and diluted the syringe with an additional 40 ml's of water then attempted to administer again in Resident 37's G-tube. LN 1 stated that there was still resistance to Resident 37's tube and removed the syringe with the medication granules still intact. LN 1 stated she should have used warm water to try and dissolve the granules prior to administration. LN 1 stated the medication cup and the syringe cup still had white undissolved granules along with the 60 ml syringe. On 8/21/24 at 10 A.M., an interview was conducted with LN 1. LN 1 stated the medications she administered to Resident 37's G-tube all still had remnants in them. LN 1 stated because the medications were not fully dissolved prior to administering all of Resident 37's medications, Resident 37 did not get the full dosage of his medications. LN 1 stated it was important that Resident 37 get the full dosage of all his medications to manage Resident 37's health complications to prevent seizures, hypertension (high BP), and stabilize his anxiety (feeling uneasy)/mood and for nutritional support because Resident 37 relied on the G-tube for medication and nutritional management. On 8/22/24 at 2:04 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that her expectations for medication administration for all residents in the facility is that the medication nurses give medications according to their medication administration policy (right resident, right medication, right dosage, right time, and right route/method). The DON stated it was important to administer medications according to the five rights per policy to prevent complications for example a resident with hypertension to have their BP medications given per Physician's order to manage BP and prevent a hypertensive crisis (extremely high blood pressure), stroke (brain attack), dizziness, anything cardiac related. For depression/psychotropic medications to have the intended therapeutic effects and levels, and seizure medications to prevent seizures. The DON stated prior to administering medications to Resident 37's G-tube, medications should be fully dissolved without remnants to get the complete dosage for the medication's intended therapeutic effects and safety. A review of the facility's policy and procedure titled ADMINISTRATING MEDICATIONS THROUGH AN ENTERAL TUBE undated, indicated, .General Guidelines . 1. Request liquid forms of medications from the pharmacy, if possible. 8. This procedure is contraindicated if the tube is obstructed .9. Dilute Medication . 2. A review of Resident 31's Admission Record indicated Resident 31 was readmitted to the facility on [DATE] with diagnoses which included a history of congestive heart failure (is a long-term condition that occurs when the heart is not able to pump enough blood to meet the body's needs. This can happen when the heart is too weak or stiff to pump properly, or if it can't fill up with enough blood. As a result, blood backs up in the heart, or becomes congested). A record review of Resident 31's Minimum Data Set (MDS- a nursing assessment tool) dated 5/21/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 15 points out of 15 possible points which indicated Resident 31 was cognitively (pertaining to memory, judgement and reasoning ability) intact. On 8/21/24 at 9:47 A.M., an observation was conducted in Resident 31's room. Resident 31 was asleep wearing a hospital gown laying in his bariatric (oversized bed) bed. On 8/21/24 at 12:32 P.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 2, outside of Resident 31's room. LN 2 stated that she missed all of Resident 31's morning medications because Resident 31 was with the rehabilitation (rehab) therapy team. LN 2 did not administer the following significant medications as ordered during her morning (9 A.M.) medication rounds which included: - Metformin an oral medication for diabetes (when the body is unable to control blood sugar in the blood stream leading to circulatory problems that can affect the heart, nerves, kidneys, eyes and cause multi-system complications) management. - Diltiazem a medication to prevent high blood pressure (BP). - Metoprolol Tartrate a medication that helps control BP. - Duloxetine a medication that treats depression (a constant feeling of sadness and loss of interest). - Senna a medication that helps prevent constipation. - Pregabalin medication to help with pain associated to neuropathy (nerve pain). On 8/21/24 at 12:41 PM an observation and interview was conducted with Resident 31 and LN 2, in Resident 31's room. Resident 31 stated he did not go to rehab in the morning and stated that I get rehab at 1 P.M. and complained of a chronic 8/10 shoulder pain but denied a headache. LN 2 stated I must have missed him in the morning then showed Resident 31's electronic medication administration record (MAR) that highlighted resident with the color red. Per LN 2 that Resident 31's MAR showed red to indicate medications were late. LN 2 stated all of Resident 31'2 9 A.M., medications were three hours late and was not given on time. LN 2 stated it was important that Resident 31 get all his medications in a timely manner and that three hours was not an acceptable time frame. LN 2 stated Resident 31 was on hypertensive medications with a BP of 177/100 heart rate (HR) 89 and stated Resident 31 had two medications (Diltiazem and Metoprolol) to help control his BP and stated complications could include a hypertensive crisis (a rapid spike in BP that can result in a stroke). LN 2 stated Resident 31 was also on medications for diabetes (Metformin) and stated complications could include hyperglycemia (high blood sugar if left untreated can lead to a decreased level of consciousness). LN 2 stated Resident 31 was also on medication for depression (Duloxetine) and it was important that resident 31 to receive medication to continue the therapeutic effects to manage depressive symptoms. LN 2 stated all of Resident 31's ordered medications should have been given timely to prevent complications with nutrition and health. On 8/22/24 at 2:08 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON) on Resident 31's clinical chart. Resident 31's progress note indicated that on 8/21/24 of a BP of 177/100 with a HR of 89 was observed on 8/21/24 during a medication pass observation with LN 1 at 12:41 P.M. The DON stated Resident 31 should have gotten his medications on time and that administering medications three hours late was not acceptable. The DON stated complications from Resident 31 not taking his BP medications on time to include uncontrolled blood pressure and a hypertensive crisis along with diabetic medications were important for the intent of keeping blood sugars stable. The DON stated it was important that medications are administered timely for the medications to continue its intended level of efficacy (effectiveness), safety, and therapeutic effects for health management for any resident's health diagnosis. A review of the facility's policy and procedure titled ADMINISTERING MEDICATIONS undated, indicated, .General Guidelines .7. Medications are administered within (1) hour of their prescribed time . 3. A review of Resident 33's Admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses which included a history of type two diabetes mellitus (abnormal blood sugar in the body). A record review of Resident 33's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 6/18/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 31 was cognitively (pertaining to memory, judgement and reasoning ability) intact. On 8/22/24 at 8:21 A.M., an observation, interview, and medication reconciliation (record review for safety prior to administration of medications) was conducted with LN 3, in front of Resident 33's room. LN 3 stated Resident 33's Januvia (oral medication to control blood sugar) was not in the medication cart during the reconciliation of medications. LN 3 stated that he would not be able to administer Resident 33's Januvia because it was unavailable. LN 3 stated he was unaware if the medication had been ordered and needed to notify pharmacy to get the medication delivered. LN 3 stated it was important for Resident 33 to receive her Januvia medication for diabetes management and complications could include hyperglycemia (high blood sugar). On 8/22/24 at 2:04 P.M., an interview was conducted with the DON. The DON stated that her expectations for medication administration for all residents in the facility is that the medication nurses give medications according to their medication administration policy (right resident, right medication, right dosage, right time, and right route/method). The DON stated it was important to administer medications according to the five rights per policy to prevent complications and for residents safety. The DON stated Resident 33's diabetic medication (Januvia) should be administered to continue the efficacy of the medication and it's intended use to control hyperglycemia and prevent further complications associated with diabetes. A review of the facility's policy and procedure titled ADMINISTERING MEDICATIONS undated, indicated, .General Guidelines .7. Medications are administered within (1) hour of their prescribed time .

Based on interview and record review, the facility failed to provide timely dental services and referral for outside care and treatment for one of three residents (Resident 1). In addition, the facility failed to provide clinical oversight of the social services department to ensure that dental services were being provided. As a result, Resident 1 had experienced tooth pain which lasted for over five months, developed infection of teeth, and was unable to eat the food she enjoyed. Findings: A review of Resident 1 's Admission Record dated 5/8/23, indicated the resident had been admitted to the facility on [DATE] with diagnoses to include end stage heart failure and was receiving palliative care/hospice (comfort care). On 5/4/23 at 2:15 P.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she had tooth pain that had lasted for months and sometimes the pain kept her up at night and she could not sleep. Resident 1 stated, The pain just drives you crazy. Resident 1 stated when the pain got so bad, she had one tooth pulled and it was infected, and she had to go on antibiotics. Resident 1 stated she needed to have all her remaining teeth pulled and to be fitted for dentures. Resident 1 stated when she or her family asked about getting her dental concerns addressed, the facility ' s social worker (SW) 1 would tell her, We ' re working on it. Resident 1 stated the facility was not following up on her dental care needs. Resident 1 further stated she had trouble chewing food because of the pain and missed being able to eat the food she enjoyed. Resident 1 stated she was tired of having soup. On 5/4/23 at 2:45 P.M., an interview was conducted with SW 1. SW 1 stated it was her job to coordinate routine and emergency dental services for the residents and to arrange and facilitate residents ' dental appointments and transportation. SW 1 stated she had been working on Resident 1 ' s dental concerns and referrals and that it had been complicated having to coordinate with hospice, different providers, and insurance issues. A review of Resident 1 ' s clinical record was conducted. Resident 1 ' s progress notes indicated: 10/29/22 Resident 1 complained of having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 11/2/22 Resident 1 was complained of having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 11/15/22 Resident 1 complained of having a toothache. 11/16/22 Resident 1 complained of having a toothache. 1/16/23 Resident 1 ' s daughter met with SW 1 to discuss dental surgery scheduling. The resident ' s daughter reported the dentist provided a referral. SW 1 asked the resident ' s daughter to provide a copy of the referral. 1/18/23 SW 1 informed Resident 1 that nursing was working on scheduling her appointment for hospital dental work. 1/23/23 SW 1 spoke to resident ' s daughter and reminded nursing to schedule appointment for (oral surgeon). 1/25/23 Licensed nurse (LN) called oral surgeon ' s office and was informed they did not accept Resident 1 ' s Medicaid (a state funded program) insurance. SW 1 was notified. 2/8/23 SW 1 received call from oral surgeon ' s office that they do not accept Medicaid. SW 1 would follow up with Resident 1 and her family. 2/10/23 Resident 1 verbalized having a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/17/23 SW 1 discussed Resident 1 ' s dental appointment concerns with the resident ' s family and that the referred oral surgeon did not accept Medicaid. SW 1 and family to find a Medicaid provider. 2/25/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/26/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/27/23 Resident 1 had a toothache. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 2/27/23 Resident 1 went out for a dental appointment. 3/14/23 (Hospice note) Resident 1 reported having tooth pain. 3/20/23 Resident on antibiotics for tooth infection. 3/23/23 Resident complained of tooth pain. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 3/26/23 .Pt [patient] continues to report severe tooth pain. There was no documentation this was reported to the resident ' s physician or the facility ' s dentist. 4/3/23 SW 1 documented she was unaware Resident 1 ' s family scheduled an outside dental appointment for 4/6/23. On 5/5/23 at 2:05 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated she was familiar with Resident 1 and that the resident had been in her assigned section since February 2023. LN 1 stated Resident 1 frequently complained of toothache and mouth pain. LN 1 stated Resident 1 usually complained of tooth pain around lunchtime and that it hurt to chew the food. LN 1 stated Resident 1 received routine Percocet (a strong pain medication that was not prescribed for the resident ' s dental concerns) around lunchtime, and she did not always document when the resident complained of having tooth pain around that time because a routine pain medication was being given. LN 1 stated she did not know what to do when the resident complained about tooth pain because that was considered a dental issue. LN 1 then stated that pain was a nursing concern, and that the resident ' s physician should have been notified. LN 1 stated Resident 1 ' s tooth pain was not a routine dental concern but required emergency dental care. LN 1 stated pain could indicate infection and that needed to be taken care of promptly. LN 1 reviewed Resident 1 ' s progress notes from October 2022 through current date of interview. LN 1 stated when Resident 1 complained of having tooth pain, there was no documentation that the LN had notified the physician or facility dentist. LN 1 further stated Resident 1 had complained of tooth pain since October 2022 and, It ' s been going on too long . LN 1 stated, Toothaches hurt. I wouldn ' t want to go more than a week without having something done about it. On 5/5/23 at 11:16 A.M., a telephone interview was conducted with Resident 1 ' s family member (FM) 1. FM 1 stated Resident 1 first complained of a toothache in October 2022 and that she had reported it to SW 1 and a LN whose name she could not recall. FM 1 stated Resident 1 frequently complained of tooth pain and that it kept her up at night and was throbbing. FM 1 stated the family had to bring soup in for Resident 1 to eat because she could not chew regular food without having a lot of pain. FM 1 stated Resident 1 had not been able to enjoy the food she liked to eat because it hurt to bite down. FM 1 stated it bothered her hearing how often Resident 1 was experiencing tooth pain and the Facility ' s lack of action. FM 1 stated Resident 1 was not a complainer, and it was significant when the resident kept talking to her about the pain. FM 1 stated she began emailing SW 1 in November 2022 in an effort to get Resident 1 ' s dental needs addressed. FM 1 stated Resident 1 ' s jaw and cheek area had been swollen starting around February 2023. FM 1 stated Resident 1 had a toothache for months until the business office manager (BOM) had seen one of her emails to SW 1 in February 2023 when SW 1 was not at work. FM 1 stated the BOM made an appointment to have Resident 1 seen by a dentist in a matter of one day. FM 1 stated she did not understand why SW 1 had been unable to address Resident 1 ' s dental needs for months. FM 1 stated she had accompanied Resident 1 on that February dental appointment where an infected tooth had been extracted. FM 1 stated Resident 1 needed all her remaining teeth extracted. FM 1 stated she had a difficult time getting the facility to assist with this. FM 1 stated due to lack of facility assistance, she had set up an outside appointment for Resident 1 to have all remaining teeth extracted (for 4/6/23). FM 1 stated when Resident 1 got to the appointment they would not see a patient in a gurney. FM 1 stated Resident 1 had to be sent back to the facility unseen by the outside provider. FM 1 stated this was frustrating. FM 1 stated this had gone on for too long and Resident 1 should not have been in pain and discomfort like this for months. A review of email correspondence between FM 1 and SW 1 was reviewed and indicated: 11/7/22, from FM 1, .Can you please provide an update on when the dentist will visit [Resident 1]? She is waiting on a new partial denture and is also experiencing a lot of pain in one of her back teeth right now. 11/8/22, from SW 1, .The dentist will here [sic] tomorrow before 4 pm, and [Resident 1] is first on her list. 1/17/23, from FM 1, .The doctor for [Resident 1], said that you would schedule the appointment at the hospital for her teeth to be taken care of, and the procedure has already been approved. Is there any word on the date yet? 2/22/23, from FM 1, .I have been emailing you [SW 1] since 11/7/2022 trying to get the procedure done for [Resident 1 ' s] teeth. I just received a call from her and she stated she was up all night with a terrible toothache. It ' s not right that she has had this same problem for months and nothing has been done. It would be appreciated if someone at [facility name] could arrange the care she needs as soon as possible as she is in a lot of pain and has been waiting a very long time. (The BOM was included in this email) 2/23/23, from FM 1 to the BOM, .Aren ' t these arrangements for dental care for [Resident 1] a matter that the facility would take care of? I emailed [SW 1] several weeks ago and her last email indicated that she was looking into it. 2/23/23, from the BOM, . Usually yes, the social worker at the facility handles these .Is any dentist that can get her in the soonest preferred? 2/23/23, from FM 1, . The soonest appointment is definitely preferred. [Resident 1] should not have to be up all night with a toothache. Because the matter was not addressed four months ago when I sent the first email, it has now become urgent. 4/26/23, from FM 1, .I just had a 40 minute phone conversation with [state sponsored insurance]. They stated that [facility name] should have a dentist that comes in and takes care of the dental needs of long term patients .If your onsite dentist is unable to provide the care [Resident 1] needs they are required .to provide a referral to someone who can help .The neglect of [Resident 1 ' s] oral care has gone on for an unacceptable period of time. 4/26/23, from SW 1, .Yes the facility has an in house dentist [dentist name], she has seen and evaluated [Resident 1]. [Dentist name] also provided the referral for the hospital doctor for the tooth extractions needed which you are aware . 4/26/23, from FM 1, .I am unaware that any referral that [dentist name] may have provided 6 or more months ago. If she did so, why didn ' t [facility] follow up and be sure [Resident 1] got to an appointment at the hospital for the necessary treatment? Last Saturday one of her teeth actually fell out while she was eating breakfast and she is in a lot of pain every day. Full dentures need to be made for [Resident 1] and an oral surgeon located to remove all her teeth immediately. This has now become an urgent matter. On 5/5/23 at 3:30 P.M., a joint interview and record review was conducted with the director of staff development (DSD). The DSD stated a resident ' s pain, including mouth or dental pain, needed to be addressed right away. The DSD stated Resident 1 ' s tooth pain could have been from infection and that was not appropriate for the social services department to manage. The DSD stated dental pain was considered an emergency dental need and nursing should have been involved. The DSD reviewed Resident 1's progress notes and stated Resident 1 should have been seen right away back in October 2022 when the resident first reported the toothache. A review of Resident 1 ' s Dental Referral Form dated 12/1/22, indicated the facility ' s dentist (DDS) 1 had referred the resident to be seen and treated by an oral surgeon for extraction of all remaining upper teeth and teeth numbered 24, 19, and 18 (specific location of the teeth). The referral also indicated the resident was bedbound and required a gurney. A review of Resident 1 ' s hospice physician ' s letter dated 3/16/23, indicated, .[Resident 1] needs dental treatment in a hospital to extract her teeth. Please work with the family to get this procedure scheduled On 5/23/23 at 3:22 P.M., a telephone interview was conducted with FM 1. FM 1 stated she was unaware DDS 1 had made a referral for Resident 1 to be seen by an oral surgeon on 12/1/22. FM 1 stated they had been given the run around by the facility about insurance issues for Resident 1 ' s needed dental treatment. FM 1 stated the facility did not discuss any problems with Resident 1 ' s Medicaid that would impede the resident ' s access to treatment. FM 1 stated Resident 1 ' s family had the ability to pay cash for the resident ' s needed dental treatment. FM 1 stated the facility did not discuss a cash option to Resident 1 and her family in order to expedite the resident ' s treatment. FM 1 stated the whole thing had taken too long and Resident 1 was in pain. FM 1 stated, She [Resident 1] should be eating tacos by now, and be able to enjoy her favorite food. On 5/24/23 at 8:36 A.M., an interview was conducted with certified nursing assistant (CNA) 2. CNA 2 stated she regularly took care of Resident 1. CNA 2 stated Resident 1 complained about her teeth and mouth pain nearly every meal. CNA 2 stated she did not know how long Resident 1 had been complaining of tooth pain because it had been going on for so long. CNA 2 stated Resident 1 would tell her that it hurt to chew and that she had to eat soup. CNA 2 stated Resident 1 was tired of eating soup. On 5/24/23 at 8:45 A.M., an interview was conducted with CNA 3. CNA 3 stated Resident 1 had complained for a long time about having tooth pain. On 5/24/23 at 8:50 A.M., a joint interview and record review was conducted with the BOM. The BOM stated he recalled being part of a bedside interdisciplinary team (IDT, different facility disciplines) meeting for Resident 1 sometime back in December 2022 or January 2023. The BOM stated during the IDT, Resident 1 ' s family discussed the resident ' s dental concerns and SW 1 had told them she was working on it. The BOM stated arranging dental care, making resident dental appointments, and arranging transportation to dental appointments was managed by the social services department or SW 1. The BOM stated sometime after the IDT, he started getting added to FM 1 ' s emails to SW 1. The BOM stated he had noticed FM 1 complaining about Resident 1 ' s dental pain and It was a lot of pain complaints. The BOM stated when he asked SW 1 about it, she would say she had taken care of the issue. The BOM stated in February 2023, when SW 1 was out, he got involved because Resident 1 ' s issue seemed urgent. The BOM stated it was not his job responsibility but, When a resident ' s in pain, you have to handle it. The BOM stated he had no difficulty and did not encounter any insurance issues and was able to schedule an emergency dental appointment a day or two later for Resident 1. The BOM reviewed resident 1 ' s Dental Referral Form dated 12/1/22 and stated, It shouldn ' t have taken so long to set something up. The BOM stated a reasonable amount of time to coordinate with Resident 1 ' s hospice, insurance, outside providers, and establish an appointment should take no longer than a week. The BOM stated if there were issues with Resident 1 ' s Medicaid, there should have been a care conference and the option to pay cash should have been discussed. The BOM stated toothaches were painful and needed to be handled right away. A review of Resident 1 ' s emergency dental visit documentation dated 5/16/23, indicated, .patient was seen at our office for dental emergency treatment on 02/27/23. Emergency exam 4 periapical [around the root of the tooth] x-rays taken. Patient presented with severe pain lower left posterior # 18. Extensive root and furcation [where tooth root splits into separate parts] decay, tooth is unsalvageable and needs to be extracted . Full thickness flap raised, bone removed DB [debridement, the removal of dead or infected tissue] .I prescribed Flagyl [antibiotic] . Patient was seen again on 3/13/23 for comprehensive oral examination, unsalvageable remaining upper and lower teeth recommend removal of all teeth and fabricate full upper denture and full lower denture. I referred patient to oral surgeon [name omitted], to remove all teeth On 5/24/23 at 10:52 A.M., a joint interview and record review was conducted with DDS 1 by telephone. DDS 1 stated she provided care and treatment to residents in nursing homes. DDS 1 stated she did not perform root canals or complicated extractions and that she would refer the resident to an outside provider if she was unable to provide the care herself inside the nursing home. DDS 1 stated Resident 1 had a partial denture on top that had been attached to broken teeth. DDS 1 stated she examined Resident 1 in August and September 2022, and the resident had no complaints of pain at that time. DDS 1 stated she saw Resident 1 in November 2022, and the resident complained of pain but declined more invasive treatment at that time. DDS 1 stated she saw Resident 1 again on 12/1/22, and the resident had required a root canal and/or extractions and she made the referral on 12/1/22 for the resident to be seen by an oral surgeon. DDS 1 stated the referral had been given to facility staff. DDS 1 stated Resident 1 required treatment in a hospital type of setting due to her medical condition. DDS 1 stated it was her expectation that the facility assisted Resident 1 in making the referral appointment since the resident was not able to do that on her own. Resident 1 ' s emergency dental visit documentation dated 5/16/23, was reviewed with DDS 1. DDS 1 stated Resident 1 ' s #18 tooth had become infected at the root and the dentist removed the infected tissue and prescribed an antibiotic to prevent the spread of the infection. DDS 1 stated the facility had not contacted her about Resident 1 after the 12/1/22 visit and she had been unaware of Resident 1 ' s 2/27/23 outside emergency dental visit. DDS 1 stated she had assumed the referral she made for Resident 1 on 12/1/22 had been carried out timely. DDS 1 stated she had a routine visit to other residents in facility on 4/12/23 and stopped by to see Resident 1. DDS 1 stated Resident 1 refused to be seen because her family was setting up a hospital appointment for her teeth. DDS 1 stated she had been surprised in April 2023, to learn her referral made on 12/1/22 for Resident 1 ' s oral surgery had not been acted upon. DDS 1 stated her referral for Resident 1 on 12/1/22 had not been carried out in a timely manner. DDS 1 stated if the 12/1/22 referral had been carried out the same month it was made, Resident 1 could have avoided further pain and tooth infection. DDS 1 stated one or two weeks was too long to have dental pain. On 5/24/23 at 12:02 P.M., an interview was conducted with Resident 1 while inside the resident ' s room. Resident 1 stated she still had tooth pain and described it as being an on and off pain. Resident 1 stated she was still waiting to have her teeth extracted at the hospital. Resident 1 stated she was told SW 1 no longer worked at the facility. Resident 1 stated, So there ' s no one to take care of it until there ' s a new social worker. Can you believe that? Resident 1 stated, It ' s aggravating. Resident 1 stated lunch was on the way, and it was probably soup again. Resident 1 stated she missed being able to eat tacos. On 5/24/23 at 2:15 P.M., an interview was conducted with the director of nursing (DON). The medical records director (MRD) was also present. The DON stated she had been In the dark about Resident 1 ' s dental issues. The DON stated she was unaware Resident 1 had a dental treatment referral from 12/1/22 that had not been carried out. The DON stated nursing should have been involved with Resident 1 ' s dental concerns since there was pain involved. The DON stated dental pain was a clinical concern and it should not have been managed by the social services department. The DON stated it was her expectation for dental referrals to be carried out in a timely manner. The DON stated while social services could make appointments and arrange transportation, there should have been clinical oversight to ensure dental care and treatment was being provided to the residents. On 5/24/23 at 4:55 P.M., an interview was conducted with the administrator (ADM). The DON and MRD were also present. Resident 1 ' s ongoing dental pain, tooth infection, and not being able to enjoy preferred foods, were discussed with the ADM. The ADM stated he had been unaware of Resident 1 ' s dental concerns and that SW 1 had been let go due to work performance issues. The ADM stated, Moving forward there would be clinical oversight to make sure residents ' dental needs were followed up on. The ADM stated for Resident 1 ' s dental issues to have been unresolved for over five months was weird and it should not have gone on for so long without being resolved. A review of Resident 1 ' s hospital progress note dated 6/2/23, indicated the resident had received oral surgery.[Resident 1] with jaw pain and dental pain . Multiple abscessed teeth [pockets of pus caused by infection], status post surgical extraction teeth . debridement maxilla mandible [upper and lower jaw] by [surgeon ' s name] A review of the facility ' s policy titled Emergency Dental Care revised April 2007, indicated, . 1. Emergency dental care is available on a 24-hour basis. 2. Should a resident need emergency dental care, the dental consultant shall be notified so that arrangements for the emergency care can be made. 3. Social Services shall contact the consultant dentist to set up the appointment . 4. Emergency dental services include services needed to treat an acute episode of acute pain in teeth, gums, or palate [roof of the mouth]; or otherwise damaged teeth, or any problem of the oral cavity appropriately treated by a dentist that requires immediate attention.

Based on interview and record review, the facility failed to protect residents from abuse for one of one resident (Resident 1) reviewed for sexual abuse, when prior employment verification was not conducted on certified nursing assistant 5 (CNA 5) before hiring. As a result, Resident 1 alleged sexual abuse by CNA 5 and the resident complained of vaginal bleeding, pain, difficulty sleeping, and repeated nightmares. Findings: Resident 1 was admitted to the facility on [DATE], per the facility's Admission Record. On 1/13/20 at 2:35 P.M., a concurrent observation and interview with Resident 1 was conducted. Resident 1 was tearful and periodically stopped to cry while being interviewed. Resident 1 stated on the afternoon of 1/10/20, she was outside vaping (nicotine ingestion via an aerosol) in the smoking patio). Resident 1 stated CNA 5 approached her and started to rub her neck. Resident 1 commented, that feels good and CNA 5 stated he knew something that would make her feel better. Resident 1 did not know what CNA 5 meant and she did not comment. Resident 1 announced she was going back inside and left. Resident 1 took a shower in the community shower room, returned to her room, and closed the door. Resident 1 stated her roommate was asleep in the first bed and she was in the bed farthest from the door. Resident 1 stated sometime after 8 P.M., she was lying in her bed, watching TV, with her privacy curtain partially pulled. Resident 1 stated CNA 5 entered her room unannounced and appeared inside her privacy curtain without saying anything. Resident 1 stated CNA 5 had never cared for her before and she did not know why he was in her room. Resident 1 stated CNA 5 suddenly pulled down her red blanket. Resident 1 stated she was shocked and confused and asked him what he was doing. Resident 1 stated CNA 5 told her he was going to make her feel good and he attempted to kiss her, using his tongue. Resident 1 stated she pulled away from CNA 5's face and he covered her mouth with his right hand. Resident 1 stated CNA 5 pulled down her underwear and began jamming his fingers in her vagina, while keeping his other hand over her mouth. Resident 1 stated she scratch CNA 5's left neck. Resident 1 stated she was able to pull her mouth away from CNAs 5 hand and she told him to stop. CNA 5 covered Resident 1's mouth again. CNA 5 told Resident 1 not to tell anyone, because no one would believe her. Resident 1 stated someone knocked on the door and CNA 5 stopped what he was doing and he pulled her red blanket back up, covering her body. CNA 5 left quickly without saying anything. Resident 1 stated she heard a female say something and then CNA 6 appeared inside Resident 1's privacy curtain. CNA 6 asked Resident 1 if she wanted a sandwich. Resident 1 stated CNA 6 saw Resident 1 was crying and CNA 6 asked Resident 1 several times, if she was okay. Resident 1 stated she was so shocked and speechless, so she did not say anything. Resident 1 stated CNA 6 left the room, saying she would come back later to check back on her. Resident 1 stated she called 911 after CNA 6 left. Resident 1 stated she was still in bed, waiting for the police to arrive when she heard someone enter without knocking or saying anything. Resident 1 stated CNA 5 returned to the same side of her bed, which was near the window. Resident 1 stated CNA 5 said, You're going to have an orgasm and you're going to thank me. Resident 1 stated CNA 5 covered her mouth again, pulled down her blanket and yanked on her underwear. Resident 1 stated she felt CNA 5 penetrate her vagina with his fingers and it hurt. Resident 1 stated CNA 5 stopped jamming his fingers into her and then he asked her if she had an orgasm. Resident 1 stated she nodded yes, because she just wanted him to leave. Resident 1 stated before CNA 5 left, he said, Now you feel good, huh. Remember no one will believe you. Resident 1 stated the police finally arrived and they later took her to the hospital for an examination. Resident 1 stated she started having vaginal bleeding that night, along with pain. Resident 1 stated she still had some vaginal bleeding and pain. Resident 1 stated she felt safe now that CNA 5 was no longer in the building. Resident 1 stated the first time CNA 5 was in her room it was about for about three minutes and the second time it was for about 2 minutes. Resident 1 stated her roommate never woke up. On 1/13/20 Resident 1's clinical record was reviewed. Resident 1's Minimum Data Set (MDS-an assessment tool), dated 12/11/19, indicated a Brief Interview for Mental Status (BIMS-a cognitive assessment) score of 15 (score of 13-15 indicates the person is cognitively intact). On 1/13/20, CNA 5's employee file was reviewed. CNA 5 was hired on 9/20/19. CNA 5 listed three previous skilled nursing facilities (SNFs) where he was employed as a CNA between 2017 and 2019. The facility's application requested, At least two professional references. CNA 5 listed four references: two former CNA co-workers, and two private business acquaintances. For CNA 5's professional reference check, Business Office Employee 2 (BOE 2) documented on the facility's Interviewers Comments form, dated 8/29/19, two CNA co-workers were contacted. There was no documented evidence any former employers were contacted. On 1/14/20 at 1:54 P.M., an interview was conducted with CNA 6. CNA 6 stated she and CNA 5 both worked a double shift on 1/10/20. CNA 6 stated for the P.M., shift she was assigned to Resident 1. CNA 6 stated on 1/10/20 after 8:00 P.M., she knocked on Resident 1's door, to offer her and her roommate an evening snack. CNA 6 stated Resident 1's roommate was asleep. CNA 6 saw CNA 5 come out around from Resident 1's privacy curtain and he left the room without saying anything. CNA 6 thought maybe CNA 5 had been in the room to answer a call light and she did not think anything of it. CNA 6 stated when she asked Resident 1 if she wanted a sandwich, Resident 1 had a strange look on her face, which she had never seen before. CNA 6 stated Resident 1 grabbed her forearm and starred at her strangely, without saying anything. CNA 6 stated she asked Resident 1 at least four times if she was all right, and the resident shook her head no and then nodded yes. CNA 6 stated she was concerned, but confused, so she told Resident 1 she would come back later to check on her. CNA 6 stated she left the room, closing the door. CNA 6 stated the police arrived about 30-40 minutes later. On 1/14/20 at 2:25 P.M., a telephone interview with CNA 5 was attempted. CNA 5 stated everything he had to say was in the written statement he gave the facility, the night he was suspended. CNA 5 stated her had nothing additional to add, and instructed me to review his written statement. On 1/14/20 at 3:10 P.M., an interview was conducted with CNA 13. CNA 13 stated he was the scheduled smoking monitor on 1/10/20 for 4 P.M., 6 P.M., and 8 P.M. times. CNA 13 stated he could not recall if Resident 1 was outside smoking that day. CNA 13 stated if Resident 1 was not smoking an actual cigarette, he would not have logged her on the smoking log. CNA 13 stated CNA 5 sometimes does come out and speak with residents on the smoking patio, but he could not remember if CNA 5 was out on the smoking patio on 1/10/20. On 1/15/20 at 8:01 A.M., a telephone interview was conducted with the State of California CNA Board Investigator (CNABI). The CNABI stated CNA 5 had three open investigations involving sexual allegations with residents at other SNFs: one from 2017, and two from 2019. On 1/21/20 at 12:12 P.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she had not been employed by the facility at the time of CNA 5's hire. The DSD stated her current role with applicants was to verify their licensure, order background checks, and check professional references. The DSD stated when references were checked, the reference comments were documented on the facility's Interviewers Comments document. The DSD stated she did not check previous employers unless the DON specifically asked her to. An interview was conducted with the Administrator (ADM) on 1/21/20 at 12:32 P.M. The ADM stated it was best practice to check and verify previous employment before hiring new staff. On 1/22/20 at 11:01 A.M., Human Resource staff (HR 2) from a former employer of CNA 5 was contacted. HR 2 stated CNA 5 was listed as involuntary leave and not eligible for rehire. On 1/22/20 at 11:23 A.M., HR 3 from a former employer of CNA 5 was contacted. HR 3 stated CNA 5 was listed as ineligible for rehire. A subsequent observation and interview was conducted with Resident 1 on 1/24/20 at 3:02 P.M., Resident 1 tearfully stated she was having nightmares and difficulty sleeping because of what CNA 5 did to her. Resident 1 stated she kept playing the incident over and over in her head and, I feel so dirty. Resident 1 stated a psychiatrist recently prescribed her medications to help her sleep and with the recurring nightmares. On 2/3/20, Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .) On 2/4/20 at 10:57 A.M., a telephone interview was conducted with the police Detective (DET). The DET reviewed his notes and stated Resifted 1 complained of vaginal pain before and after the sexual assault. The sexual assault exam revealed vaginal bleeding, along with redness and tenderness on the left interior (inside) vaginal wall. The DET stated the DNA (deoxyribonucleic acid-genetic information) test results would take months. On 2/10/20 at 12:01 P.M., an interview was conducted with Resident 2. Resident 2 stated everyone kept asking her if she heard anything involving her roommate, Resident 1. Resident 2 stated she does not know anything, she was sleeping and all she remembers was her roommate going to the hospital. On 2/11/20, Resident 1's Forensic Medical Report, dated 1/10/20, was reviewed. The sexual assault nurse examiner (SANE) documented Resident 1's external (outside) genital exam included redness, a bruise, and an abrasion. Resident 1's internal vaginal exam included redness and bruising to the vaginal walls. According to the facility's policy, titled Abuse Prevention Program, dated December 2016, As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff 2. Conduct employee background checks

Based on observation, interview, and record review, the facility did not follow it's policy and procedure related to pain management when the licensed nurses failed to ensure 1 of 15 sampled residents (21) with chronic pain and a pressure ulcer (an injury to the skin and underlying tissue) free from pain. As a result, the resident experienced unnecessary ongoing pain during repositioning and wound care treatments. Findings: Per the facility policy and procedure revised (MONTH) 2010, titled Pain Assessment and Management: Purpose. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. and, General Guidelines 1. The pain management program is based on a facility-wide commitment to resident comfort . On 4/28/17, Resident 21 was admitted to the facility with a stage 3 pressure ulcer (an injury to the full thickness of the skin and underlying tissue) and chronic pain, per the Record of Admission. On admission the physician ordered, 1 tablet of Tylenol for mild pain or 2 tablets of Tylenol for moderate pain as needed. On 10/2/17 at 8:35 A.M., during the initial tour of the facility, Resident 21 was observed and interviewed. Resident 21 was lying on her back with the head of her bed raised. Resident 21 had a urinary catheter (a tube inserted into the bladder to drain urine) which drained dark yellow urine and a wound suction device was attached to her. The resident stated, I can't walk. It is hard to get in and out of bed. Resident 21 stated she had chronic pain and the staff did not ask her if she had pain. Resident 21 stated she thought the staff was aware of her chronic pain and how difficult it was to move her arms. Resident 21 also stated her bottom was sore. On 10/3/17 at 3:20 P.M., an interview with the DSD was conducted. The DSD stated Resident 21 needed to be repositioned for the pressure ulcer to be healed. The DSD stated the nurses should have alleviated Resident 21's pain with the Tylenol that was ordered. The DSD stated the nurses should have asked about pain before and after moving or repositioning Resident 21. On 10/4/17 at 3:05 P.M., Resident 21's wound treatment was observed. Prior to beginning the treatment, LN 4 did not inquire if the resident would like to have pain medication before she began the wound treatment. As Resident 21 was moved to her right side she cried, Oh no it hurts!! LN 4 began to spray wound cleanser onto Resident 21's wound. As the wound cleanser was sprayed, Resident 21 cried, Ouch, ooooh! LN 4 ignored the resident's cries and continued to spray the wound cleanser onto wound. After completing the wound treatment and while LN 4 finished attaching the new tubing for the wound suction device, Resident 21 cried, .ouch, ouch, my legs hurt, it hurts! LN 4 never asked the resident what her level of pain was or if she would like to have some pain medication to relieve her pain. LN 4 completed her care and left the resident's room. On 10/4/17 at 3:35 P.M., an interview was conducted with the treatment nurse, LN 4. LN 4 stated Resident 21 had the pressure ulcer wound since admission 4/28/17. LN 4 stated she did not medicate her for pain prior to the wound treatment provided today. LN 4 explained she only medicated the resident for pain if she told her she was in pain. LN 4 stated she provided the majority of Resident 21's wound care and did not remember the last time she had medicated Resident 21 prior to wound treatments she had given. The resident's medical record was reviewed. LN 4 had documented she had provided wound care to the resident on 5/21/17, 7/23/17, 7/26/17, 8/7/17, 8/10/17, and 8/16/17. On 10/4/17 at 4:30 P.M., a joint record review and interview was conducted with LN 2 (the medication nurse). LN 2 stated he could not remember when he had last administered pain medication to Resident 21. LN 2 reviewed Resident 21's record and stated the last time Resident 21 was medicated for pain was 7/2/17. LN 2 stated Resident 21 had received 1 Tylenol tablet at 10:16 A.M. on 7/2/17. LN 2 stated there was an order for [REDACTED]. On 10/5/17 at 11:50 A.M., an interview was conducted with the DON. The DON stated Resident 21's pain should have been assessed every shift and the nurses should have used a pain scale of 1-10 or a non-verbal pain scale if Resident could not verbalize pain. The DON stated she had answered Resident 21's call light when Resident 21 had complained about pain. The DON stated Resident 21 should have received pain medication on many occasions. The DON stated she did not believe 1 tablet of Tylenol over 5 months was adequate pain management for the resident. The DON stated all licensed nurses were responsible for pain assessments and to provide pain medication. The DON stated it should have been myself, the other nurses, and CNAs to report Resident 21 had pain. The DON stated the nurses should have reported Resident 21's pain to her physician. On 10/5/17 at 9:10 A.M., an interview was conducted with LN 9. LN 9 stated she provided the skin treatments to Resident 20 on 5/17/17, 6/11/17, 7/5/17, 7/17/17, 8/1/17, 8/13/17, 8/19/17, 8/22/17, and 8/28/17, when she was the charge nurse. LN 9 stated she did not remember medicating Resident 21 prior to wound care on any of those occasions. LN 9 stated the procedure for pain management was for the wound treatment nurse to tell the medication nurse if the resident needed pain medicine. LN 9 stated she was unsure if the medication nurse or the wound management nurse were responsible for the follow up pain assessments. LN 9 stated most wounds have pain related to them and she believed Resident 21's pain was the reason she did not want to be move. On 10/5/17 at 11:30 A.M., the Medical Director stated staff should have informed both the primary care physician and the wound care physician regarding the resident's pain issues. On 10/5/17 at 4:05 P.M., the facility pharmacist (Pharm 1) was interviewed. Pharm 1 explained when she did her monthly medication regimen reviews, she had not noticed Resident 21 had only been given 1 tablet of Tylenol since she was admitted on [DATE]. Pharm 1 stated Resident 21's lack of using the Tylenol prescribed with no other pain medication prescribed should have been questioned since the resident had a history of [REDACTED]. Pharm 1 stated the resident's [DIAGNOSES REDACTED]. On 10/9/17 at 5 P.M., an interview was conducted with the wound care doctor. The wound doctor stated Resident 21's wound had worsened over the past week. The wound doctor stated the facility staff had not reported Resident 21 had pain, and there was no communication about pain management between himself and the primary care physician. On 10/10/17 at 9:45 A.M., an interview was conducted with Resident 21's primary care physician. The physician stated Resident 21's pain was not reported to her. On 10/10/17 at 10:20 A.M., the DON was interviewed. The DON stated she had not identified pain management as a problem for the resident, and had not noticed the trends and patterns related to pain assessment. On 10/10/17 at 10:30 A.M., the ADM was interviewed. The ADM stated there had been a break down in communication related to Resident 21's care. The ADM stated Resident 21's pain should have been discussed among the direct care staff, the medical director, the physician, and the wound doctor. On 10/4/17 at 4:40 P.M., Resident 20's record was reviewed. Based on a scale of 0 to 10, (0 being no pain to 10 being severe pain) LNs documented on the Weights and Vitals Summary, under the section titled Pain level that Resident 21 rated her pain as follows: Dated Time Pain level 5/26/17 06:42 2 5/26/17 17:27 6 5/27/17 15:43 6 5/29/17 22:58 6 6/8/17 15:50 6 6/6/17 20:50 7 6/12/17 10:12 9 6/13/17 14:41 6 6/26/17 08:42 8 6/21/17 10:06 5 7/7/17 09:51 5 7/12/17 15:42 5 7/18/17 02:41 10 7/24/17 09:46 6 8/1/17 10:49 6 8/27/17 12:06 5 8/27/17 12:06 5 9/10/17 09:57 8 9/11/17 09:57 8 9/19/17 09:42 6 9/26/17 20:52 6 Per Resident 20's Care Plan for Pain dated 4/29/17, .Goal, Will verbalize pain relief 30-45 minutes after pain interventions.Interventions/Tasks, Decrease environmental stimuli as much as possible .medication as ordered, monitor for crying/grimacing/moaning. Per the facility policy and procedure revised (MONTH) 2010, entitled Pain Assessment and Management, .2. Pain Management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment plan. 3. Pain management is a multidisciplinary care process that include the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable regarding care and treatment of [REDACTED]. As a result Resident 21's wound worsened over a 5 month period of time, and Resident 52 developed a pressure ulcer while in the facility. Findings: On 4/28/17, Resident 21 was admitted to the facility with a stage 3 pressure ulcer (an injury to the full thickness of the skin and underlying tissue) of the sacrum (tailbone) which measured 7.5 cm x 3.0 cm x 1.5 cm, generalized weakness, and chronic pain per the Record of Admission. On 10/2/17 at 8:35 A.M., during the initial tour of the facility, Resident 21 was observed and interviewed. Resident 21 was lying on her back with the head of her bed raised. Resident 21 had a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) which drained dark yellow urine and a wound suction device (a hollow tube attached to the skin by a secure dressing and attached to a device which enables vacuum-assisted wound closure). The resident stated, I can't walk. It is hard to get in and out of bed. Resident 21 stated, .no one turns me, and the only time I am moved is when I am cleaned up. Resident 21 stated she had chronic pain and the staff did not ask her if she had pain, but felt they were aware of her chronic pain and how difficult it was to move her arms. On 10/2/17 at 9:05 A.M., an interview was conducted with Housekeeper 1 (HSK 1). HSK 1 stated she had cleaned Resident 21's room on many occasions and had not seen Resident 21 out of her room and only remembered her to be lying on her back. Resident 21 was subsequently observed in the same position lying on her back with the head of her bed raised: 10/2/17 at 12:15 P.M., 2:10 P.M., 3:35 P.M., 4:15 P.M. 10/3/17 at 7:15 A.M., 8:10 A.M., 8:45 A.M., 9:10 A.M. 10/4/17 at 8:35 A.M. On 10/2/17 at 2:20 P.M., an interview was conducted with LN 2. LN 2 stated Resident 21 did not get out of bed due to the wound suction device and it was difficult to reposition Resident 21. On 10/2/17 Resident 21's medical record was reviewed. On 5/11/17, the wound care physician documented on the Surgical Consult the wound measured, 7.0 cm x 2.5 cm x 1.0 cm (wound area total 17.5 cm²). On 5/16/17, LN 7 documented in Resident 21's Nursing Progress Notes, wound had worsened and had foul odor and copious exudate. On 5/23/17, the physician ordered, Wound to Sacrum: Place wound vac at 120 mm/Hg Continuous suction, change every 3 days and PRN soiled or dislodged. Call MD if unable to maintain a seal to wound, as needed for Wound Care Change every 3 days and as needed if dislodged, leaking, or not keeping good seal. And one time a day every 3 days for wound care. On 5/30/17, the wound care physician documented on the Surgical Consult the wound measured, 5.0 cm x 5.0 cm x 3.9 cm (wound area total 19.5 cm²). Per the physician progress notes [REDACTED].stage 4 sacral wound continue local care. On 10/3/17 at 2:05 P.M., Resident 21 was interviewed. Resident 21 stated she was moved only when the staff needed to change her. Resident 21 stated she was not able to turn herself. Resident 21 stated she had not received any education from staff about turning or repositioning. Resident 21 stated the soreness made it hard for her to move because all of her joints hurt. On 10/4/17 at 8:35 A.M., an observation of Resident 21 was conducted. Resident 21's wound suction device was unplugged from the wall and there was no indicator light displayed on the front of the machine. On 10/4/17 at 3:05 P.M., Resident 21's wound treatment was observed. As Resident 21 was moved to her right side by LN 4 (who was the treatment nurse), she cried, Oh no it hurts! LN 4 sprayed wound cleanser on Resident 21's wound. LN 4 stated, .the wound was 4 inches in height, 3.1 inches in width and had a depth of 3.2 inches, (when converted from inches to cm the measurement was 10.16 cm x 7.87 cm x 8.13 cm.) LN 4 further stated she did not document wound treatments in the nurses notes but only initialed the Medication Administration Record [REDACTED] As LN 4 continued to spray the wound cleanser, Resident 21 cried, Ouch, ooooh, LN 4 continued to spray the wound cleanser unto Resident 21's wound. The skin on the resident's bottom was observed to be covered with feces extending approximately 1/2 inch from the wound edges outward. The feces remained on Resident 21's skin even after a new dressing and the wound suction device were applied. As LN 4 connected the new tubing for the wound suction device, Resident 21 cried, .ouch, ouch, my legs hurt, it hurts. LN 4 informed Resident 21 she had a sore on her bottom and said, You have a sore because you are not getting up and you are lying on your bottom all of the time. LN 4 then attempted to turn the wound suction device on and said, The battery is dead, I have to plug it into the wall. Following the observation of wound care, Resident 21's medical record was again reviewed. LN 4 had documented she had provided wound care on 5/21/17, 7/23/17, 7/26/17, 8/7/17, 8/10/17, and 8/16/17. On 10/5/17 at 9:10 A.M., an interview was conducted with LN 9. LN 9 stated she performed the wound treatments for Resident 21 on 5/17/17, 6/11/17, 7/5/17, 7/17/17, 8/1/17, 8/13/17, 8/19/17, 8/22/17, and 8/28/17, when she was the charge nurse. LN 9 stated she had not been trained in the proper use of the [DEVICE]. LN 9 stated she thought the wound was not getting better and the depth of the wound had increased. LN 9 stated she had worked at the facility for 5 years and had not had any training on wound care during her employment. LN 9 further stated only the supervisors of each department met to discuss care for Resident 21 and the direct care staff who assessed Resident 21 had not been invited to the meetings. LN 9 stated she had no formal training by the DSD on wound care or the use of the wound suction device and stated another nurse showed her what to do. LN 9 stated she was not checked off by anyone at the facility regarding use of the wound suction device set up. LN 9 stated the [DEVICE] had been found OFF on several different days and she had plugged it back in. LN 9 stated she was unsure if Resident 21's entire wound suction system would need to be changed if the [DEVICE] was off for a certain amount of time. LN 9 stated most wounds have pain related to them and she believed Resident 21's pain was the reason she did not want to be moved. LN 9 stated Resident 21 was a quiet, pleasant woman who did not want to bother anyone. On 10/5/17 at 11:30 P.M., an interview was conducted with the facility's Medical Director (MD 1). MD 1 stated he was not the physician who treated Resident 21 and was not involved with Resident 21's care. The MD stated he made a recommendation to the Administrator to change the wound care doctor for Resident 21 because there seemed to be no improvement in the wound. The MD stated he was not involved with changing or updating policies and procedures related to wound care for the facility. MD 1 stated the role of the Medical Director was to meet with the Administrator and to provide in-service education to the staff. The MD stated the DON should initiate training for the wound suction device. Per the facility's undated policy entitled, Medical Director, .d. Overseeing and helping develop and implement care-related policies and practices. e. Participating in efforts to improve quality of care and services ., g. Serving as a source of education, training, and information , and 3. Medical Director functions also include, but are not limited to: .b. Acting as a consultant to the director of nursing services in matters related to resident care services. c. Helping assure that residents receive adequate services appropriate to meet their needs. On 10/5/17 at 11:50 A.M., an interview was conducted with the DON. The DON stated there had been no training on wound care or in-services related to Resident 21's wound suction device. The DON stated the wound doctor was changed a few months ago because the wound was not getting better. The DON stated the treatment nurse did not report problems to the wound doctor. The DON stated the depth of the wound increased from 1.9 inches to 3.2 inches. The DON stated the pressure ulcer had worsened after months of treatment. The DON stated she did not ensure nurses had proper training for Resident 21's wound care and the nurses were teaching each other. The DON stated she expected the nurses to properly clean feces off Resident 21's skin prior to applying a clean dressing and had not observed wound treatments, or ensured the treatments and measurements were charted correctly. On 10/5/17 at 3:10 P.M., an interview was conducted with the RD (registered dietician. The RD stated Resident 20's [MEDICATION NAME] levels were not checked upon admission. The RD stated in 2 weeks Resident 21 had lost 20 lbs. The RD stated she was not told the pressure ulcer had worsened. On 10/9/17 at 7:10 A.M., LN 6 was interviewed. LN 6 stated Resident 21 was seldom turned during the night shift. LN 6 stated Resident 21 would frown when being moved. LN 6 stated Resident 21 was connected to a [DEVICE] and that was the reason Resident 21 was not moved. LN 6 stated the pressure ulcer on Resident 21's coccyx did not seem to be healing. LN 6 stated the [DEVICE] had beeped at night, and was found disconnected. The tubing was found kinked, and the battery was low on power. LN 6 stated he found the [DEVICE] to have been unplugged at the beginning of his shifts in the past. LN 6 stated he was not trained on Resident 21's [DEVICE]. LN 6 stated the night shift staff were concerned it might become dislodged if Resident 21 was moved, and they would not know what to do to fix it. On 10/9/17 at 4:30 P.M., an interview was conducted with the DON. The DON stated there was no care plan for the [DEVICE] for Resident 21, and there were no instructions for the licensed nurses on what to do if the [DEVICE] malfunctioned. The DON stated the care plans for Resident 21's wound dressing changes had only been updated one time and was not specific to the individual needs. On 10/9/17 at 5 P.M., an interview was conducted with the wound care doctor (MD 2). MD 2 stated the edges of Resident 21's wound had widened as the skin breakdown worsened from the prior week. MD 2 stated Resident 21's [MEDICATION NAME] levels should have been checked when the resident was admitted to the facility and evaluated by the RD. The RD should have made dietary recommendations to promote wound healing. On 10/10/17 at 8:50 A.M., a joint interview and record review was conducted with the DON. The DON acknowledged the physicians' documentation indicated the wound was not getting better. On 10/10/17 at 9:45 A.M., an interview was conducted with Resident 21's physician. The physician stated Resident 21's pain was not brought to his attention by nursing staff. The physician stated he had not discussed Resident 21's wound with the wound doctor, and the wound doctor never reported any issues about the wound not improving. On 10/10/17 at 10:30 A.M. The ADM was interviewed. The ADM stated there had been a break down in communication related to Resident 21's pressure ulcer. The ADM stated one of the roles of the administrator should be to lead the communication among the medical director, the physician, the wound doctor, and the facility staff. The facility provided a policy and procedure dated 2014, titled Negative Pressure Wound Therapy, General Guidelines, . change dressings per manufacturer guidelines ., the policy provided step by step instructions for dressing changes and use of the [DEVICE]. In addition, the facility was able to provide the manufacturers guidelines / Clinical Manual for the [DEVICE] in use for Resident 21, which also provided step by step instruction LNs could refer to for help. Per the facility policy and procedure, revised (MONTH) 2010, entitled Wound Care, .Documentation, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Per the facility policy and procedure revised (MONTH) 2011,entitled Change in a Resident's Condition or Status, .2. A significant change' of condition is a decline or improvement in the resident's status that: .c. requires interdisciplinary review and or revision to the care plan. 2. Resident 52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 52's clinical record was reviewed on 10/3/17. Per the admission MDS, dated [DATE], Resident 52 had no pressure ulcers (wounds caused by prolonged pressure on a bony prominence, such as tailbone and heels) on admission. Per the Nurse Progress Note, change of condition: skin, dated 9/17/17, the LN documented, Resident noted both reddened heels .keep both heels elevated with pillows. Per the Nurse Progress Note, change of condition: skin, dated 9/24/17, the LN documented, CNA .noticed pressure ulcer on coccyx area, notified charge nurse .stage 2 pressure ulcer. Per the Nurse Progress Note, change of condition: skin, dated 9/27/17, the LN documented, Skin discoloration to left heel 4.5 cm x 3.9 cm (Suspected deep tissue injury, caused by prolonged pressure on the heel). There were no care plans for the aforementioned skin problems in Resident 52's clinical record, until three days after Resident 52 was transferred to the hospital (10/5/17). Per review of (MONTH) (YEAR) TAR, Resident 52 had a treatment administration order for: Menthol-zinc oxide ointment (a medicated skin barrier) to be applied to the perineal/coccyx area topically (on the skin around the tailbone) every shift (3 times a day) for moisture related skin breakdown. The TAR contained three blocks per day (day, eve, and night shift), for the LN to document treatments provided. There were no treatments provided on the following days/shifts: 9/13/17 day shift, eve shift 9/14/17 day shift 9/15/17 day shift, night shift 9/21/17 day shift, eve shift 9/22/17 eve shift 9/23/17 day shift, eve shift 9/24/17 day shift 9/26/17 day shift 9/30/17 day shift, night shift In an interview on 10/9/17 at 10 A.M., LN 4 said she could not say why she didn't initial the TAR for Resident 52's wound treatments, and acknowledged if a treatment was not documented, it was possible the treatment wasn't done. LN 4 said she was not trained to document the skin condition or other information about the treatment provided. In an interview with the DON on 10/9/17 at 3:57 P.M., the DON said, related to treatments, If it's not signed, it wasn't done. Per the facility policy and procedure titled Wound Care, revised (MONTH) 2010, The following information should be recorded in the resident's medical record: The type of wound care given .All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .and, How the resident tolerated the procedure .

Based on observation, interview, and record review, the facility failed to ensure a safe smoking environment for 4 of 4 sampled residents (Residents 1, 2, 3, and 4), including Resident 1, who could not speak. As a result, residents were at risk for injury and/or death due to burns. Findings: On 5/25/16 at 8:40 A.M., the facility was entered. Complaint # CA 288 was initiated with the Director of Nursing (DON). An observation of the smoking area was conducted on 5/25/16 at 8:50 A.M. The smoking area was located on facility grounds, bordered by the facility on the west, a fence on the east side, a closed grated gate on the north side, and open to the parking lot on the south side. The area was about 6 feet by 10 feet in size. There were 4 chairs, 2 sun umbrellas, and a tall ash tray in the area. There were no fire extinguishers, no smoking aprons, no fire blankets, or a call light in the smoking area. Resident 1 was sitting alone, in a wheelchair, smoking a cigarette. Resident 1 pointed to her wrist band when asked her name. Resident 1 nodded to acknowledge she had her own cigarettes, and nodded that she also had her own lighter. Resident 1 nodded her head and reached in her breast pocket and produced the lighter when asked if she could light her own cigarette. Resident 1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 1's most recent Minimal Data Set (assessment of cognitive patterns), dated 5/2/16, indicated Resident 1 was rarely/never understood. On 5/25/16 at 9 A.M., Licensed Nurse (LN) 1 was interviewed. LN 1 stated the residents sign out on the Parkway Hills sign out sheet, located in a binder at the nursing station, when they go out to smoke. Resident 1's sign out sheet was observed with her signature on 2 lines with no date, no destination, no time in or out, and no staff initials of acknowledgement. LN 1 acknowledged the missing information from Resident 1's sign out sheet. LN 1 was given the sign out sheets from Resident 1, Resident 2, and Resident 4, acknowledged the missing information, and proceeded to made copies of the incomplete sign out sheets. At 9:05 A.M., a second observation was made of the smoking area. Resident 1 was still in the area, and Resident 2 had joined her, and was also smoking a cigarette. Resident 2 stated she did not sign out when she came out to smoke. Resident 2 also stated she had her own cigarettes and lighter, and kept them in her room. Resident 2 stated Resident 1 could not speak, but she (Resident 2) could understand her (Resident 1). At 9:25 A.M., an interview was conducted with Resident 4. Resident 4 acknowledged she smokes, and stated she was allowed to have her cigarettes and lighter in her room. Resident 4 acknowledged the process was to sign out before going out to smoke, and she did sign out for the first couple of days (after admission), then stated, now I don't - I have a gown on - I'm not going anywhere. An interview was conducted with LN 1 on 5/25/16 at 9:30 A.M. LN 1 produced a list of 4 residents who reside at the facility who smoke. Resident 1, Resident 2, Resident 3, and Resident 4. On 5/25/16 at 1:05 P.M., Resident 3 acknowledged he possessed his own cigarettes and lighter, and kept them in his room. A record review was conducted on 5/25/16 at 9:50 A.M. Resident 1, 2, and 3, had a Smoking Assessment in the clinical record. No smoking assessment was produced for Resident 4. For Resident 's 1, 2, and 3, question #9, . Facility to store lighter and cigarettes? .Yes was marked. On the 3 assessments, there was no indication if the residents were safe to smoke without supervision. All four residents who smoke had no signed Smoking Agreement in the clinical record. Resident 1's smoking assessment did not indicate the resident was non-verbal. A concurrent interview and record review was conducted with LN 1, at 10:25 A.M. LN 1 acknowledged the Smoking Assessment indicates the facility will store the lighter and cigarettes, and the residents currently have their own supplies in their room. LN 1 stated the assessment was to be done on admission, and quarterly. An observation was made with LN 1 at 10:35 A.M. in the smoking area. LN 1 acknowledged there was no fire extinguisher in the area, there was no fire blanket in the area, and there were no smoking aprons in the area. LN 1 also acknowledged Resident 1, probably couldn't call out for help, if she were on fire. An observation was made with the DON at 10:45 A.M. in the smoking area. The DON acknowledged there was no fire extinguisher, no smoking aprons, no fire blanket in the area, and there was no way to call for help, if needed. The DON stated, I don't think it's safe for them (the residents) to smoke out here. Per the facility policy and procedure, titled, Smoking Policy and Guidelines, dated 10/14/15, Resident will be assessed upon admission for safety to smoke unsupervised A nursing care plan regarding the resident's inability to handle his/her own smoking materials independently . On 5/25/16 at 11:55 A.M., a meeting was held with the Administrator, the Administrator in training, and the Director of Nursing. A determination of Immediate Jeopardy (IJ) was relayed to those present. The determination of IJ was based on Resident 1 was unable to call out for help if needed, and there was no alarm or call bell provided in the area to alert staff. In addition, there was no fire extinguisher, no fire blanket, no smoking aprons, and no supervision by the staff in the smoking area. The residents were not signing out of the facility to go outside the building to smoke. One of 4 residents was not care planned for smoking, 3 of 4 care plans had no information regarding smoking safety or if they could smoke unsupervised. Three of 4 assessments were not updated quarterly. Three of 4 assessments were not accurate, indicating the facility was to store the lighter and cigarettes, and 1 of 4 residents who smoke, had no smoking assessment completed. The facility submitted an acceptable plan of correction (POC) on 5/25/16 at 4:40 P.M. Each item in the POC was observed to be completed before it was accepted. In the plan of correction, the facility immediately changed the location of the smoking area to a patio, in the rear of the facility. In the new smoking area, a fire extinguisher, and 4 smoking aprons were hanging on the wall. Signage was placed on the wall indicating the times supervision would be available for smokers, and who would be performing the supervision. The fire blanket was purchased, and being delivered to the facility. Each resident signed a smoking agreement. Each resident had an updated nursing care plan to include smoking. Each resident had an updated assessment, which included, Is Resident verbal?. A revised facility policy and procedure, titled, Smoking Policy - Residents, .All smoking residents shall have the direct supervision of a staff member during designated smoke break schedule .Smoking materials/paraphernalia are to be kept at the nurses station at all times .to prevent unsupervised smoking. On 5/25/16 at 4:45 P.M., the deficient practice was corrected, and the IJ was removed.