Every finding on record at Pine Lodge

Based on record review and staff interview the facility failed to ensure Resident # 3 was free from neglect. Nurse Aide #137 was assigned to be on one to one supervision with Resident #3 due to multiple falls. NA #137 neglected the resident by leaving the residents room braking the one to one supervision to go to the nurses station to plug up his phone. While he was out of the room Resident #3 got out of bed and fell and sustained a fracture to her facial bones. The neglect perpetrated by Resident #137 resulted in actual harm for Resident #3 when she sustained a [NAME] Fort 1 fracture (A horizontal fracture separating the teeth and hard palate from the upper maxilla. The upper teeth are mobile, but the nose and eyes remain stable). This was true for one (1) of nine (9) residents reviewed for abuse during the long term care survey. This will be cited as past non compliance because the facility identified the failures, identified the harm, and put a plan in place to correct the failures prior to 05/17/26 the first day of this Long Term Care Survey. Resident Identifier: #3. Facility Census: 117. Findings Included: a) Resident #3 A review of a reportable incident dated 11/17/25 indicated an incident occurred on 11/16/25 at 8:25/8:30 PM. The description of the event read as follows, Neglect resulting in fall with a serious bodily injury. Resident noted to have fall on 11/16/25. Upon assessment no injuries observed at this time. Resident was sent to acute setting at 11:20 am on 11/17/25. During the ER (Emergency Room) visit resident was noted to have orbital fracture. The alleged perpetrator was named as NA #137. A review of the five day follow up dated 11/21/26 found a summary which contained the following findings: .Through interviews and documentation, Mrs. (Last Name of Resident #3) had a previous falls and was placed on 1:1 (1 to 1) supervision after returning from the ER on [DATE]. On 11/16/25 CNA (NA #137) assigned to resident 1:1 supervision had left the room and the resident had a fall. On 11/17/25 resident was noted to have a change in condition and the provider was notified and gave order to send resident to the ER. A CT (Computed Tomography) scan was performed. The CT of head was negative for any acute abnormality. CT of the left orbit impression was left inferior wall fracture without CT evidence of entrapment. Fracture about the left lateral maxillary sinus wall. Associated hemorrhage within the left maxillary sinus. Left periorbital facial swelling/contusion. Resident was placed on 1:1 supervision after 11/15/25 fall. Tylenol was ordered and given Mrs. (Last Name of Resident #3) had another change of condition on 11/18/25 and was sent to (Name of Local Hospital) she was sent (Hospital in another state) due to LE fort 1 fracture. The resident had been assigned 1:1 supervision, an unapproved interruption in the delivery of these services occurred. During this period, the assigned Certified Nursing Assistant (CNA) was not in attendance with the resident resulting in a lapse in required supervision. The CNA was removed from duty and placed on suspension pending the outcome of a formal investigation. A new CNA was promptly assigned by the Director of Nursing to resume 1:1 supervision and immediate re education was initiate for staff regarding facility expectations and procedures related to 1:1 supervision. After investigating this occurrence the IDT (Inter Disciplanrr Team) team substantiated neglect resulting in Serious Bodily Injury. CNA suspended and terminated from employment at the facility. Education to be completed with all Nursing Staff on 1:1 supervision Responsibilities. A statement from Nurse Aide #137 was found in the investigation it read as follows: (Name of RN) gave me my assignment of 1:1 with (First and Last Name of Resident #3) At approximately 2030 (8:30 PM) she was getting up to go to the bathroom and I had just left room with her and she started going down to the floor. I contacted Nurse. I had gone to the nurses station to put my phone on charge. She was asleep when I left the room. I didn't think she get up because she was asleep. I was attempting to get some additional information on her is another reason I had left the room. An interview with the Director of Nursing (DON), Nursing Home Administrator (NHA) and the Assistant Director of Nursing on the afternoon of 05/19/26 confirmed this incident did occur. They agreed the nurse aide left the room and the resident fell and sustained fractures to the face. They indicated the completed a plan of correction including education and audits. Facility's Plan of Correction The following was the facility's plan of correction: Event: CNA that was assigned to 1:1 with a resident (related to fall interventions) walked away and the resident obtained a fracture. The CNA was immediately suspended and another staff member was assigned to the resident. Education will provided to employees starting on 11/17/25 to ensure 1:1 is followed per policy. A post test to validate understanding. Any employees not available during this time frame will be provided re- education, including post test upon the beginning of the next shift to work. The Director of Nursing (DON)/ designee will monitor 1:1 events to ensure that 1:1 is being implemented per policy daily for two weeks including weekend and holidays, then 3 times a week for 2 weeks then randomly for 1 week. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or inservices until the issue is resolved, then randomly thereafter as determined by the QIC committee. The surveyor reviewed facility staff education which was all completed by 11/21/25. The daily audit for 1:1 supervision was reviewed they occured daily from 11/17/25 to 11/21/25 and then stopped. The DON was asked about this on the morning of 05/20/26, she stated that is when the 1:1 was discontinued for Resident #3 and no other residents have been placed on 1:1 supervision since. After reviewing the plan of correction and its implementation it was determined the facility was back in compliance beginning on 11/22/25.

Based on observation, record review staff interview and resident interview, the facility failed to provide a safe, comfortable home-like environment by failing to ensure clean bed and bath linens in good condition available for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #31, #78 and #38. Facility Census: 117.Findings included: a) The facility's policy and procedure for Laundry handing and Processing policy stated. Laundry in a healthcare facility may included bed sheets, blankets, towels, personal clothing, patient apparel, gowns, and other linens. Par levels should be maintained to meet the residents' needs. On 05/17/26, the par level for linens were requested by this surveyor. The facility staff were unable to state the par level for this facility. The policy and procedure for Safe and Homelike Environment stated the center must provide: 1.3 Clean bed and bath linens that are in good condition.b) On 05/17/26 at 2:55 PM, the North Hall closet was investigated. Nurse Aide #57 confirmed there were no towels or washcloths available. The South Hall linen closet was investigated at 3:00 PM. The closet contained two (2) towels, ten (10) washcloths and no flat sheets. Nurse Aide #37 confirmed the amount of linen available and reported they have trouble getting linen daily. Nurse aide #37 sated there were daily issues and a problem with linen looking dirty and not clean. At 3:08 PM, the Administrator reported she had called another facility to get more linen.c) On 05/19/2026 at 3:34 AM, the following areas were investigated: South Hall Linen Cart 1 - No washcloths, No blankets, No flat sheets. South Hall Linen Cart 2 - One (1) blanket, No towels. North Hall Linen Cart 1 - One (1) blanket. No towels. North Hall Linen Cart 2 - One (1) towel. No blankets. No flat sheets. On 05/19/26 at 5:02 AM, the linen carts were reviewed and confirmed with the Director of Nursing. d) Resident #31 On 05/17/2026 at 11:50 AM, Resident #31 was observed lying across her bed with no linens. The resident had been served lunch in her bed. Nurse Aide #37 confirmed there were no linens and reported that she had gotten the resident up earlier, but didn't have clean sheets. Registered Nurse #3 confirmed there were no sheets on the bed and the resident had been served lunch. e) Resident #38 On 05/17/26 at 1:00PM, Resident #38 reported the facility runs out of linen and laundry. She stated beds require bedding and that the facility does not keep clean linen. f) Resident #78 On 05/19/26 at 10:00 AM, a Resident Council Meeting was held. Resident #78 reported being bathed by towels when washcloths weren't available and being dried by pillow cases when towels were not available.

Based on record review and staff interview, the facility failed to correctly interpret the results of an investigation related to neglect for Resident #54, #83, #93, and #105. This was true for four (4) of eight (8) residents under the care area of neglect. Resident Identifiers: #54, #83, #93, and #105. Facility Census: 117. a) Facility-Reported Incident On 05/20/2026 at 1:38 PM, a facility-reported incident (FRI) dated 12/11/25 was reviewed. The FRI noted the following, On 12/11/25, Resident #54 alleged to staff that she was not changed all night the night of 12/10/25 into the morning of 12/11/25. The alleged perpetrator Nurse Aide (NA) #139 was suspended pending investigation. Through witness statements and documentation, the assigned CNA (certified nursing assistant) stated that she had changed and checked on Resident #54 multiple times throughout the night. She stated that there were a couple of times that the call light was on and Resident #54 was asleep. She stated that she did still check to see if Resident #54 had been needing to be changed and she was dry. Per her statement, the assigned CNA stated that she last checked Resident #54 at approximately 4 AM and that she was dry and asleep. When day shift CNAs changed Resident #54 later that morning, it was noted that Resident #54 was soaked, however, the urine was not dry. (Typed as written.) All residents with a BIMS (Brief Interview for Mental Status) of 8 (eight) or higher on the staff member's assignment (rooms 127-138) were interviewed regarding the allegations. Through witness statements, three (3) additional residents voiced they had experienced a delay in call light response time that night. Skin checks were performed on these residents. The skin checks showed no new skin impairments. These residents were also asked follow-up questions regarding the incident. These residents voiced that they are comfortable using the call light and notifying the nurse if they are unhappy with their care. These residents also denied experiencing any psychosocial distress following the incident and denied feeling that they were abused and/or neglected by this incident. (Typed as written.) After investigating this occurrence, the IDT (interdisciplanary team) unsubstantiated the allegations due to Resident #54 denying any psychosocial distress following the incident and no skin impairments were noted on the skin check .Three (3) residents on the same assignment voiced that they had experienced a delay in call light response time, however they denied abuse/neglect .Call light audits conducted with no trends noted. Education to be completed with the staff member on customer service and call light response time. (Typed as written.) At this time, the surveyor reviewed the residents' statements. The statement taken from Resident #54 was as follows: I wasn't changed last night after (Name of staff member) changed me at 5 PM until this morning. I don't know who my CNA was, I never saw anyone. I was soaked and my bed was soaked this morning. Signed by Resident #54. (Typed as written.) The following statement was taken from Resident #93. The resident responded to the question of did you have a concern with care over night shift 12/10/25-12/11/25? The resident stated, I didn't see anybody until this morning. The resident responded to the next question, did you receive incontinence/ADL (activities of daily living) over the night shift 12/10/25-12/11/25? The resident stated, Not at all. A statement was taken from Resident #105 with the same questions given to Resident #93. The resident responded, Yes, help was slow and I had to be wet longer. She was by herself. Lastly, the following statement was taken from Resident #83. The same questions were answered. The resident stated, Needed to be changed .didn't get me up at 6AM .didn't change me. An interview was held with Social Services Specialist (SSS) #107 on 5/20/25 at approximately 12:15 PM. The SSS #107 was asked about the incident which took place from 12/10/25 to 12/11/25. SSS #107 was asked, Why was neglect unsubstantiated? SSS #107 stated, The residents denied feeling neglected and they did not have any psychosocial issues. SSS #107 did agree three (3) other residents did express an issue with a delay in call light response time as well as the residents stating, They were not changed in a timely fashion and some hadn't seen anyone all night. SSS #107 stated, I didn't substantiate it because they denied neglect but also denying any psychosocial issues. After reviewing the definition of neglect, and understanding the resident does not need to feel neglected or have any psychosocial issues, SSS #107 confirmed the allegation of neglect should have been verified.

Based upon record review and staff interview, the facility failed to maintain accurate medical records for three (3) residents in the area of Minimum Data Set (MDS), and care plan. Resident identifiers: #2, and #12. Facility census: 117. Findings included: a) Resident #12 A review of Resident #12's medical record on 05/20/25 found she was admitted to hospice services on 06/05/25. A significant change Minimum Data Set (MDS) was completed with an Assessment Reference Date (ARD) of 06/20/25. A review of this MDS found that under Section J1400 Prognosis the following question was answered No: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? Further review of the MDS with an ARD of 06/20/25 found Section O (Special Treatments, Procedures, and Programs), section K1 (Hospice care) was not marked, indicating the resident was not receiving this service even though she was receiving it. An interview with MDS Coordinator #5 and the Director of Nursing (DON) on the afternoon of 05/20/26 confirmed the MDS with ARD of 06/20/25 was inaccurate and needed correction. b) Resident #2 A review of Resident #2's medical record found the resident had an unstageable pressure ulcer present upon her readmission to the facility on [DATE]. A review of the MDS with an Assessment Reference Date (ARD) of 03/17/26 found that under Section M (Skin Conditions), the resident was coded as having one (1) unstageable pressure ulcer under F1. The question F2 read as follows: Number of these unstageable pressure ulcers that were present on admission or reentry? This question was answered with a zero (0). An interview with MDS Coordinator #5 and the Director of Nursing (DON) on the afternoon of 05/20/26 confirmed the MDS with ARD of 03/17/26 was inaccurate and needed correction because the pressure ulcer was present on admission.

Based on record review and staff interview, the facility failed to ensure resident care plans were revised for four (4) residents. The issues included a resident declining assistance with meals, a resident receiving dialysis, a resident preferring to sleep in the dining room and a resident whose discharge status had changed. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #22, #63, and #102. Facility Census: 117. Findings included: a) Resident #5 On 09/20/26, Resident #5's care plan was reviewed. The resident was admitted to the facility on [DATE]. The resident's care plan stated, Resident/patient has potential for discharge, or is expected to be discharged , related to: admission for skilled short-term stay. Possible LTC. Date Initiated: 09/03/24. On 05/21/26 at 8:59 AM, the Director of Nursing confirmed the resident was long term care and the care plan had not been revised. b) Resident #22 On 05/19/25 at 12:45 PM, Resident #22's care plan was reviewed with the Administrator and the Director of Nursing. the Director of Nursing (DON) confirmed the resident's current plan of care and stated, She was supposed to go home. The resident is currently long term care at the facility. The resident's care plan stated, Resident/patient has potential for discharge, or is expected to be discharged related to: admission for skilled short-term stay. Possible long term-care due to being unable to care for self in the community. The resident's admission date was 06/14/24. The resident reported she sleeps in the dining room at night frequently sitting at a table. The resident was observed on 05/19/26 at 2:49 AM asleep in the main dining room by herself with her head on the table and throughout the night including at breakfast. The DON reported at 3:34 AM, She likes to be alone. A Progress noted dated 05/19/26 at 01:45 stated, Resident sleeping in dining room this shift, resident was offered multiple times to have assistance into bed, resident refused, attempted to redirect resident to sleep in her bed tonight, redirection unsuccessful. Resident checked and monitored numerous times, every attempt to return resident to bed to rest unsuccessful. Resident #22's care plan stated, I like to utilize internet on cell phone, lay down/rest, watch TV/movies, by myself inmy bedroom, Date Initiated: 06/21/2024. The resident's care plan had not been revised for frequently sleeping in the dining room. c) Resident #63 On 05/17/26 at 11:40 AM, Resident #63's tray card was reviewed during the lunch meal. The resident's tray card stated, Staff cut food into small bites. Nurse Aide #42 confirmed the resident declined to have his hamburger cut into small bites. On 05/19/26 at 7:30 AM, the resident was observed eating breakfast consisting of pancakes and sausage links. Resident #63 stated, No, I cut my own food. when asked about cutting up his food. Licensed Practical Nurse (LPN) #39 reported the resident frequently refuses to have his food cut into pieces. LPN #39 reported she would look for additional refusal documentation. No further information was provided. On 05/19/26 at 7:45 AM, Resident #63's care plan was reviewed and confirmed with the Assistant Director of Nursing. The resident's care plan stated, Provide Regular/Liberalized diet Regular Texture texture, Standard, Thin liquids consistency, NO straws, cut up large pieces, cut sandwiches in half, double portions as ordered.: the resident's care plan was not updated for declination of cutting food into small pieces. The resident's care plan also stated, NMES applied to laryngeal area during speech therapy targeting CN 10 to improve innervation and excursion needed for improved function. Date Initiated: 01/15/2025. The resident no longer received skilled speech therapy services. d) Resident #102 During an interview with Resident #102 he stated he use to have a fistula in his right upper arm but they had to remove it because it became infected. He stated that his current dialysis port was near his shoulder and motioned toward his right shoulder. When asked if he ever had one in his neck he stated, Yes but itt quit working so they moved it. He stated, They put the new one in when he was in the hospital in April. Furtherer review of the medical record found the resident was readmitted to the facility on [DATE]. A review of the hospital records found they placed a new dialysis access in his right clavicle and removed the one from the Juglar. A review of the residents care plan found the following: Focus statement: Resident exhibits or is at risk for impaired renal function and Immunodeficiency and is at risk for complications related to hemodialysis. This goal was initiated on 01/17/26 Goal: Hemodialysis access will remain patent. Date Initiated: 01/17/26 Resident will not experience any complications related to chronic insufficiency days. Date Initiated: 01/17/26 Interventions included: Monitor dialysis access for +bruit/+thrill q shift and prn Date Initiated: 01/17/2026 PermCath to the right jugular 2 lumens, do not change end caps Date Initiated: 04/30/26 An interview with the Director of nursing on 05/19/26 at 12:05 pm confirmed the resident care plan was not updated to reflect the removal of the fistula and the location of his dialysis access.

Based on record review, staff interview, resident interview and observation, the facility failed to ensure menus were followed as posted and stated on the resident's tray cards. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #31, #67, #68, #17 and #27. Facility Census: 117.Findings included: a) The facility's posted menu for 05/17/26 was as follows: Roasted turkey w/Gravy, Carrots, Oven Browned Potatoes, Dinner Roll or Egg & Sausage Casserole, [NAME] toast-Butter-Jelly, and Vanilla Ice Cream. Tray cards observed varied with vanilla ice cream, mixed fruit and peanut butter pie printed for dessert. The Week at a Glance menu given to the state surveyor for a Regular Liberalized diet stated the resident was to receive vanilla ice cream. The Week at a Glance menu for Therapeutic Lifestyle change stated the resident was to receive fruit sherbet. The facility's policy and procedure for Menu Standards stated, 5. Daily menus will be posted & the Week-At-A-Glance Menu may be used when state regulations require portion size and/or posting of the entire week. b) Resident #31 On 05/17/2026 at 11:50 AM, the resident received chocolate ice cream. The resident's tray card stated peanut butter pie. Registered Nurse #3 confirmed the resident's tray card and that the resident received chocolate ice cream, not vanilla. c) Resident #67 On 05/17/26 at 11:40 AM, the received chocolate ice cream but reported liking strawberry ice cream. Nurse Aide #42 confirmed the resident's tray card stated peanut butter pie, but the resident received chocolate ice cream. d) Resident #68 On 05/17/26 at 11:30 AM, the resident received chocolate ice cream. Nurse Aide #30 confirmed the resident did not receive vanilla ice cream as posted on the menu. The resident's tray card stated mixed fruit cup, but the resident received peaches and chocolate ice cream. e) Resident #17 On 05/17/26 at 11:35 AM, the resident received chocolate ice cream, but her tray card stated vanilla ice cream. Nurse Aide #42 confirmed that the resident's tray card stated vanilla ice cream, but the resident received chocolate. f) Resident #27 On 05/17/26 at 11:42 AM, the resident received chocolate ice cream for dessert, but her tray card stated peanut butter pie. Nurse aide #23 confirmed the resident received chocolate ice cream.

Based on observation, record review and staff interview, the facility failed to ensure food was stored, prepared, distributed, and served in a manner that prevented foodborne illness to the residents. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 117. Findings included: a) On 05/17/2026 at 10:15 AM, the Kitchen Investigation was initiated. The following items were observed by the state surveyor and confirmed by [NAME] #112 at 10:22 AM: -House Recipe Quick Oats - not sealed.-Muffin Mix - opened with use by date 04/26.-Cream Soup Base - opened with use by date 05/15/26.-Iced over freezer chest (Good Humor) containing ice cream with two (2)- three (3) inches of ice inside the entire chest. b) On 05/17/2026 at 10:25 AM, the following items were found and confirmed by [NAME] #112: -Eight (8) boxes piled in the floor by the door with trash in the top box (containing gloves and wrappers).-Pieces of paper and dirty floor in the dry storage room. c) On 05/17/26 at 10:36 AM, the following items were observed by the state surveyor and confirmed by [NAME] #112: -Water inside four (4) clean adaptive cups on a cart ready for lunch.-Two (2) dirty carts with spills and crumbs with clean adaptive equipment on one of the carts were observed.-Sandwich bread - opened and not labeled. [NAME] #112 stated the carts were Ready for lunch. d) On 05/17/26 at 10:31 AM, the following item was observed by the state surveyor and confirmed by [NAME] #123: -Salad Mix - use by date 05/14/26 - opened and brownish in color. e) On 05/17/26 at 10:35 AM, the following items were observed by the state surveyor and confirmed by [NAME] #123: -Box of hamburgers buns - opened and on the freezer floor.-Pepperoni slices -opened and not labeled. [NAME] #123 stated, I can't pick it up. referring to the box of hamburger buns. f) On 05/17/26 at 10:40 AM, the following items were observed by the state surveyor and confirmed by [NAME] #112: -North and South igloo coolers (blue and white) were dirty with a sticky substance that rubbed off. [NAME] #112 reported the coolers were used for snacks. g) On 05/19/26 at 6:55 AM, [NAME] #112, confirmed the handles in a untensil storage container were not all facing the same direction. h) The facility's policy and procedure for Refrigerated/Frozen Storage stated, Refrigerator 1.4 All foods are labeled and dated with the name of the product, date opened, and use by date. The policy for the Freezer stated, 2.5 Foods are kept in their original containers. If removed from the original container, foods are completely covered and labeled with the name of product and use by date. and 2.6 Freezers are kept clean and organized. Cleaning is routinely scheduled and completed.

Based on observation and staff interview, the facility failed to ensure garbage and refuse were disposed of properly in the kitchen. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 117. Findings included: a) On 05/17/2026 at 10:15 AM, the Kitchen Investigation was initiated. Eight (8) boxes were plied on the floor by the kitchen door. The top box contained included gloves and wrappers. Torn pieces of paper were on the floor in the dry storage room. The garbage and refuse were confirmed by [NAME] #112 at 10:25 AM.

Based on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #62's Physician Order for Scope of Treatment (POST) form, a transfer form for Resident #13, accurate weights for Resident #15. This was true for three (3) of 33 residents reviewed during the survey process. Resident Identifiers: #62, #13, #15. Facility Census: 117.Findings Include: a) Resident #62 On 05/17/26 at 11:45 AM, the POST form was reviewed for Resident #62. The review found the signature of the resident representative was not dated. On 05/18/2026 at 12:02 PM , the Assistant Director of Nursing (ADON) #51 confirmed the resident representative's signature was not dated. b) Resident #13 On 05/19/26 at 6:00 AM, a record review was completed for Resident #13. The review found the resident had been sent to an acute care facility on 02/25/26. However, the date on the transfer form was 06/17/25, which was incorrect. On 05/19/26 at 6:16 AM, the Director of Nursing (DON) confirmed the date was incorrect on the transfer form. c) Resident #15 The facility's policy and procedure for Weights and Heights stated, 2. If the body weight of a patient is not expected, re-weigh the patient. An Inaccurate medical record for weights with an 40.8 pound (lbs.) weight gain in one (1) week was documented. On 05/04/2026, the resident weighed 114.2 lbs. On 05/11/2026, the resident weighed 155 lbs. which is a 35.73% Gain. On 05/18/26 at 12:00 PM, the Director of Nursing (DON) confirmed the resident's weights and the 40.8 pound weight gain. The DON reported the Assistant Director of Nursing (ADON) had more information on the weights. On 05/19/26 at 5:15 AM, the Assistant Director of Nursing confirmed the weight documented and stated, I didn't catch it until you guys asked for it.

Based on observation, resident interview, and staff interview, the facility failed to maintain an infection control program during medication administration for Resident #53 and #62, cleanliness for the East and [NAME] shower rooms, and the facility laundry room. These were random opportunities for discovery. Resident Identifiers: #53, #62. Facility Census: 117.Findings Include: a) Medication Administration On 05/19/26 at 8:00 AM, medication administration was being observed for Resident #53 completed by Licensed Practical Nurse (LPN) #13. When LPN #13 started to obtain the medication for Resident #53, hand hygiene was not completed prior to pulling the medication. Prior to completing an accucheck for the blood sugar level, no hand hygiene was completed. After the accucheck was completed hand hygiene was not completed. Upon returning to the medication cart, LPN #13 cleansed the glucometer with a sani-wipe. No hand hygiene was completed after cleansing the glucometer. On 05/19/26 at 8:15 AM, LPN #13 began pulling medication for Resident #62. After administering Resident #62's medication, the resident asked LPN #13 to brush her hair. LPN #13 did brush the resident's hair as requested. On 05/19/26 at 8:22 AM, LPN #13 left the resident's room. No hand hygiene was completed. The breakfast trays arrived on the hall. At this time, LPN #13 began passing breakfast trays and hand hygiene was not completed. On 05/19/26 at 8:35 AM, LPN #13 was advised about the observations when hand hygiene should have been completed. LPN #13 stated, okay. On 05/19/26 at approximately 8:45 AM, the Director of Nursing (DON) was notified and confirmed hand hygiene should be completed during medication administration as well as when passing meal trays. b) Shower rooms On 05/17/26 at 2:57 PM, the East shower room was toured. The tour found the trash overflowing into the floor, bagged dirty linen spilling into the floor from a trash can, and dirty, brown floors. On 05/17/26 at 2:58 PM, Nurse Aide (NA) #106 confirmed the trash was overflowing and the dirty linen was spilling into the floor from a trash can. NA #106 verified the floor were dirty. On 05/17/26 at 3:05 PM, the [NAME] shower room was toured. The tour found the trash overflowing into the floor, bagged dirty linen spilling into the floor from a trash can and dirty, brown floors. On 05/17/26 at 3:07 PM, NA #41 confirmed the trash was overflowing, the bagged linen was spilling into the floor and the floors were dirty. On 05/17/26 at 3:08 PM, the Administrator was notified and stated, we will get this cleaned up right away. c) Laundry room On 05/17/26 at 3:08 PM, a tour of the laundry room was completed. The Administrator entered the laundry room approximately one (1) minute after the Surveyors entered. The clean side of the laundry room was found to have dirty floors, a torn brief in the floor as well as a dirty linen cart. On 05/17/26 at 3:10 PM, the dirty side of the laundry room was found to have a dried, brown substance on the floor as well as dirty floors. On 05/17/26 at 3:20 PM, the Administrator stated, I'll get this taken care of right away.

Based on record review, resident interview and staff interview, the facility failed to provide dependent residents with necessary activities of daily living (ADL) for Resident #62's nail care. This was true for one (1) of three (3) residents reviewed under the care area of ADLs. Resident Identifiers: #62. Facility Census: 117.Findings Include: a) Resident #62 On 05/17/2026 at 12:30 PM, an initial interview was held with Resident #62. The resident stated, Look at my nails, they need cut. At this time, the resident's nails were observed to be long and in need of filing. On 05/18/26 at 9:15 AM, the resident was observed in her room. At this time, the nails remained long. On 05/19/26 at 4:45 PM, the Director of Nursing (DON) stated, I think they trimmed them yesterday but let me check. Activities usually does the nail care .they are going to start doing manicures once or twice a month. The DON did confirm the nail care should have been provided by the Activities department. The DON did not confirm at this time if the nails had been trimmed. On 05/20/2026 at 10:00 AM, an observation of Resident #62's finger nails appeared to be trimmed and filed.

Based on observation, resident interview and staff interview, the facility failed to ensure an accident-free environment, of which it has control, for storage of medication for Resident #10. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 117.Findings Include: a) Resident #10On 05/17/26 at 12:10 PM, an initial interview was held with Resident #10. An observation of two (2) inhalers and a medication cup containing one (1) TUM at the bedside. At this time, the resident was asked, Do you keep medication at the bedside? The resident responded, I haven't taken them yet .I was getting dressed and putting lotion on. On 05/17/26 at 12:13 PM, Licensed Practical Nurse (LPN) #75 was asked to come into the resident's room. LPN #75 was asked, Is this resident supposed to have medication at bedside? LPN #75 stated, My bad. On 05/17/26 at approximately 12:30 PM, the Director of Nursing (DON) was notified of the medication at the bedside. The DON stated, Medication is not supposed to be at bedside.

Based on observation, record review and staff interview, the facility failed to ensure oxygen therapy was maintained for Resident #124 and #15. These were random opportunities for discovery. Resident Identifers: #124 and #15. Facility Census: 117,Findings Include: a) Resident #124 On 05/17/2026 at 12:10 PM, an initial interview was conducted with Resident #124. An observation of the oxygen concentrator found the humidy bottle was empty. An interview was held with Licensed Practical Nurse (LPN) #75 regarding the oxygen therapy and the humidity bottle on 05/17/26 at 12:13 PM. LPN #75 stated, let me go get a new bottle .it should be on there. On 05/17/26 at approximately 2:00 PM, the Administrator was notified. The Administrator confirmed the humidy bottle should not be empty if used with oxygen therapy. b) Resident # 15 During the initial surveyor process, Resident #15 reported she was on four (4) liters of oxygen and she had difficulty breathing at times. The resident's oxygen concentrator was set on 3.5 liters upon observation. Licensed Practical Nurse (LPN) #22 reported she thought the resident as ordered 3.5 liters. LPN #22 confirmed the order for oxygen and stated, It is four (4). and It was a hair under. Resident #15's order stated, Oxygen at 4 L/min via Nasal Cannula continuously. every day and night shift for COPD. The resident's care plan stated, Administer Oxygen as ordered/indicated. The facility's policy and procedure for Oxygen Therapy Administration stated, 17.1 Open oxygen source and set flow rate on the flow meter to achieve the prescribed flow rate or fraction of inspired oxygen (FiO2).

Based on record review and staff interview the facility failed to ensure a medication used in dialysis patients to help decrease the phosphate levels in a residents blood which was ordered to be given outside of the recommened dose or freqency was given only after consultation with the dialysis provider. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey. Resident Identifier: #102. Facility Census: 117. Findings included: a) Resident #102 A review of Resident #102's medical record found he was discharged to the hospital on [DATE] and returned on 04/28/26. A review of the physician orders found a physician order for Sevelamer Carbonate Oral Tablet 800 MG (Sevelamer Carbonate) (Generic for Renvela): Give 1 tablet by mouth with meals for Hyperphosphatasemia, starting 01/17/26. This was the current order when the resident was sent to the hospital on [DATE]. Upon his readmission to the facility the following order was entered into the medical record: Renvela Oral Tablet 800 MG (Sevelamer Carbonate) Give 3 tablets by mouth one time a day for CKD (Chronic Kidney Disease). Start Date: 04/30/26. According to the Renevla Patient information Site the following pertains to this medication: Renvela(R)IndicationRenvela(R) (sevelamer carbonate) is used to control phosphorus levels in adults and children 6 years of age and older with chronic kidney disease (CKD) on dialysis.Important Safety InformationDo not use Renvela if you have a history of bowel obstruction or if you are allergic to sevelamer carbonate, sevelamer hydrochloride, or to any of the ingredients in Renvela.Talk to your doctor if you have had difficulty swallowing or swallowing disorders; or if you have had digestive tract surgery or other digestive disorders, including severe constipation.The most common side effects with sevelamer include vomiting, nausea, diarrhea, indigestion, abdominal pain, flatulence, and constipation.Cases of hypersensitivity, itching, rash, stomach pain, bleeding gastrointestinal ulcers, colitis, ulceration, necrosis, fecal impaction and less commonly, slow bowel activity, bowel obstruction, and bowel perforation have been reported.Cases of difficulty swallowing the Renvela tablet have been reported. Talk to your doctor if you have difficulty swallowing medicines in tablet form. Renvela powder for oral suspension may be considered by your doctor if you have a history of difficulty swallowing.Your doctor should monitor bicarbonate and chloride blood levels.Reduced vitamins D, E, and K (clotting factors) and folic acid blood levels may be followed by your doctor.Talk to your doctor when taking sevelamer with other medications.Promptly contact your doctor if you experience severe abdominal pain, new or worsening constipation, or other severe intestinal symptoms while on sevelamer.Take sevelamer with meals and adhere to your prescribed dietThis order is outside of the recommended dose or frequency.Renvela Oral Tablet 800 MG (Sevelamer Carbonate) Give 3 tablet by mouth one time a day for CKD- The frequency of daily is below the usual frequency of 3 to 4 times per day.Provider aware.This note was entered into the medical record on 04/29/26 at 2:05 PM. An interview with the Director of Nursing (DON) on the afternoon of 05/19/26 confirmed the medication was only ordered for one time daily upon his readmission to the hospital because the hospital had sent that order back on the discharge summary. When asked if it had been clarified with his physician at dialysis she indicated it had not. She stated, We will get it clarified.

Based on record review, observation and resident interview, the facility failed to ensure a diet was provided that took into the consideration the resident's preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #22. Facility Census: 117. Finings included: a) Resident #22 - On 05/19/26 at 7:25 AM, Resident #22 was observed in the dining room and was not eating her breakfast. The resident stated she received cornflakes and did not like them and would not eat them, The resident reported she disliked hard boiled eggs. The resident's Tray Card stated, 2 bowls of fruit loops (with 'out' handwritten), NO EGGS or pork. and Assorted fruit juices - 8oz. The resident was served cornflakes, two (2) boiled eggs and no juice. Following surveyor intervention, the resident received two bowls of fruit loops since the delivery truck had just run. Registered Nurse #5 confirmed the resident's tray card and the food the resident was served. b) The facility's policy and procedure for Dining Service Standards stated, 8.1 Meal Selection: meal selection is done by pre-selected menus, point-of-service choice, or resident preference driven selection.

Based on observation, record review and staff interview, the facility failed to ensure residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #31 and #68. Facility Census: 117.Findings included: a) Resident #31 On 05/17/2026 at 11:45 AM, during the initial investigation process, Resident #31's lunch tray and tray card were observed. The resident's tray card stated, Large portions for meals. The resident did not receive large portions. Registered Nurse #3 confirmed the resident received a regular size serving of food on her tray. The resident's care plan stated, Resident is of nutrition concern related to potential for inadequate po intake, GERD. The resident's diet order stated, Regular/Liberalized diet, Regular Texture texture, Standard Thin Liquids consistencyLarge portions. b) Resident #68 On 05/17/26 at 11:30 AM, Resident #68 was observed in the dining room at the lunch meal. the residents tray card stated, Large Protein. The resident was served a regular size portion of protein. Nurse Aide #30 confirmed the resident did not receive a large portion of protein. The resident's care plan stated, Provide Consistent Carbohydrate (CCD) diet, Regular Texture texture, Standard Thin Liquids consistency small carb portions/large protein portions, fruit instead of dessert diet as ordered. The residents diet order stated, Consistent Carbohydrate (CCD) diet Regular Texture texture, Standard thin Liquids consistency, small carb portions/large protein portions, fruit instead of dessert.

Based on observation, record review, resident interview and staff interview the facility failed to provide a safe, clean, comfortable home like environment by not taking reasonable care to protect residents personal property from loss, and by not ensuring comfortable temperatures in the dining area. This failed practice was found true for (1) one of (3) three residents reviewed for personal property and was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #108. Facility census 113. Findings Include: a) Resident #108 During the initial interview on 06/16/25 at 12:19 PM, Resident #108 stated, I came here in march and some of my stuff is still missing. They say the washing machine is broken and that it will be down for 6 months. They say they are looking for my stuff, but how long do I have to wait? A review of the Grievance Log on 06/17/25 at 8:30 AM, revealed a grievance filed by Resident #108 dated 06/05/25 and reads that Resident #108 was missing the following items: Size large red polo golf shirt, Short sleeve large charcoal shirt, Gray t-shirt short sleeve size large, 3 pairs of shorts size large black, navy blue, and brown. All Boxer briefs, Reebok brand, and white [NAME] crew socks. The grievance read that the issue would be resolved by 06/10/25. During an interview, on 06/17/25 at 9:30 AM, Social Service Specialist (SSS) #72 stated, We looked for his things. No we have not replaced them yet, because the washer has been down and we were so backed up in laundry we were waiting for it to get caught up to see if it was in there. The SSS further confirmed that the grievance was to be resolved by 06/10/25 and had not.

Based on record review and staff interview, the facility failed to ensure the resident's right to formulate an advanced directive. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #111 and #65. Facility Census: 3. Findings included: a) Resident #111 On 06/16/25 at 02:38 PM, Advanced Directives were not found on the electronic chart for Resident #111. The resident was coded as a Full Code. On 06/17/25 at 9:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on the medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code. b) Resident #65 On 06/16/25 at 4:14 PM, Advanced Directives were not found on the electronic chart for Resident #65. The resident was coded as a Full Code. On 06/17/25 at 09:42 AM, the Interim Administrator confirmed there was no Advanced Directive completed on medical chart. The Interim Administrator reported without an advanced directive; the resident is automatically made a full code.

Based on resident interview, staff interview and record review the facility failed to provide treatment in accordance with professional standards of practice by not passing medications at their scheduled administration times. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #70. Facility Census 113. Findings include: a) Resident #70 During the initial interview on 06/16/25 at 11:17 AM, Resident #70 stated, Sometimes I have to wait a long time on my medicine. Our medications are never on time. A record review on 06/18/25 AT 11:30 AM, of Resident #70's Medication Administration Audit Report (MAAR) revealed the following: -04/06/25 Lyrica Capsule 50 Milligrams (MG) was to be given at 6:00 AM and was not administered until 8:16 AM -04/07/25 Lasix oral tablet 20 MG was to be given at 12:00PM and was not administered until 2:27 PM. -04/24/25 Cholecalciferol Oral Capsule 1.25 MG was to be given at 8:00 AM and was not administered until 2:20 PM -04/30/25 Potassium Chloride 10 MEQ, Sennosides-Docusate Sodium Tablet 8.6 to 50 MG, Wixela Inhub Inhalation Aerosol Powder Breath, Calcium Carbonate Oral Tablet, Allopurinol Oral Tablet 100 MG, Tylenol extra strength oral tablet 500 MG, and Apixaban oral tablet 5 MG was all to be given at 8:00 AM and was not administered until 12:34 PM. -06/18/25 Ipratropium-Albuterol Inhalation Solution 3 MG/3ML was to be given at 12:00AM and was not administered until 1:30 AM. During an interview on 06/18/25 at 3:13 PM, Unit Manager Registered Nurse (UMRN) #15 stated, I can answer for April 30, The nurse had a family emergency and had to leave, so we had to have another nurse come in to give the meds that is why they were late that day. There is a note, where the doctor was notified. The other days I do not know, and do not have an answer for. UMRN #15 further confirmed that the medications were late and not administered within the (1) one hour window. A review on of the policy titled {Medication Administration Policy}, under Medication Administration, 14. Reads as follows: Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at meal times or in the dining room unless specifically ordered with meals.

Based on observation, record review and staff interview the facility failed to ensure catheter had proper drainage during a transfer. This was a random opportunity for discovery during the Long-Term Care survey and had the potential to affect a minimal number of residents. Resident Identifier: #104 Facility Census: 113 Findings Include: During an observation on 06/19/25 at 10:55 AM the surveyor observed therapy staff transferring Resident #104 from their wheelchair to stretcher. While transferring the catheter bag was hooked to the transfer belt staff was using to transfer Resident #104. The transfer belt was placed above the waste and not allowing proper drainage that can allow for the possibility for a UTI. Interview with the Director of Nursing (DON) on 06/19/25 at 11:30 AM confirmed the catheter back should have been below the waste to maintain proper flow stating, I have already educated staff when i heard this had happened.

Based on observation and staff interview, the facility failed to ensure residents were free from verbal and emotional abuse. The surveyor was witness to the verbal and emotional abuse of Resident #71 in the public hallway by the nurses station. The Nurse Practitioner verbally berated Resident #71 on two (2) occasions. She was removed from the situation and then returned to continue the verbal assault of Resident #71 for a second time. This cause psychosocial harm to Resident #71. Resident #54 was also verbally abused by a nurse at the facility on the same day. Resident #54 did not appear to suffer any harm from this. but the potential existed for him to suffer psychological harm. These were random opportunities for discovery. Identified Residents #71, and #54. Facility census 109. Findings included: a) Resident #71 On 01/05/22 at 10:12 AM, the facility Nurse Practitioner (NP) was in the hallway by the nursing station screaming at Resident #71. The NP yelled, I am going to have you sent out of here right now. I do not have to let you talk to me in that way! I will write an order right now! The NP was standing over Resident #71 while pointing her finger in his face while she was yelling at him. Resident #71 was laying on his back on a shower bed with a sheet over him. The resident was being transported to the shower room when he was stopped by the NP and verbally assaulted by her. Resident #71 said to NP, You Fucking Bitch get out of my face! The NP continued to yell, you are out of here. Other staff members physically took the NP in an office and Nurse Aide #18 who was standing at the bottom of the shower bed Resident #71 was laying on said something to him that could not be heard by the surveyor and Resident #71 said Bitch you can get away from me too. and he threw a towel towards her. She began yelling I'm done and walked away. NP came out of the office she was asked to go to by the Administrator and again began yelling and going towards the resident once again. NP repeated YOU are out of here; I will not let you or anyone else talk to me like that and call me a FUCKING BITCH. Staff was trying to get NP to go back in the office. Resident #71 threw a towel in the floor and said get that Fucking whore away from me. After several attempts the staff did push the NP in an office and closed the door. Resident #71 was visibly shaking from being upset. Several staff members were standing around him telling him to calm down. Which did not appear to help him. Nurse Aide #37 approached Resident #71 after several minutes and called him by name and asked him if she could help and if he wanted to go back to his room. He said no all I want is a shower. She said I will give you a shower and he asked her if she would get his shampoo from his room, and she said yes. The Administrator when asked who was the women yelling at Resident #71, he stated, she is our Nurse Practitioner, and her behavior is not acceptable and stated he needed to call his corporate office. A review of Resident #71's medical record found a physician's order dated 01/05/22 at 10:39 AM (just minutes after the altercation with the NP) to give Resident #71 Ativan 1 mg two times a day for behaviors. He was not receiving any medications for behaviors prior to this day. A note was found in the electronic chart by Social Worker #103 dated, 01/05/22 at 10:17 AM, (this was wrote while the Resident was being verbally attacked by the NP). It read as follows: Resident had angry outburst while waiting for a shower. Resident was cursing and threatening others as well as throwing items at others. Staff attempted to calm resident down. Resident was redirected after many attempts The social worker made no mention the resident was also yelled at and threatened by the NP. At 1:10 PM 0n 01/05/22, the Administrator and Director of Nursing provided information about the actions taken in regard to the NP. They stated a reportable was completed and she was escorted off the property and her supervisor was notified. Also, the Director of Nursing said she was notified of an order to give Resident #71 Ativan twice a day for behaviors and she called the Attending physician and explained what had happened to the resident and the order was stopped and Resident #71 was not given any Ativan. b) Resident #54 On 01/05/22 at 10:26 AM, Licensed Practical Nurse # 91 was heard coming out of the room of Resident #54, saying in a rude tone I'm done with you I don't have to be talked to like that and I won't. She was stopped in the hall and asked who was she talking to like that? LPN # 91 called Resident #54 by name and said he did not want her to do an assessment on him right now and she just got aggravated. On 01/05/22 at 11:00 AM, the Administrator was informed about what LPN #91 had said to Resident #54. He stated, he would report it and take care of it immediately. He then stated he does not tolerate any type of abuse in his facility. At 1:10 PM, on 01/05/2022 Administrator and Director of Nursing provided a reportable completed for LPN #91. They went on to say they are in servicing all staff about abuse and that verbal abuse of any kind will not be tolerated and if anyone hears it they must report it immediately.

Based on record review, observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents residing in the facility. The facility failed to provide Resident #87's [CONDITION(S)] care, gastroscopy tube care, and pressure ulcer care in a manner to prevent the spread of infection. The facility failed to maintain Resident #31's Oxygen (O2) concentrator in a sanitary. The facility also failed to provide laundry services in a manner to prevent the spread of infection. The survey team determined the facility's failure to clean the glucometer between resident use placed residents receiving fingerstick blood glucose monitoring at immediate risk for serious harm and/or death. The State Agency was contacted and agreed that these failures posted an immediate jeopardy (IJ). The facility was notified of the Immediate Jeopardy on 3/16/21 at 12:08 PM. The facility submitted a plan of correction to the state agency at 1:21 PM on 03/16/21. The plan of correction was accepted by the state agency at 2:00 PM on 03/16/21. The state agency observed for implementation of the accepted plan of correction and the Immediate Jeopardy was abated at 3:00 PM on 03/16/21. The scope and severity of the immediate jeopardy was reduced to a E after the verification of the facility's abatement plan. Resident identifiers: #41, #16, #56, #40, #87, #31. Facility census: 101. Findings included: a) Resident #41, Resident #16, Resident #56, Resident #40 On 03/16/21 at 08:06 AM, Licensed Practical Nurse (LPN) #58 was observed performing a point-of-care blood glucose finger stick on R#41. Fingerstick blood glucose monitoring is a procedure performed utilizing a blood glucose monitor, or glucometer, and a drop of blood obtained by sticking the resident's finger with a small lancet. The drop of blood is placed on a test strip, which is in the glucometer. LPN #58 removed the glucometer from the medication cart drawer and did not clean it before performing Resident #41's fingerstick. LPN #58 then returned the glucometer to the drawer without cleaning it. On 03/16/21 at 08:25 AM, LPN #58 removed the glucometer from the medication cart drawer. The surveyor had been in attendance at the medication cart the entire time. Again, she did not clean the glucometer. She said she was going to perform a fingerstick on Resident #16. LPN #58 knocked on Resident #16's door to enter the room with the glucometer. She was stopped by the surveyor and told that she had not cleaned the glucometer between use between residents. LPN #58 took the glucometer back to the medication cart and exited the area to obtain bleach wipes from a supply area. She returned with the bleach wipes and cleaned the glucometer with the wipes. She then performed Resident #16's fingerstick. LPN #58 then cleaned the glucometer after use. The failure to clean the glucometer between residents could cause a potential to transfer blood-borne disease and pathogens from one resident to another. The Centers for Disease Control and Prevention (CDC) article titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration states, Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer ' s instructions .An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV, [CONDITION(S)] virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared .Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include .Using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. During an interview on 03/16/21 at 10:30 am, LPN #58 stated she had performed fingerstick blood glucose monitoring on Resident #56 at 07:40 am this morning and on Residnet #40 at 07:57 am this morning. When asked if she had cleaned the glucometer before and after use on Residents #56 and #40, LPN #58 stated, I probably didn't. She agreed that she did not have the bleach wipes on her cart and had to obtain them. The facility's policy entitled, Glucose meter with effective date 06/01/96 and revision date 11/01/19 states, Disinfect meter before and after each patient use. The survey team determined the facility's failure to clean the glucometer between resident use placed residents receiving fingerstick blood glucose monitoring at immediate risk for serious harm and/or death. The State Agency was contacted and agreed that these failures posted an immediate jeopardy (IJ). The facility was notified of the Immediate Jeopardy on 3/16/21 at 12:08 PM. The facility submitted a plan of correction to the state agency at 1:21 PM on 03/16/21. The plan of correction was accepted by the state agency at 2:00 PM on 03/16/21. The state agency observed for implementation of the accepted plan of correction and the Immediate Jeopardy was abated at 3:00 PM on 03/16/21. b) Resident #87 On 03/17/21 at 9:04 AM, observation was made of Resident #87's [CONDITION(S)] care, gastroscopy tube care, and pressure ulcer care. The procedure was performed by Licensed Practical Nurse (LPN) #50 with assistance by Nursing Assistant (NA) #22. During the procedures, a disposable [CONDITION(S)] tube was observed to be lying in Resident #87's bed. The [CONDITION(S)] tube contained a small amount of sputum and appeared to be used. NA #22 removed the [CONDITION(S)] tube from the bed. She stated she would change Resident #87's sheets. When the surveyor entered the room, Resident #87's suction tubing was observed to be lying on the floor. On 03/17/21 at 9:30, LPN #50 was informed the suction tubing was lying on the floor. She stated she would change the tubing. No further information was provided through the completion of the survey. c) Laundry Room During observation and tour of laundry services on 03/16/21 at 12:44 PM with Environmental Services Supervisor (ESS), a metal shelving unit was found in the soiled laundry room in use as a drying rack and storage for clean items that were used throughout the facility. The metal shelving unit contained the following items: three (3) milk crates containing clean mop heads, one (1) milk crate containing clean green dust mop covers and one (1) milk crate with clean rags (ESS stated they were used thorough the facility for cleaning things such as hand rails and carts). The top shelf of the metal storage unit contained two (2) blue positioning wedges used for resident care, and four (4) blue heel protector boots used for resident care. The metal shelf was positioned under the negative airflow vent allowing unsanitary air within the soiled laundry room to flow across and over the clean items, (contaminating the items), as the air exited the room through the vent. A plastic storage bin was also located in the floor beside the metal shelving unit with 3 drawers containing clean mopping pads. The ESS verified these items were considered clean would have been used for cleaning and resident care. The ESS stated he would re-wash all items in the storage bin and all items located on the shelving unit and find a clean, sanitary place to store them. The ESS stated he was unaware clean items and clean linens could not be properly stored in the soiled laundry room. d) Resident #31 On 03/15/21 at 12:50 PM Resident's Oxygen (O2) concentrator was found to be in poor maintenance and unsanitary. The external filter on the back of the )2 concentrator was visibly soiled with thick gray dust particle matter. The Resident stated the I cleaned it myself the other day to get better air, I beat the dirt out of it on wall. No date on concentrator to indicate last maintenance date or on supply bag. The Director of Nursing (DON) said only one sticker stating June 29th, 2020 was present on the O2 concentrator and that may be a maintenance sticker. On 3/15/21 at 12:56 PM, the Resident's [CONDITION(S)] Mask was found not properly stored in order to prevent the spread of infection. The [CONDITION(S)] mask was laying across the Residents bedside table (open to air) and per DON dangling off the side but not touching the floor. The DON confirmed the [CONDITION(S)] mask should be stored in a supply bag at all times when not use, and usually the Resident has a bag hanging in the room for that. Record Review indicated the following active Respiratory orders: (typed as written) Oxygen at 2L/min via nasal canula continuously, start date 8/31/20. Trilogy Pressure: 30cm H20 max pressure Oxygen flow (for bleed in): 5 LPM 40% Apply at HS ad remove in AM. Interface type: Full face mask Humidification (if appropriate) Heated or Cool Fill Humidifier with sterile or distilled water. On HS/OFF AM related to ACUTE RESPIRATORY FAILURE WITH [CONDITION(S)]. Review of the facility's policy titled Respiratory Equipment/Supply Cleaning/Disinfection effective date 01/01/07, revision date 11/01/19 revealed in addition to surface disinfection, perform the following on oxygen concentrators: Rinse and dry the external filter weekly and PRN (as needed) when visibly dusty. Schedule for supply changes noted oxygen delivery devices are to be done every seven (7) days.

Based on record review and staff interview, the facility failed to ensure all residents were free from neglect. Resident #67 had an enteral feeding tube in place to receive increase nutrition and received nutrition by mouth. The facility neglected to identify his nutritional intake by mouth had decreased to 0% over 10 consecutive days before it was addressed by the facility. As a result, Resident #67 suffered an avoidable severe weight loss resulting in actual harm. For Resident #30 the facility failed to identify a decrease in food intake, which resulted in a significant, unintended weight loss from declining food and fluids. The facility also failed to weigh the resident weekly as ordered by the physician which could have identified the weight loss sooner. These failures have resulted in actual harm to the resident. This was true for one (1) out of one (1) residents reviewed for enteral tube feeding and two (2) out of seven (7) residents reviewed for nutritional status. Resident identifier: #67 and #30. Facility census: 82. Findings included: a) Resident #67 A review of Resident #67's medical record revealed the Resident receives part of his nutrition via an enteral feeding tube. On 07/22/20, Resident #67 weighed 195.6 pounds, and on 08/19/20 the resident's weight was recorded as 181.2 pounds on 08/19/20. Resident #67 lost 7.4% of his body weight in one month. This represents a severe weight loss. Resident #67 had an enteral feeding tube (a tube inserted into the stomach to bypass the mouth for direct nutrition). He was readmitted to the facility on [DATE]. The Registered Dietitian (RD) stated on the nutrition assessment dated [DATE] that he was tolerating bolus tube feedings well and was transitioning to oral intake which started on 07/15/20. This nutritional assessment also indicated that due to his diagnosis of COVID-19 his by mouth intake had declined. The following change was made to the tube feeding orders: --Change tube feeding to provide 50 percent of his estimated nutrition needs. --Jevity 1.5 via feeding tube at 65 millimeters (ml) per hour for 10 hours with 80 ml of water per hour concurrently While reviewing the Activity of Daily Living records (ADL) it was discovered Resident #67 had very good oral intake starting on 07/20/20 to 07/24/20, he consumed 100% of all three meals on each of those days. From 07/25/20 to 07/28/20 his oral intake declined to 36%. This resulted in the change to his feeding tube orders made on 07/28/20. Further review of the ADL record revealed his oral intake declined to 0% for all three (3) meals from 07/29/20 through 08/07/20 before it was addressed and/or identified by facility staff. On 08/07/20 the RD wrote a note stating, Resident #67 has had a decline of oral intake and over the past six (6) days his oral intake has been 0%. The RD failed to identify Resident #67's oral intake had actually been 0% for 10 days. For these 10 days he was only receiving 50 percent of his estimated nutritional requirements via his feeding tube. On 08/07/20 his enteral feeding was increased to meet 100 percent of his estimated nutritional requirements. On 08/26/20 at 4:07 PM, the RD was asked about Resident #67's weight loss and awareness he was receiving only 50% of his nutritional needs via his feeding tube for the 10-day period because his oral intake was 0%. She said she normally does a week look back but did not look back any farther. Therefore, she did not identify his oral intake had been 0% for 10 days and had only noted the six (6) days on the assessment. She denied receiving any information from the staff caring for him any sooner alerting her to the fact Resident #67 was not taking anything by mouth. She went on to say that she may have underestimated his nutritional needs because he still has not returned to his baseline weight. During the month Resident #67 sustained his severe weight loss he was diagnosed with COVID-19 and his oral intake decreased from 100% to 0%. The facility neglected to identify this decrease nutritional intake and did not increase his enteral feeding for a period of 10 days from 07/29/20 through 08/07/20. At which time the Registered Dietician only identified a 0% intake for six (6) days even though it was actually 10 days. The residents tube feeding was not increased until 08/07/20 to meet his nutritional needs. The facility neglected to identify the decrease oral food intake which resulted in a severe weight loss which could have been avoided. This has resulted in actual harm for Resident #67. b) Resident #30 A review of Resident #30's medical records on 08/20/20, revealed a physician order to obtain weekly weights for four (4) weeks and then monthly, and to notify the Nurse Practitioner (NP) and Physician of any loss or gain. This order was dated 07/23/20. On 07/23/20 Resident #30's weight was recorded as 173.3 pounds. There was not another weight obtained until 08/19/20 which was recorded at 158 pounds. Which was a severe weight loss of 8.2 percent in one month. The facility had not weighed the resident weekly for four (4) weeks as ordered by the physician. Resident #30 tested positive for Covid-19 on 07/29/20. A new order for House Supplements to be given three (3) times a day for weight loss was obtained on 08/20/20 after the facility obtained the weight on 08/19/29 and identified the weight loss. On 08/21/20 an order for Dronabinol (use for weight loss), to be given daily was obtained. A review of the ADL sheets for July found that on 07/24/20, 07/28/20, 07/30/20, and 07/31/20 no dinner meal was recorded. On 07/17/20 there was no breakfast or lunch recorded. A review of the ADL sheets for August 2020 found on 08/04/20, 08/10/20, 08/12/20, 08/12/20, 08/13/20, 08/14/20, 08/15/20, and 08/16/20 all three meals were not recorded as given. For the month of August 2020 on the 08/06/20, 08/07/20, 08/08/20, 08/09/20, 08/11/20, 08/18/20, 08/19/20, and 08/20/20 there was no dinner meal recorded. From 07/24/20 through 08/20/20 only one (1) bedtime snack was provided. The facility failed to monitor and record the resident's meal intake during an acute illness which causes a loss of taste, smell and appetite. They also failed to obtain weekly weights to monitor for weight loss as ordered by the physician which caused a delay in identifying and intervening in a severe unintended weight loss. This has resulted in actual harm for Resident #30 During a phone interview on 08/21/20 at 12:45 PM, the DON was asked about the blanks left on the ADL sheets. She stated the facility discovered this yesterday evening and have addressed it with the staff. She was then asked if it is left blank are, we to assume it was not done. She said yes. During a phone interview on 8/27/20 at 2:45 PM, the Administrator and DON were notified of no weights being done as ordered by the attending physician. He stated, I think all weights for Covid-19 positive cases were stopped by NP. He was informed that is what was being reviewed and weights were being done. He stated, he would look into it.

Based on record review, staff interview and observation, the facility failed to ensure all residents maintained acceptable parameters of nutritional status such as usual body weight unless unavoidable. For Resident #67 the facility failed to identify the Resident, who had an enteral feeding tube in place had a decrease in his by mouth intake to zero percent for 10 consecutive days before it was identified and/or addressed by facility staff. The failure to identify the decrease and implement changes to his enteral feeding resulted in a severe weight loss which could have been avoidable. Therefore, this failed practice resulted in actual harm for Resident #67. For Resident #30 the facility failed to identify a decrease in food intake, which resulted in a significant, unintended weight loss from declining food and fluids. The facility also failed to weigh the resident weekly as ordered by the physician which could have identified the weight loss sooner. These failures have resulted in actual harm to the resident. For resident #20, #45, #23 and #66 the facility failed to monitor food intake making the staff unable to determine if residents were receiving adequate nutrition. For Resident #40 the facility was not documenting and monitoring meal percentages for this resident therefore they had no way to identify if this resident had a decrease in meal intake during her acute illness. The facility also failed to clearly communicate to staff that Resident #40 needed assistance with her meals and was not able to feed herself. Resident identifiers: Resident #67, #20, #30, #45, #40, #66, and #23. Facility census 82. Findings included: a) Resident #67 A review of Resident #67's medical record revealed the Resident receives part of his nutrition via an enteral feeding tube. On [DATE], Resident #67 weighed 195.6 pounds, and on [DATE] the resident's weight was recorded as 181.2 pounds on [DATE]. Resident #67 lost 7.4% of his body weight in one month. This represents a severe weight loss. Resident #67 had an enteral feeding tube (a tube inserted into the stomach to bypass the mouth for direct nutrition). He was readmitted to the facility on [DATE]. The Registered Dietitian (RD) stated on the nutrition assessment dated [DATE] that he was tolerating bolus tube feedings well and was transitioning to oral intake which started on [DATE]. This nutritional assessment also indicated that due to his diagnosis of COVID-19 his by mouth intake had declined. The following change was made to the tube feeding orders: --Change tube feeding to provide 50 percent of his estimated nutrition needs. --Jevity 1.5 via feeding tube at 65 millimeters (ml) per hour for 10 hours with 80 ml of water per hour concurrently While reviewing the Activity of Daily Living records (ADL) it was discovered Resident #67 had very good oral intake starting on [DATE] to [DATE], he consumed 100% of all three meals on each of those days. From [DATE] to [DATE] his oral intake declined to 36%. This resulted in the change to his feeding tube orders made on [DATE]. Further review of the ADL record revealed his oral intake declined to 0% for all three (3) meals from [DATE] through [DATE] before it was addressed and/or identified by facility staff. On [DATE] the RD wrote a note stating, Resident #67 has had a decline of oral intake and over the past six (6) days his oral intake has been 0%. The RD failed to identify Resident #67's oral intake had actually been 0% for 10 days. For these 10 days he was only receiving 50 percent of his estimated nutritional requirements via his feeding tube. On [DATE] his enteral feeding was increased to meet 100 percent of his estimated nutritional requirements. On [DATE] at 4:07 PM, the RD was asked about Resident #67's weight loss and awareness he was receiving only 50% of his nutritional needs via his feeding tube for the 10-day period because his oral intake was 0%. She said she normally does a week look back but did not look back any farther. Therefore, she did not identify his oral intake had been 0% for 10 days and had only noted the six (6) days on the assessment. She denied receiving any information from the staff caring for him any sooner alerting her to the fact Resident #67 was not taking anything by mouth. She went on to say that she may have underestimated his nutritional needs because he still has not returned to his baseline weight. During the month Resident #67 sustained his severe weight loss he was diagnosed with COVID-19 and his oral intake decreased from 100% to 0%. The facility neglected to identify this decrease nutritional intake and did not increase his enteral feeding for a period of 10 days from [DATE] through [DATE]. At which time the Registered Dietician only identified a 0% intake for six (6) days even though it was actually 10 days. The residents tube feeding was not increased until [DATE] to meet his nutritional needs. The facility neglected to identify the decrease oral food intake which resulted in a severe weight loss which could have been avoided. This has resulted in actual harm for Resident #67. b) Resident #30 A review of Resident #30's medical records on [DATE], revealed a physician order to obtain weekly weights for four (4) weeks and then monthly, and to notify the Nurse Practitioner (NP) and Physician of any loss or gain. This order was dated [DATE]. On [DATE] Resident #30's weight was recorded as 173.3 pounds. There was not another weight obtained until [DATE] which was recorded at 158 pounds. Which was a severe weight loss of 8.2 percent in one month. The facility had not weighed the resident weekly for four (4) weeks as ordered by the physician. Resident #30 tested positive for Covid-19 on [DATE]. A new order for House Supplements to be given three (3) times a day for weight loss was obtained on [DATE] after the facility obtained the weight on [DATE] and identified the weight loss. On [DATE] an order for Dronabinol (use for weight loss), to be given daily was obtained. A review of the ADL sheets for July found that on [DATE], [DATE], [DATE], and [DATE] no dinner meal was recorded. On [DATE] there was no breakfast or lunch recorded. A review of the ADL sheets for [DATE] found on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] all three meals were not recorded as given. For the month of [DATE] on the [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] there was no dinner meal recorded. From [DATE] through [DATE] only one (1) bedtime snack was provided. The facility failed to monitor and record the resident's meal intake during an acute illness which causes a loss of taste, smell and appetite. They also failed to obtain weekly weights to monitor for weight loss as ordered by the physician which caused a delay in identifying and intervening in a severe unintended weight loss. This has resulted in actual harm for Resident #30 During a phone interview on [DATE] at 12:45 PM, the DON was asked about the blanks left on the ADL sheets. She stated the facility discovered this yesterday evening and have addressed it with the staff. She was then asked if it is left blank are, we to assume it was not done. She said yes. During a phone interview on [DATE] at 2:45 PM, the Administrator and DON were notified of no weights being done as ordered by the attending physician. He stated, I think all weights for Covid-19 positive cases were stopped by NP. He was informed that is what was being reviewed and weights were being done. He stated, he would look into it. c) Resident # 20 A review of Resident #20's medical record on [DATE], revealed Resident #20 had a severe weight loss. On [DATE] her weight was 184.6 and on [DATE] her weight was recorded at 167.4, this is a 9% weight loss in one month. A Registered Dietitian (RD) assessment on [DATE] recorded oral intake for the month of July to be 53%. The assessment also indicated Resident #20's Juven (is used for wound healing) order expired on [DATE] and nursing stated it was helping. The RD indicated they would renew the Juven and continue with hardboiled egg with every meal and cottage cheese for a snack at 10 AM and 2 PM. A review of the Activity of Daily Living (ADL) sheet for the month of July found that on 16 days a snack was not recorded at bedtime. For the month of August there was zero (0) bedtime snacks recorded. The two (2) daytime snacks at 10 AM and 2 PM were not recorded on the ADL sheets for the month of July and August. Therefore, the facility staff had no way to track Resident #20's consumption of these in order their effectiveness. During an interview on [DATE] at 6:30 PM the Director of Nursing (DON) stated Resident #20's weight loss was desired. During a review of records there was no mention of a desired weight loss in the medical record review. During a phone interview on [DATE] at 12:30 PM, the Administrator and Director of Nursing (DON) were asked about how they track and monitor the extra snacks recommended by the RD and how the percentage of consumption is communicated to the RD. The Administrator stated the communication is verbal. He went on to say that if the surveyor was in the facility, they could see it. He was again asked where the snack consumption percentage was documented. He stated, I just know it is being done. During a phone interview on [DATE] at 4:07 PM, the RD was asked how she monitors whether or not the resident receives and/or consumes the snacks she recommends. She stated, I ask the residents if they can tell me and I look in the coolers, and sometimes I ask the staff. She said that she is only allowed to work in the facility 30 hours a week. She stated the DON told her she cannot put snack times anymore, because if so she would have to get an order. She also stated, it would be a good idea to record percentage of the snack consumed by the resident. d) Resident # 45 A review of Resident #45's medical record on [DATE] found Resident #45 weighed 117.4 pounds on [DATE] and weighed 110.8 pounds on [DATE] which was a 5.6 percent weight loss which was a severe weight loss in one (1) month. A nutrition assessment by the Registered Dietician (RD) on [DATE], noted Resident #45 had a decreased by mouth intake due to acute illness. The RD increased Resident #45's supplements to twice a day and added Eight (8) ounces of whole milk. A review of Resident #45's Activity of Daily Living (ADL) sheets, that record the percentage of oral intake for each meal and snacks, for the month of [DATE] Resident #45 had no documentation for all three meals on [DATE], [DATE], [DATE], [DATE], and [DATE]. Resident #45 had not documentation for two of three meals on [DATE]. Finally, Resident #45 had no documentation for one (1) of three (3) meals on [DATE]. A review of the ADL sheets for the month of [DATE] found: On [DATE] and [DATE] only two (2) of the three (3) meals were recorded. On [DATE], [DATE], [DATE] and [DATE] were missing documentation for two (2) of three (3) daily meals. On [DATE], [DATE], [DATE], and [DATE] all three meals contained no documentation to indicate the meal percentage consumed by Resident #45. The was only one day during the month of [DATE] where a snack was recorded on the ADL sheets. The facility had no way of monitoring if Resident #45 was having a decrease in appetite due to the missing documentation. During a phone interview on [DATE] at 12:45 PM, the DON was asked about the blanks left on the ADL sheets. She stated they (the facility) discovered this yesterday evening and have addressed it with the staff. She was then asked if it is left blank are we to assume it was not done. She said yes. e) Resident #40 A review of Resident #40's medical record on [DATE] revealed Resident #40 weighed 110.2 pounds on [DATE] and weighed 99.6 pounds on [DATE]. This was 9.6 percent weight loss in in one month. This is a severe weight loss. Further review of the medical records revealed on the Activities of Daily Living (ADL) sheets there was no meal percentages recorded on [DATE], [DATE], [DATE], and [DATE]. On [DATE], [DATE] [DATE], [DATE] two (2) meals for the day were not recorded. On [DATE], [DATE], and [DATE] one meal on each day was not recorded. Bedtime snacks for the month [DATE] through [DATE] had only one (1) day recorded to indicate the snack had only been given once during this time period. With the missing documentation the facility had no way to monitor or identify a decrease in oral intake for Resident #40. A nutrition assessment by the Registered Dietitian (RD) on [DATE] noted, Resident # 40 is of nutritional concern related to inadequate intake by mouth due to dementia; weight has been stable for one month. On another nutrition assessment dated [DATE] the RD noted, Resident #40 has an acute illness, 17% intake by mouth for the month of July. Interventions: House Supplement twice a day for 30 days, cottage cheese with breakfast, grilled cheese with lunch and dinner, and offer snacks The last update on her care plan was on [DATE] related to ADL's. It stated Resident requires assistance for ADL care related to Muscle Weakness, and dementia with behaviors. Improvement noted with self- feeding. On [DATE] at 11:45 AM, Unit Manager # 5 provided a copy of a paper titled, South feed assists. On this list she wrote the name of the persons responsible for assisting each resident. She also stated that when the trays arrive the residents that are independent receive their food first, after they are served then they will serve the ones that require assistance. During an observation on [DATE] at 12:13 PM, Unit Manager # 5 told Nurse Aide # 3 that Resident # 40 was a feeder. He answered no, her roommate is. She very quietly told him to just stay in the room and feed her. On [DATE] at 12:28 PM, NA # 3 was out of the room that Resident #40 and was in carrying a pitcher of tea to give Licensed Practical Nurse (LPN) #4. NA #3 spent 15 minutes assisting Resident #40 with her meal. On [DATE] at 12:45 PM, NA # 3 was asked if he knew that Resident #40 needed to be assisted with eating. He stated that he did not know, but he did feed her and her roommate. During an observation on [DATE] at 12:42 PM, it was noted that three (3) of the five (5) people that were assigned to assist each resident did not follow the assignment. During an interview with Director of Nursing (DON) on [DATE] at 6:30 PM, when asked about NA # 3 not knowing Resident # 40 needed assistance. She stated Unit Manager #5 had added her but could not tell this surveyor when. There was no order, nor was it care planned and no nursing note could be found. During a phone interview on [DATE] at 12:45 PM, the DON was asked about the blanks left on the ADL sheets to record all meal and snack intake percentages not being recorded. She states that they (the facility) discovered this yesterday evening and have addressed it with the staff. She was asked if it is left blank are we to assume it was not done. She said yes. During a phone interview on [DATE] at 4:07 PM, the RD was asked how she monitors whether or not the resident receives and/or consumes the snacks she recommends. She stated, I ask the residents if they can tell me and I look in the coolers, and sometimes I ask the staff. She said that she is only allowed to work in the facility 30 hours a week. She stated the DON told her she cannot put snack times anymore, because if so she would have to get an order. She also stated, it would be a good idea to record percentage of the snack consumed by the resident. f) Resident # 66 During a record review it was discovered Resident #66 's weight on [DATE] was 124.6 pounds and on [DATE] it was 116.6 pounds. She had a 6.4 percent weight loss. This was a severe weight loss. On [DATE] the facility RD wrote in the nutrition assessment for Resident #66 to receive ice cream for her bedtime snack. There was no new nutrition assessment. A review of the Activities of Daily Living (ADL) for the month of July found on eight (8) days one meal was not recorded. The bedtime snack was left blank 21 days. The ADL meal log for this resident was left blank for dinner four (4) days [DATE] - [DATE]. Three meals not recorded on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. On [DATE] two meals were not recorded on this date. There was 16 out of 19 blanks for the bedtime snack. During a phone interview on [DATE] at 12:45 PM, DON was asked about the blanks left on the ADL sheets to record all meal and snack intake percentages not being recorded. She states that they (the facility) discovered this yesterday evening and have addressed it with the staff. She was asked if it is left blank are, we to assume it was not done. She said yes.

Based on staff interview, resident interview, and medical record review, the facility failed to ensure that a resident having pressure sores received necessary treatment and services to prevent new sores from developing for one (1) of three (3) residents reviewed with pressure ulcers. A resident developed a Stage III pressure ulcer before staff identified skin impairment. Resident identifier: #68. Facility census: 113. Findings include: a) Resident #68 An electronic medical record review, on 08/08/14 at 9:00 a.m., revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment noted pressure ulcers (PU) on his upper mid back. Review of physician's orders [REDACTED]. They indicated a Stage II PU on his left lower back and a Stage III PU on his left hip. The Stage III pressure ulcer, in-house acquired, measuring 1.5 centimeters (cm) x 1.5 cm x 0.5 cm with 1 cm undermining/tunneling at 12:00 (12:00 indicates the anatomical position of the undermining/tunneling). Review of the pressure ulcer logs revealed the tissue around the wound was inflamed and the wound had purulent drainage. According to the resident's admission minimum data set assessment (MDS), with an assessment reference date of 05/16/14, the resident scored 15 on his Brief Interview for Mental Status (BIMS) indicating he was cognitively intact. His [DIAGNOSES REDACTED]. According to the assessment, the resident was at risk for developing pressure ulcers and was also noted to have existing pressure ulcers. During an interview with Resident #68, on 08/08/14 at 10:00 a.m., he related he had been in the facility a few months related to a neck injury. The resident said he could move his extremities, but could not feel them. The resident said he was aware of the pressure ulcers, but related he could not feel them due to the paralysis. He indicated he was unable to determine whether he had a skin impairment. An interview with Employee #33, a registered nurse (RN), on 08/08/14 at 12:00 p.m., revealed she had identified the wound while completing treatments. The RN confirmed no evidence was present to indicate the wound had been identified or treated prior to her assessment. She confirmed the wound was identified on 07/16/14 as a Stage III pressure ulcer, with tunneling and drainage. Additionally, the skin integrity report completed by the RN described the peri wound area as inflamed, and the wound edges macerated (when the skin becomes softened from being wet - it is more susceptible to bacteria and fungi). A physician's orders [REDACTED]. The culture reports revealed the wound grew three (3) different isolates of bacteria. Review of activities of daily living (ADL) records found Resident #68 was totally dependent for toilet use and required the assistance of two (2) staff on 07/15/14 and 07/16/14 on 7-3 shift. The ADL record also indicated he was totally dependent for a bed bath on 07/15/14. Upon further inquiry, Employee #33 confirmed staff should have identified an abnormality while completing resident care. An interview with the interim DON (Employee #44) on 08/08/14 at 12:40 p.m., confirmed the left hip pressure ulcer wound was identified on the date of 07/16/14 as a Stage III ulcer. She related she spoke with therapy after the identification of the pressure ulcer; and it was determined it was "caused by the way he laid in the bed." Upon inquiry, as to why the ulcer was assessed as Stage III prior to identification by staff, she indicated the wound was newly acquired, and developed as a Stage III PU with purulent drainage. She denied the skin was broken before that time, and therefore, could not have been identified. An interview with the certified occupational therapy assistant (COTA), Employee #136 on 08/08/14 at 12:30 p.m., revealed he worked with Resident #68 for ADLs and transfers with the slide board, and strengthening exercises. He related he sometimes assisted with the resident's shower, but not routinely. He said he did not complete a body assessment at the time of the shower, to observe for potential issues with skin. He related he concentrated on ADL skills. The COTA indicated he may or may not have been able to observe the lower part of the resident's back/hip area, due to positioning in the chair. He related he was not aware of a pressure ulcer on the resident's left lower back and hip area. He said, "I knew he had an area on his coccyx." Therapy notes were reviewed with Employee #136, at which time he verified he had not showered Resident #68 during therapy sessions from 07/11/14 through 07/15/14. The COTA related he had not visualized the posterior aspect of the resident's body during transfers due to the area was covered; and confirmed he could not verify he observed the left lower back and hip area while completing the resident's shower on 07/16/14, due to the shape of the shower chair. Another interview with the interim DON, on 08/08/14 at 1:30 p.m., revealed she believed the Stage III pressure ulcer with tunneling and purulent drainage, which was cultured with three (3) strains of bacteria, happened just prior to finding it, "because pressure ulcers can develop in 2 hours, and it may have come from the inside out." She denied the resident had any change in skin tone or impairment prior to identification. Additionally, the vice president of operations, Employee #146, related, "It was only the size of a dime." .

Based on medical record review, staff interview, and policy and procedure review, the facility failed to consistently administer pain medication when a resident complained of pain, failed to evaluate and assess the resident's pain, failed to assess the efficacy of the pain medication after administration, failed to follow the resident's care plan interventions to alleviate / treat pain, and failed to follow the facility's policy and procedures for assessment, management, monitoring and evaluating the effectiveness of the pain management program. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. This was true for two (2) of thirty-one (31) residents reviewed in Stage II of the QIS (quality indicator survey). Resident identifiers: #12 and #207. Facility census: 109. Findings include: a) Resident #12 1. Review of the medical record found an alert, oriented Resident who had been deemed to have capacity to make medical decisions. The Resident was admitted to the facility on [DATE] at 5:30 p.m. for rehabilitation after surgery to repair a [MEDICAL CONDITION] upper arm. An admission nursing note written at 5:30 p.m. on 07/20/12 found, "...Resident is complaining of pain, repositioned till (sic) medication arrives...." There was no documentation to determine if the repositioning was effective. The resident's medication admission orders [REDACTED]. There were no other medications prescribed to treat the resident's pain upon admission. Further review of the medication record found the [MEDICATION NAME] was not administered on 07/20/12. The first dose of [MEDICATION NAME] was administered at 10:30 p.m. on 07/22/12, two (2) days after the resident complained of pain. The medical record contained no evidence the resident's pain was assessed, treated or eliminated on 07/20/12. Review of the Medication Administration Record [REDACTED]. On 07/20/12, the day of the resident's admission, the facility completed a pain evaluation. The evaluation found the residents pain was acute and daily. The intensity of the pain had not been completed. According to the evaluation, the resident was cognitively intact and described her pain as aching, and affecting her completion of activities of daily living (ADLs) and mobility. Medications, cold, and positioning were listed as currently and historically managing the resident's pain. Documentation revealed, "Resident stated the [MEDICATION NAME] had been effective in controlling her pain." It was not clear from the evaluation as to how the resident knew the [MEDICATION NAME] was effective in managing her pain. Included on the MAR indicated [REDACTED]?" The directions to nursing staff were, "Assess resident pre-medication and post medication. 0-10 scale." The rating scale was not completed on 07/20/12. On 07/21/12 the resident's pain was rated as a 10/0 on the MAR indicated [REDACTED]. On 7/22/12, the MAR indicated [REDACTED]. There was no follow up documentation to determine if the medication was effective. On 07/23/12 at 1:35, a nurse noted, "Resident complain of pain. Rated pain at a 6. [MEDICATION NAME] was given for pain. Resident stated that pain was still rated @ (symbol for at) 6. Positioned resident in bed (symbol for with) ice on shoulder to help relieve pain. Will cont. (continue) to monitor. Call light in reach." There was no further documentation the treatment was effective and no further assessment of the resident's pain. Review of the MAR found no evidence the medication, [MEDICATION NAME], was administered on 07/23/12, although the nurses note contained documentation the medication was administered. The next nursing note was written on 07/24/12, (time was not documented), "Resident stated [MEDICATION NAME] was not helping pain and requested Tylenol. Order obtained for 650 mg q (every) 6 hours for pain PRN of Tylenol. Will continue to monitor." Tylenol was administered on three (3) occasions on 07/24/12. The pain was rated as a 0 on all three (3) occasions, although the MAR indicated [REDACTED]. It was unclear if the pain was rated as a 0 before or after administration of the medication. Further review of the MAR found the resident received [MEDICATION NAME] at 11:00 p.m. on 07/24/12. According to the documentation on the MAR, the resident was not having any pain. A nursing note, dated 07/25/12 at 12:00 p.m. "...receives Tylenol 650 mg PRN for pain, seems effective." Again on 07/25/12, review of the MAR found the resident's pain was rated as a 0 on three (3) separate occasions (day, afternoon and night shift). If was unknown if this rating was before or after the administration of the medication of Tylenol. Further review of the MAR found the resident received Tylenol at 12:25 p.m. and 8:48 p.m. On 07/26/12 the resident's pain was rated as a 6 on the MAR indicated [REDACTED].) There was no further documentation present to determine if the pain was relieved. Tylenol was not administered on the afternoon shift of 07/26/12. [MEDICATION NAME] was administered at 8:35 p.m. on 07/26/12. The next nursing note referencing the resident's pain was written on 07/27/12, "Resident up and down out of bed. Complaints of pain to shoulder and bladder, states having problems urinating. Given Tylenol 650 mg. Resident states meds. (medication) don't help (symbol for with) pain. U/A urinalysis ordered awaiting results. Cont. (continue) to monitor..." There was no rating of the resident's pain on 07/27/12 and no documentation to determine if the pain was relieved with Tylenol. Review of the MAR indicated [REDACTED]. Tylenol was administered on four (4) separate occasions with no rating of the resident's pain before or after the administration of Tylenol. On 07/29/12, 07/30/12 and 07/31/12 Tylenol was administered on two separate occasions on each day with the residents pain rated as 0. Again there was no documentation to determine if the Resident's pain was a 0 before or after the administration of the Tylenol. From 07/27/12, until the resident was discharged from the facility on 08/03/12, no further nursing notes were written indicating an assessment of the resident's pain. Review of the MAR found Tylenol was the only medication administered for pain on 08/01/12. Review of the resident's MDS (Minimum Data Set) with ARD (assessment reference date) of 07/27/12, section ( J), revealed the resident rated her pain as almost constant and severe over the last five (5) days. The care plan, initiated on 07/23/12, identified pain related to [MEDICAL CONDITION] humerus with s/p (status [REDACTED]." Interventions included: "Monitor pain on scale of 1-10, position pillows as needed for comfort, administer pain medication as per MD (doctors) orders and note the effectiveness. Notify MD if pain not reduced, encourage resident to communicate presence of pain, assist to reposition for comfort, implement relaxation and/or distraction techniques to assist with pain control, document/report complaints and non-verbal signs of pain." Review of the facilities policy for Pain Management Program policy and procedure, PRN (as needed) Pain Medication, directed use of the form PRN Pain Management Flow Sheet. "...when [MEDICATION NAME] are administered in response to an episode of pain, licensed nurses must document their evaluation, treatment, and the effectiveness of the treatment on the PRN Pain Management Flow Sheet." Further instructions for licensed nurses was documentation of the following information: "1. Pain evaluation and treatment, date and time, pain rating, non-pharmacological treatments provided, location of the pain, medication dose, administering nurses's signature and initials." "2. Effectiveness of treatment: date and time, pain rating level of sedation, nurses signature and initials." The medical record contained two (2) copies of the PRN Pain Management Flow Sheets. One listed the resident's name at the bottom, but neither copy had been completed. The facility failed to follow their policy and procedure to complete the flow sheets as required in #1 and #2 above. The Policy further directed the interdisciplinary team to: "1. Identify residents with pain, 2. Develop an individual pain management program, 3. Implement the program, 4. Monitoring and evaluating the effectiveness of the program." The policy detailed why pain management was important. It contained the statement, "Studies indicate that 45-80% of nursing home residents have substantial, untreated pain. Additionally, a study of the standardized MDS data shows that 41% of elderly people who are admitted to a nursing home continue to experience moderate-to-severe pain, even up to 60-80 days later..." "The goal of this program is to manage the resident's pain to optimize their quality of life. Pain management is an important component of our care process-part to take seriously. The goal of the interdisciplinary team is to promptly identify pain and develop an effective Pain Management Plan...." Review of the nurse practitioners visit on 07/25/12 found the written statement, "Resident admitted post hospitalization for post surgical repair of left humerus fracture post fall. Had complaints of drainage from op (operation) site and pain..." There were no details on how the pain would be treated. An interview was conducted with the administrator, Employee #46, and the interim director of nursing (DON), Employee #157 at 10:30 a.m. on 09/20/12. The above information was discussed with both employees. The DON verified the facility failed to complete the PRN Pain Management Flow Sheet as required by their policy and procedure, and failed to follow the policy for pain management. She stated she did not know why the facility waited for two (2) days before administering the resident's pain medication, when the resident was complaining of pain. She stated she was not at the facility at the time of the resident's admission and could not account for the care the resident received. Another interview was conducted with the administrator and Employee #62, the clinical care manager, on 09/24/12 at 2:46 p.m., regarding the above findings and no further information was received. Further review of the nursing notes found the resident was discharged to her home on 08/03/12. Nursing staff continued to chart on the resident on 08/05/12 and 08/06/12 with both entries documenting"...call light within reach." Employee #62 and the administrator were presented with the following question, "If staff were evaluating her pain daily, then why were nursing notes written after the resident was discharged to home?" These staff members were unable to answer this question and were unable to provide further evidence the facility was assessing, monitoring, and implementing an effective pain management program. 2) Review of the nursing notes found an entry for 07/31/12 at 11:30 a.m., "Resident complained of being constipated gave enema at 11:30 a.m., resident stated still no relief, told oncoming nurse at 3:00 p.m., She stated she see what she can give her." Review of the nursing notes found no documentation from the oncoming nurse regarding the resident's reports of constipation on 07/31/12, or if the enema had been effective. Further review of the MAR found no evidence the enema was given. Additionally, there was no evidence the nurse administering the enema received an order for [REDACTED]. The Resident Functional Performance Record, completed daily by the nursing assistants, found no bowel movement was recorded for 07/31/12. The next recorded bowel movement was on the afternoon shift of 08/01/12, when the resident had a medium bowel movement. Further review of the Resident Functional Performance Record, found the resident did not have a bowel movement from 07/20/12, the day of admission until 07/28/12, when she had a medium bowel movement. The resident resided at the facility for eight (8) days with no recorded bowel movement and no evidence of any staff intervention. The DON (director of nursing) and administrator were interviewed at 10:30 a.m. on 09/20/12. The DON verified the nurse would have to have a physician's orders [REDACTED]. She was unable to provide any written evidence this was completed. The DON was also asked for a copy of the facility's bowel protocol, and the facility's policy for bowel functioning and monitoring to prevent fecal impaction. The DON presented the following, "If resident complains of constipation and or has no bowel movement for three days notify physician and follow physician orders." The information was typed on facility letterhead stationary and was not dated. At 9:30 a.m. on 09/26/12, Employee #119, a registered nurse and regional director of clinical services, was interviewed regarding the facility's bowel protocol. She verified the facility did not have a bowel policy or protocol. When asked how the facility monitored bowel functioning to prevent fecal impaction, she replied the resident's functional performance record was reviewed at morning meeting, and if the resident had no bowel movement for three (3) days, the physician would be contacted for intervention. A copy of the resident's functional performance record was presented to this employee. Documentation from the nursing assistants verified the resident had no bowel movement from 07/20/12 to 07/28/12. This employee was asked if physician intervention had been requested in this time frame. She was unable to present any evidence the physician was contacted or evidence the issue was addressed by the facility. She stated she did not know why the facility had not noticed the lack of bowel movements at the daily meetings. She verified an order was required from the physician before giving an enema to a resident. Further review of the MAR found the resident was receiving [MEDICATION NAME] 100 mg daily and [MEDICATION NAME] 17 gram powder daily for a [DIAGNOSES REDACTED]. Review of the Resident's care plan, initiated on 07/25/12, found the problem, "Bowel elimination alteration; constipation related to: lack of exercise, pain medications." The goal associated with this problem was: "Resident will be free of constipation as evidence by having a BM (bowel movement) at least q (every) three days thru review period." Interventions included, "Record BM. note size and consistency. Report any abnormalities to Licensed nurse. Certified Nursing aide report to licensed nursing staff on 3rd day if no BM for further follow-up." At the close of the survey, no further information was provided by the facility. . . b) Resident #207 Resident #207 was a [MEDICAL TREATMENT] patient. She went to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. Review of the physician's orders [REDACTED]. Further review of the care plan and "Quick Reference Guide" identified the facility was also to monitor pre and post vital signs, obtain pre and post weights, and observe the site after [MEDICAL TREATMENT] for excess bleeding. Review of the medical record, on 09/24/12, found the facility had not been consistently obtaining vital signs prior to and after the resident returned from [MEDICAL TREATMENT]. The facility also failed to obtain pre and post weights from the [MEDICAL TREATMENT] center. On 09/17/12, the facility obtained faxed pre and post weights for the visits for 09/15/12, 09/13/12, and 09/11/12. According to the physician's orders [REDACTED]. Review of a nursing interdisciplinary progress note revealed Employee #68 (nurse) failed to assess the resident's site upon return to the facility on [DATE]. Employee #90 (nurse) failed to obtain vital signs prior to [MEDICAL TREATMENT] on the same day. According to the Medication Administration Record, [REDACTED]"Quick Reference Guide" used by the facility. During an interview with Employee #68 on 09/25/12, at approximately 1:45 p.m., she confirmed she did not assess the resident after [MEDICAL TREATMENT] on 09/18/12. .

Based on family interview, medical record review and staff interview, the facility failed to ensure a resident who was known to spit out his medication, swallowed medications after they were administered. This was found for one (1) of three (3) sampled residents. Resident identifier: #139. Facility census: 107 Findings include: a) Resident #139 During an interview with the family member for Resident #139, on 12/13/12 at 9:42 a.m., it was disclosed earlier that morning she had found two (2) pills on the floor beside the resident's nightstand. She added that she reported this to Employee #1, the Director of Nursing (DON). The care plan was reviewed on 12/17/12. The care plan included an updated intervention, dated 12/04/12, to encourage the resident to take his medications related to him spitting them out. An interview was conducted, on 12/17/12 at 10:32 a.m., with Employee #1, (DON). She confirmed the resident's responsible party brought her two (2) pills, which she verified were two (2) 250 mg capsules of [MEDICATION NAME] Acid ([MEDICATION NAME]). This resident received [MEDICATION NAME] for agitation and combative behaviors associated to his [MEDICAL CONDITION] disorder. She further stated Employee #71, Licensed Practical Nurse (LPN), should have been aware of the resident's practice of spitting his pills out, and needed to remain with the resident until the medication had been swallowed. .

Based on the results of the QIS (quality indicator survey) beginning on 09/16/12 and staff interview, the governing body failed to ensure all deficient practices cited during a complaint survey conducted on 04/04/12 were corrected, as alleged in the plan of correction signed by the administrator on 05/04/12. Deficient practices remained in the following Federal Regulatory Groupings: Resident Behavior and Facility Practices, Quality of Life, and and Quality of Care. This deficient practice had the potential to affect all residents who reside in the facility. Facility census: 109. Findings include repeat deficiencies in the following areas: a) Resident Behavior and Facility Practices Review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, staff interview, and review of facility policy and procedures revealed the governing body failed to ensure all allegations of neglect and abuse were investigated and reported. b) Quality of Life 1) Review of medical records and staff interviews revealed the governing body failed to ensure an accurate,comprehensive assessment of the resident's functional capacity was completed for each resident. 2) Review of medical records, resident interview, and staff interview revealed the governing body failed to ensure a comprehensive care plan was completed for each resident. c) Quality of Life Review of medical records, staff interview, and policy and procedure review,revealed the governing body failed to assure residents maintained the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The staff failed to provide appropriate care and services for one resident resulting in actual harm. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. Additionally pain medications were not consistently administered when a resident complained of pain, and pain was not evaluated and assessed. .

Based on the results of the re-visit survey, beginning on 11/26/12, and staff interview, the governing body failed to ensure all deficient practices cited during the quality indicator survey (QIS) ending on 09/26/12 were corrected, as alleged in the plan of correction signed by the administrator on 11/02/12 . Deficient practices remained in the following Federal Regulatory Groupings: Resident Assessment, Dietary Services, Pharmacy Services, and Infection Control. These deficient practices had the potential to affect all residents who reside in the facility. Facility census: 106. Findings include: a) Resident Assessment Review of the medical record, care plan, and staff interview revealed the governing body failed to ensure a comprehensive care plan was established to include the use of personal alarms. b) Dietary Services Observation and staff interview revealed the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The temperature log to be completed before each meal was incomplete. Items in the kitchen and the pantry refrigerators had not been labeled and dated. Dishware containing debris had been stored as clean. c) Pharmacy Services Observation and staff interview revealed the facility failed to date medications, when opened and failed to dispose of expired medications. d) Infection Control Observation, staff interview, and review of the facility's infection control policy and procedures revealed the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Appropriate signage was not posted for a resident with [MEDICAL CONDITION] in his sputum and the isolation precautions had not been implemented in accordance with facility policy or the resident's care plan. An IV bag was not discarded for five (5) days after the medication had been administered. An emesis basin containing vomitus was left sitting in a residents room for more than 24 hours after the resident was sent to the hospital. .

Based on the results of the second revisit survey, beginning on [DATE], and staff interview, the governing body failed to ensure all deficient practices cited during the first revisit survey on [DATE] to the Quality Indicator Survey (QIS) ending on [DATE], were corrected, as alleged in the plan of correction signed by the administrator on [DATE]. Deficient practices remained in the following Federal Regulatory Groupings: Pharmacy Services and Infection Control. These deficient practices had the potential to affect all residents residing in the facility. Facility census: 107. Findings include: a) Pharmacy Services Observation and staff interview revealed the facility failed to dispose of an expired medication. b) Infection Control Observation, resident interview, staff interview, and review of the facility's infection control policy and procedures revealed the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. A nursing assistant was observed transporting clean laundry and briefs holding them against her clothing. This was contrary to facility policy. Clean linens and other clean items were found stored on the floor, soiled shoes were found atop clean gloves, and debris was found on the floor of the laundry room. Similar conditions were observed in the linen closets on the units. Additionally, a staff member's jacket was observed hanging in the clean linen room with clean lift pads. The lift pads were also noted to be touching the floor. A bag of contaminated gowns, that had been worn while providing care to a resident with [MEDICAL CONDITION] (MRSA) and E. coli in a wound, was observed hanging from a the door knob of the resident's room. A wandering resident was found in the room if a resident who was on droplet precautions [MEDICAL CONDITION]. The resident said the wandering resident and another resident were always coming in his room. .

Based on observation, record review, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement and monitor actions to ensure that previously cited deficient practices were corrected. The process did not assure that practices were being consistently applied to prevent negative outcomes in areas where the facility's governing body was aware they have been deficient in the past. The QIS (quality indicator survey), beginning on 09/16/12 found four (4) repeated deficiencies cited in the complaint survey conducted on 04/04/12. One repeated deficient practice with continuing non-compliance was cited at a severity level of actual harm. These practices have the potential to affect all residents at the facility. Facility census: 109. Findings include: a) Quality Assessment and Assurance Committee During the QIS survey conducted on 09/16/12, the survey team found continuing non-compliance with four (4) regulatory requirements which were found to be deficient during the complaint survey conducted on 04/04/12. The following areas remained non compliant: 1) Resident Behavior and Facility Practices Review of the facility's concern/complaint files, review of the reportable allegations in the facility's abuse/neglect files, staff interview, and review of facility policy and procedures revealed the QAA committee failed to implement and monitor actions to ensure all allegations of neglect and abuse were investigated and reported. 2) Quality of Life a) Review of medical records and staff interviews revealed the QAA committee failed to implement and monitor actions to ensure an accurate,comprehensive assessment of the resident's functional capacity was completed for each resident. b) Review of medical records, resident interview, and staff interview revealed the QAA committee failed to implement and monitor actions to ensure a comprehensive care plan was completed for each resident. 3) Quality of Life Review of medical records, staff interview, and policy and procedure review,revealed the QAA committee failed to implement and monitor actions to ensure residents maintained the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being in accordance with the comprehensive assessment and plan of care. The staff failed to provide appropriate care and services for one resident resulting in actual harm. The facility failed to monitor the resident's bowel regimen, secure physician's orders [REDACTED]. The facility also failed to assess a resident who received [MEDICAL TREATMENT] services upon return from the [MEDICAL TREATMENT] center, and failed to follow their care plan and guidelines for assessment of a resident receiving [MEDICAL TREATMENT]. Additionally pain medications were not consistently administered when a resident complained of pain, and pain was not evaluated and assessed. 4) The current administrator was interviewed at 11:17 a.m. on 09/26/12. She stated she was not the administrator of record when the prior deficient practices occurred. .

Based on medical record reviews, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement plans of action to correct identified quality deficiencies. Four (4) deficient practices identified during the annual Quality Indicator Survey (QIS), which ended on 09/26/12, were still out of compliance during the re-visit survey which ended 11/28/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and / or ensure the correction of the deficient practices cited at F279, F371, F431, and F441. This had the potential to affect all residents at the facility. Facility census: 106. Findings include: a) Interview with the administrator, on 11/28/12 at 10:30 a.m., revealed the issues identified from the previous QIS survey had been addressed in the monthly quality assessment and assurance committee (QA committee.) The administrator stated she thought the deficiencies had been corrected. The QA committee did not ensure the deficient practices cited during the survey, which ended on 09/26/12, were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans failed to correct the deficiencies previously cited at F279, F371, F431 and F441. They remained out of compliance during the re-visit which ended on 11/28/12. b) Staff interview and medical record review revealed the facility failed to care plan an alarming seat belt for one (1) of four (4) sampled residents. c) Observations and staff interview revealed the facility failed to ensure food was stored, prepared and served under sanitary conditions. Food items were not labeled and dated, pre-meal services logs were incomplete, and dishware was not clean. d) Observation and staff interview revealed the facility failed to date medications, when opened and failed to dispose of expired medications e) Observation, staff interview, and review of the facility's infection control policy and procedures revealed the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on medical record reviews, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Two (2) deficient practices, identified during the 11/28/12 revisit to the annual Quality Indicator Survey (QIS) survey which ended on 09/26/12, remained out of compliance during the second re-visit survey which ended 12/18/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F431 and F441. This had the potential to affect all residents at the facility. Facility census: 107. Findings include: a) The administrator was advised on 12/17/12 at 2:30 p.m. that previous deficient practices identified during the second revisit had not been corrected by the quality assessment and assurance committee (QA committee.) The QA committee did not ensure the deficient practices cited during the first revisit on 11/28/12 to the QIS survey which ended on 09/26/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans failed to correct the deficiencies previously cited at F431 and F441. They remained out of compliance during the second revisit which ended on 12/18/12. b) Staff interview and observation revealed the facility failed to dispose of expired medications. c) Observation, staff interview, and review of the facility's infection control policy and procedures revealed the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. A nursing assistant was observed transporting clean laundry and briefs holding them against her clothing. This was contrary to facility policy. Clean linens and other clean items were found stored on the floor, soiled shoes were found atop clean gloves, and debris was found on the floor of the laundry room. Similar conditions were observed in the linen closets on the units. Additionally, a staff member's jacket was observed hanging in the clean linen room with clean lift pads. The lift pads were also noted to be touching the floor. A bag of contaminated gowns, that had been worn while providing care to a resident with [MEDICAL CONDITION] (MRSA) and E. coli in a wound, was observed hanging from a the door knob of the resident's room. A wandering resident was found in the room if a resident who was on droplet precautions [MEDICAL CONDITION]. The resident said the wandering resident and another resident were always coming in his room. .

Based on observation, resident interview, and staff interview, the facility failed to provide goods and services to avoid physical harm and mental anguish for one (1) of thirteen (13) sampled residents. Resident #99 was left in his room clad in only an incontinence brief and a hospital gown (without a cover sheet or blanket) and with the air conditioning / heating unit next to this bed set to the fan mode. Resident #99 was also found to have dried bowel movement on his scrotum, buttock, and leg. Resident identifier: #99. Facility census: 102. Findings include: a) Resident #99 During random observations of the facility on 10/26/11 at 9:40 a.m., a male voice could be heard yelling, "Nurse, nurse. Get me a blanket, nurse. I'm freezing, nurse." A licensed practical nurse (LPN - Employee #28) was noted to be in the hallway with a medication cart. Observation of this male resident (#99), made from the doorway to his room, found him in his bed with only a hospital gown (which was pulled up to his chest) and a loosely applied incontinence brief. Resident #99 was rolling from side to side in his bed and opening his legs, and his pubic hair and scrotum were visible from the hallway. - After obtaining his permission, the resident's room was entered by this nurse surveyor. The resident immediately started yelling again to bring him a blanket, that he was freezing. Observation found there was no sheet or blanket on the resident's bed or on the floor next to the bed. Closer observation found the resident had a dried brown substance on the front of his leg, and the resident's fingernails were long, jagged, and packed with a brownish-colored substance. The resident stated that a "nurse" had come into his room, took his blanket, and turned the heat off. He repeatedly stated that he was freezing and asked this nurse surveyor to get him a blanket and turn his heat on. Observation of the air conditioning / heating unit by the resident's bed found it was set on fan mode and was blowing cool air. This nurse surveyor turned the heat on and informed the resident that staff would be notified of his request for a blanket. - Upon exiting the room, this nurse surveyor notified Employee #28 that Resident #99 did not have a sheet or blanket and was complaining of freezing. Employee #28 stated, as she entered his room, that the resident throws his covers in the floor. She looked around the resident's bed and did not find a sheet or blanket. She stated she would get him a blanket. - At 9:50 a.m. on 10/26/11, a nursing assistant (Employee #15) entered the resident's room with linens. The dried brown substance on the resident's leg was pointed out to Employee #15, who stated the resident had "dried poop" on him from last night and he wasn't like that when she left last night. She stated that she came in at 6:00 a.m. this morning (10/26/11) and Employee #63 (the nursing assistant who had cared for the resident on the previous shift) asked her to do a "walk through". Employee #15 reported that she had a resident who was going home that day and she wanted to give him a shower so he would be nice and clean, so she signed that she had done the "walk through" even though she did not actually do one with Employee #63. Employee #15 said she knew she shouldn't have done that, and that she realized this failure to perform the "walk through" with Employee #63 made the "dried poop" on Resident #99 her responsibility, even though he wasn't like that when she left last night. When asked if she had checked any of her residents for incontinence care needs this morning, she stated she had not. - Observations were conducted while Employee #15 provided incontinence care to Resident #15. The nursing assistant utilized three (3) washcloths to remove the copious amount of dried bowel movement from the resident's scrotum, left buttock, and left leg. - Employee #28 was informed that the resident was found with dried bowel movement on his body. The director of nursing (DON - Employee #12) was also notified of these findings at 10:15 a.m. on 10/26/11. .

Based on medical record review, policy review, and staff interview, the facility failed to ensure three (3) of forty-five (45) Stage II sample residents received adequate supervision and assistance devices to prevent avoidable accidents, resulting in actual harm to one (1) resident. Additionally, staff failed to follow the facility's Fall Management Program with respect to documentation, assessment, care planning, and post-fall evaluations. Resident #206 was admitted on [DATE] and sustained five (5) falls between 06/22/11 and 07/18/11; two (2) of the falls required transfer to the hospital, one (1) of which resulted in a fractured clavicle. The resident had diminished cognitive ability due to malignant brain cancer. The interdisciplinary team (IDT) did not develop new interventions that were appropriate for a resident with diminished cognitive ability, relying upon the resident to exercise good judgment to promote her own safety (e.g., instructing the resident to ask for staff assistance with transfers). The facility kept the same interventions in place after the resident continued to sustain falls with serious injuries. Resident #214 sustained a fall on 07/26/11, and staff did not complete a physical assessment of the resident after the fall, nor did they follow the other post-fall action steps outline in the facility's policy. Resident #37 had a care plan intervention for his bed to be in the lowest position due to falls. Observation revealed this intervention was not implemented as planned. Resident identifiers: #206, #214, and #37. Facility census: 105. Findings include: a) Resident #206 1. The medical record for Resident #206, conducted on 08/04/11 at approximately 12:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Medical records from Resident #206's hospital stay prior to her admission to the nursing home included a form titled "Determination of Capacity / Incapacity / Designated Surrogate", which was not signed or dated. The person completing this form checked Item C "_______ demonstrates INCAPACITY to make medical decisions" and designated the resident's daughter to serve as health care surrogate. Upon the resident's admission to the facility, no physician's determination of capacity was made. (A form titled "Physician's Determination of Capacity" was found in Resident #206's medical record; it was signed by the physician and dated 07/06/11, but the form was otherwise blank - with no indication was to whether the resident did or did not possess the capacity to understand and make her own health care decisions.) On the day of her admission (06/20/11), a "Resident Fall Evaluation" form was completed. The assessor recorded "Y" for "yes" in response to the following questions: - "fell in Last 30 Days?" - "Has there been a change in mobility?" - "Has there been a change in gait?" - "Does resident need assistance with bed mobility, transfer or ambulation?" - "Has resident had changes in their medication?" - "Is resident on any new medications?" - "Does resident wear glasses?" - "Can the resident communicate their needs?" - "Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?" - Review of the resident's physician orders [REDACTED]. - 06/20/11 - "haldol 0.5mg tab By mouth (oral) - PRN PRN: Give Q 8 hours prn - psychosis" - 06/21/11 - "Ativan (Lorazepam) 1 MG Tablet By mouth (Oral) - Every four hours Everyday: Hold ativan if drowsy - Anxiety" - Episodic care plans, dated 06/21/11, included the following problems, goals, and approaches (quoted as written): - Problem - "(Arrow pointing down) ADL (activities of daily living), weakness, (arrow pointing down) activity tolerance, (arrow pointing down) balance, (arrow pointing down) mobility." Goal - "Max I (maximum independence) /c (with) ADL for safe D/C (discharge) to appropriate level of care." Approaches - "See HCFA 700 for POC (plan of care)." (This care plan was written by the occupational therapist.) - Problem - "(Arrow pointing down) cognitive skills." Goals - "(Arrow pointing up) cognitive skills." Approaches - "See HCFA 700 for POC." (This care plan was written by the speech-language pathologist.) - Problem - "(Arrow pointing down) bed mob (mobility), (arrow pointing down) transfer, (arrow pointing down) amb (ambulation)." Goal - "Safe / I to return to Home." Approaches - "See HCFA 700." (This care plan was written by the physical therapist.) No care plan was developed upon admission to address the resident's risk for falls, which would have been appropriate given the intrinsic risk factors for falling that had been identified on the "Resident Fall Evaluation" form completed on the day of her admission. -- 2. According to an incident / accident report dated 06/22/11 at 2:15 p.m. (quoted as written): "Resident was in bathroom in her room doing an unassisted ambulation. Resident went to sit on toilet & fell . Resident hit (L) (left) forehead on floor has hematoma there (symbol for 'no') C/O (complaint of) pain. (Symbol for 'no') further distress noted." On Page 2 of the incident report, the results of the facility's investigation into this fall were as follows (quoted as written): "(Symbol for 'no') further injuries. Bed locked in lowest position. Call light in reach." A "Fall Investigation Worksheet" form, dated 06/22/11, identified the resident fell from a standing position, she was wearing socks but no shoes at the time of the fall, she was receiving narcotics and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. A "Resident Fall Evaluation" form was completed on 06/22/11, on which the assessor recorded "Y" for "yes" in response to the following questions: - "fell in Last 30 Days?" - "Has there been a change in mobility?" - "Has there been a change in gait?" - "Does resident need assistance with bed mobility, transfer or ambulation?" - "Is the resident confused?" - "Has there been a change in mental status?" - "Does resident wear glasses?" - "Can the resident communicate their needs?" (The assessor responded "N" for "no" to the question "Is the resident receiving any medications that could cause orthostatic B/P (blood pressure) changes?", although the resident continued to receive medications that affected blood pressure and the episodic care plan discussed below identified the need to monitor the resident's orthostatic blood pressure every shift.) On 06/22/11, an episodic care plan was developed as follows (quoted as written): - Problem - "Fall /c (with) hematoma to (L) (left) forehead." Goal - "(Symbol for 'no') further falls." Approaches - "(1) Bed locked in lowest position. (2) Call bell in reach. (3) Room clutter free. (4) Notify MD of (symbol for 'changes')." A second problem statement also dated 06/22/11 stated: - Problem - "Fall /c hematoma." Goal - "(Symbol for 'no') further falls." Approaches - "(5) Orthostatic B/P (blood pressure) QS (every shift). (6) Ativan 0.5 mg q (every) 4 hours. Hold if drowsy. (7) Haldol 0.5 mg q 8 hours PRN (as needed)." This episodic care plan did not take into account the information recorded on the "Resident Fall Evaluation" form, which noted the resident had exhibited a change in mental status and was now confused - two (2) intrinsic fall risk factors that had not been identified on the "Resident Fall Evaluation" form completed on 06/20/11. - Review of the resident's physician orders [REDACTED]. - 06/26/11 - "Apply bed alarm to bed for residents safety and check for placement every shift R/T (related to) H/O (history of) Falls. - Every Shift Everyday" - 06/26/11 - "Apply chair alarm and check placement every shift for resident's safety R/T H/O Falls - Every Shift Everyday" - 06/26/11 - "Apply safety mats at bedside for resident's safety while in bed and check placement every shift, while in bed R/T H/O Falls - Every Shift Everyday" -- 3. According to an incident / accident report dated 07/01/11 at 4:15 a.m. (quoted as written): "Resident attempted to sit in a chair, missed the chair, and slid to floor landing on buttocks. Moves all extremities /s (without) difficulty." This fall occurred at the nurses' station. A "Fall Investigation Worksheet" form, dated 07/01/11, identified the resident fell from a standing position when attempting to sit, she had an unsteady gait, she was wearing socks and shoes at the time of the fall, she was receiving antipsychotics, antianxiety medications, narcotics, and antihypertensives, and she was confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. No "Resident Fall Evaluation" form was completed following this fall. - On 07/01/11, the comprehensive care plan was updated with the following problem, goal, and interventions (quoted as typed): - Problem - "Potential for further decline in cognition related to [DIAGNOSES REDACTED]." Goal - "Respond to questions/ statement with appropriate verbalization and will know where she is and current month and year when ask at least 5 out of 7 days per week thru next review." (Target date: 09/20/11) Interventions - "Give one simple direction at a time and repeat it as necessary. Encourage participation in self-care within individual abilities. Encourage small group activities. Establish daily routine with resident. Explain each activity/ care procedure prior to beginning it. Provide reality orientation. Observe and report changes in cognitive status. Keep questions simple. Ensure access to clock/ calendar." Additionally on 07/01/11, an episodic care plan was developed as follows (quoted as written): - Problem - "Fall." Goal - "(Symbol for 'no') further falls through review." (No review date was provided that would make this goal measurable.) Approaches - "(1) Necessary items within reach at all times. (2) Call light within reach. (3) Bed alarm / chair alarm. (4) Floor matts. (5) Encourage resident to ask for assistance /c (with) all xfers (transfers)." A form titled "Multidisciplinary Screening Form", dated 07/01/11 and completed by the physical therapist, found the following (quoted as written): "4:15 am - 7/1/11 - patient was sitting in a chair missed the chair and fell pt (patient) is on caseload." -- 4. A nursing note, dated 07/02/11 (with no time), stated (quoted as written): "Resident keep getting up and turning off her alarms. Will not listen to reason. She keeps getting up and staggering around. Reported to charge nurse." The next consecutive note (which was no in chronologic order when viewed with the rest of the nursing notes on other pages), was dated "7/9/10/11 7p-7a" and stated (quoted as written): "Resident turns her alarms off and walks around the nurses desk and her room. She refuses help and says she can do it herself." Additional entries in the nursing notes periodically noted Resident #206 was alert and oriented to person and place only, with episodes of confusion noted at times. On 07/06/11, the order for placement of floor mats beside the resident's bed was discontinued. -- 5. According to an incident / accident report dated 07/11/11 at 5:17 p.m. (quoted as written): "Resident fell in dinning room. Chair alarm didn't alarm until resident was in floor. Resident fell on left side. C/O (complained of) left shoulder pain. 3cm S/T (skin tear) to left elbow." A "Fall Investigation Worksheet" form, dated 07/11/11, identified the resident fell while engaging in unassisted ambulation from her wheelchair, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was alert. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", the person who completed this section (which was not signed or dated) wrote: "Advise resident not to ambulate without help. Apply new alarm pad." No "Resident Fall Evaluation" form was completed following this fall. A nursing note, dated 07/11/11 at 1815 (6:15 p.m.), stated (quoted as written): "Resident fell in dining room chair alarm was on but did not activate alarm til resident was on floor. She said she hit her head. C/O left shoulder pain 3 cm skin tar at elbow. ... Called Dr. (name) wants sent out for X-Rays ..." A nursing note, dated 07/13/11 (with no time noted), stated (quoted as written): "late entry for 7/11/11 Resident is noncompliant of chair alarm. Explain to resident the importance of chair alarm & resident is still non-compliant." A nursing note, dated 07/11/11 at 2200 (10:00 p.m.), stated (quoted as written): "Resident back from hospital ... Res dx of (illegible) fx (fracture) of the clavicle. N.O. (new order) for Vicoprofen q 6 hours PRN for pain #15. Report from hosp stated resident to be careful of falls. ..." An episodic care plan was developed on 07/11/11 with the following (quoted as written): - Problem - "Fall /c injury to (illegible)." Goal - "(1) Resident will have (symbol for 'no') more falls (illegible)." Approach - "(1) Resident to be instructed on call light to call for assist /c transfer to bathroom & other needs assist x 1 /c ambulation QS." (This intervention identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's psychosis and decline in cognition associated with the progression of the resident's brain cancer.) A form titled "Multidisciplinary Screening Form", dated 07/12/11 and completed by the physical therapist, found the following (quoted as written): "7/11/11 - pt (patient) fell - on caseload for balance, safety awareness due to poor judgment Working /c Daughter re: (regarding) inability to direct patient to safe behavior spoke /c them re: DC (discharge) placement since pt won't follow Directions." -- 6. According to an incident / accident report dated 07/12/11 at 6:10 p.m. (quoted as written): "CNA (certified nurse aide) escorted resident to room after dinner. CNA had to go help get other residents fr (from) dining room. Pt (patient) was in chair when CNA left room. Another CNA was passing by in hallway and heard a thump and quickly ran to room for help. The alarm was not going off when room was entered. Pt is known to turn off chair alarm. Found pt laying on (L) (left) side laceration above (L) eye brow & skin tear on top of (L) wrist & complaining of (L) hip pain. Resident sent out immediately." This fall occurred in the resident's room. A "Fall Investigation Worksheet" form, dated 07/12/11, identified the resident fell from a stationary chair and that she was trying to transfer herself from chair to bathroom, she was wearing socks and shoes at the time of the fall, she was receiving narcotics, and she was and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. No "Resident Fall Evaluation" form was completed following this fall. The next consecutive nursing note following the resident's return from the hospital on [DATE], dated 07/12/11 at 1815 (6:15 p.m.), stated (quoted as written): "Resident fell in room. Laceration on (L) side of head. C/O (L) hip pain. Called Dr. (name) ... Dr. (name) said send to ER (emergency room ) ... also has aprox 3cm skin tear to top of (L) wrist." The next consecutive nursing note, dated 07/12/11 at 2315 (11:15 p.m.), stated (quoted as written): "Resident back from (hospital) ... Resident alert. Steri-strip noted to laceration (L) side of head. (Symbol for 'no') new orders sent per Hosp. Dr. (name) called. N.O. for resident to be instructed to use call light for assist for transfer for bathroom or other needs et (and) assist of 1 for ambulation as (illegible) (checkmark) compliance QS (every shift). ..." An episodic care plan was developed on 07/12/11 with the following (quoted as written): - Problem - "Pt had fall in room." Goal - "Pt will free of falls for next evaluation." Approach - "(1) Encourage pt to use call light. (2) Encourage pt to shout out for help. (3) Call light within reach." (Again, these interventions identified staff's expectation of the resident to exercise good judgment to promote her own safety in preventing falls and failed to acknowledge the resident's psychosis and decline in cognition associated with the progression of the resident's brain cancer.) A form titled "Multidisciplinary Screening Form", dated 07/13/11 and completed by the physical therapist, found the following (quoted as written): "7/12/11 - pt (patient) fell - on caseload for safety see previous fall screen 7/11/11 same issues as previously noted." -- 7. According to an incident / accident report dated 07/18/11 at 12:30 p.m. (quoted as written): "Resident stood up out of w/c (wheelchair). I redirected resident. While resident was sitting back down, w/c rolled back resident fell to floor on left side. Resident has c/o (complained of) pain (L) leg. N/O (new order) for x-rays obtain. Neuro's started." This fall occurred in the dining room. A "Fall Investigation Worksheet" form, dated 07/18/11, identified the resident fell from a wheelchair while attempting unassisted ambulation, she had a malignant neoplasm of the brain and spinal cord, she was wearing socks and shoes at the time of the fall, she was receiving antianxiety medications, narcotics, and antihypertensives, and she was alert and confused. On Page 2 of this form, where members of the interdisciplinary team where to record "Recommendations to prevent further falls (document interventions below and on the Care Plan)", this section of the form was left blank. No "Resident Fall Evaluation" form was completed following this fall. A form titled "Multidisciplinary Screening Form", dated 07/19/11 and completed by the physical therapist, found the following (quoted as written): "7/18/11 - pt fell in DR (dining room) trying to get up out of chair. Antiroll (illegible) orders for wc (wheelchair) Patient on caseload being DC's (discharged ) - today Daughter aware working /c family for safety awareness." After the resident sustained [REDACTED]. They continued to rely on the intervention of reminding the resident to use her call light for assistance. No new interventions by nursing or therapy staff were added between the falls on 07/11/11, 07/12/11, and 07/18/11. -- 8. Review of the facility's Fall Management Program (adopted January 2008; revised December 2010) found the following expectations in Section 1 (Fall Prevention) (quoted as typed): "... A licensed nurse performs a head-to-toe evaluation of each new admission. When evaluating a resident who may be at risk for falling, the licensed nurse should consider the medical history, [DIAGNOSES REDACTED]. .. "... After the head-to-toe assessment, the licensed nurse completes a Fall Evaluation on every new admission. This evaluation identifies both the intrinsic and extrinsic risk factors that apply to the particular resident. "... Once the assessment and evaluation are completed and risk factors have been identified, the licensed nurse selects appropriate interventions. The Fall Evaluation Intervention tool is utilized to provide a standardized, quick, easy to use crosswalk that relates risk factors to suggested interventions. These practical intervention options can help the licensed nurse with the next task - developing a comprehensive individualized Care Plan. ... "... Each week, the interdisciplinary team teams residents who are new admissions and residents who have fallen in the past 90 days during the C.A.R.E. meeting. The knowledge and expertise that is shared at these meetings enhances the quality of care provided to residents. During the C.A.R.E. meeting, care strategies are evaluated and the care plan is adjusted, as necessary. ..." - The following expectations were found in Section 2 (Fall Management) (quoted as typed): "... A specific procedure is followed to report and investigate falls. This ensures that the resident receives appropriate care after a fall, that an investigation is begun, and that the resident's care plan is adjusted, as needed. ... "... After the resident has been cared for (when a resident falls), the licensed nurse: "1. Completes an interdisciplinary progress note, including a brief summary of the fall, the nursing evaluation, actions taken, who was notified, and the resident's condition. Note: Licensed nurses continue to document the resident's condition in the Interdisciplinary Progress Notes during each shift for the next 24 hours, and daily for the next 48 hours, noting any changes in condition - a total of 72 hours) "2. Completes a Fall Evaluation to determine if there have been any changes in resident condition and to identify interventions that may help in preventing future falls "3. Completes an incident and accident report ... including a fall investigation "4. Updates the Care Plan with the identified interventions "5. Updates the Nursing Assistant Care Card with any new procedures "6. Completes the 24-Hour Report, to alert following shifts to the fall, as well as Care Plan updates "7. Residents are followed via the 24 Hour Report x 72 hours ..." - The following expectations were found in Section 3 (Performance Improvement in Fall Management) (quoted as typed): "... Daily: The center interdisciplinary team reviews the 24-Hour Report at morning meetings and discusses residents who have fallen. "Weekly: The center team discusses residents during the C.A.R.E. meeting to determine the effectiveness of the Care Plan. "Monthly: The Safety Committee receives information on any falls resulting from environmental (extrinsic) factors, investigates, and reports its findings to the Quality Assurance Committee. The Performance Improvement Committee reviews fall to determine if there are trends in the center that require action. ..." -- 9. When interviewed on the afternoon of 08/04/11, Employee #9 (the minimum data set manager) reported the facility wanted to initiate a program that would date the alarms and alert staff as to when these alarms / batteries needed to be changed. An interview with the registered nurse (RN) consultant (Employee #28A), on 08/04/11, revealed the facility had not conducted the C.A.R.E. meetings as stated in the Fall Management Program provided by the facility. Employee #28A said the facility had not conducted these meetings due to not having a director of nursing. However, the facility utilized an interim director of nursing (DON - Employee #27A) during the time period these falls occurred. -- 10. On 08/04/11 at approximately 3:00 p.m., Employee #1A (the therapy program manager) said the resident experienced a lot of agitation while at the facility. Her functioning abilities fluctuated. She said this made the resident's abilities difficult to judge. She said the facility did not try a Rock-N-Go chair with this resident, but this may have been beneficial to her. On 08/04/11 at approximately 3:15 p.m., Employee #9 said the resident often tried to get up from her chair when her family would leave the facility. The facility did not incorporate into the care plan and/or develop approaches to promote resident safety based on this information. -- b) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. Item #15 on Page 3 of her admission nursing assessment, completed on 07/19/11, noted she had a history of [REDACTED].". Resident #214's interim care plan, which was initiated upon her admission on 07/19/11, did not address the resident's risk for falls, even though staff was aware that the resident had sustained one (1) or more falls prior to her admission. - According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or whether she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (vac) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound vac to measure and apply a new dressing. The wound vac dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on Diflucan (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for Ativan 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. - On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her medication administration record (MAR), Resident #214 received her first dose of Ativan at 10:00 a.m. on 07/23/11.) Review of the "Resident Fall Evaluation" completed on 07/23/11 revealed the assessor wrote "N" for "no" in response to the following questions: - "Has resident had changes in their medication?" - "Is resident on any new medications?" - "Was resident experiencing pain prior to the fall?" An episodic care plan, dated 07/23/11, contained the following problem, goal, and approaches (quoted as written): Problem - "Fall r/t (related to) poor safety awareness." Goal - "No further falls." Approaches - "(1) Call bell in reach. (2) Visualize resident frequently. (3) Safety mats to bedside when in bed. (3) Pressure alarm to bed to alert staff to unassisted transfers." On 07/24/11, nursing notes stated: "S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place." There was no documentation to reflect the resident had been exhibiting any behaviors at that time. -- 2. Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. - On 07/27/11, the resident's medical record was reviewed for documentation of the factors surrounding this resident's falls. There was no contemporaneous entry in the nursing notes to correspond with the fall on 07/26/11, and there was no evidence to reflect staff conducted a physical assessment of the resident and no evidence to reflect staff conducted an investigation to identify possible intrinsic and/or extrinsic factors that may have contributed to this fall. A nursing note, dated "07/24/11", stated Resident #214 had a fall on 07/26/11. This was brought to the attention of Employee #28A, who stated this note was probably dated incorrectly, because it was written after a note dated 07/25/11. She said this note must have been intended for 07/26/11, as the next consecutive note, dated 07/27/11, stated the resident had no further falls. Employee #28A verified there was no note in the medical record to describe the details of the fall that had occurred on 07/26/11. - The facility's incident / accident reports were reviewed, and no report was found for Resident #214's fall on 07/26/11. Additionally, "Resident Fall Evaluation" and "Fall Investigation Worksheet" forms were not completed following this fall on 07/26/11. - Subsequent review of the resident's care plan found it was not reviewed / revised after the fall on 07/26/11 as required by the facility's Fall Management Plan, to include new or different interventions to prevent future falls from occurring. . Employee #28A was questioned again on 08/03/11 at 10:00 a.m. about the fall on 07/26/11. She did not provide evidence to reflect the resident had been thoroughly assessed after the fall or that the circumstance of the fall had been thoroughly investigated, as there was no incident / accident report, no "Resident Fall Investigation" form, no "Fall Investigation Worksheet" form, and no details about the fall recorded in the nursing notes. - The facility's Fall Management Program was reviewed, and on 08/03/11 at 2:00 p.m., Employee #28A was questioned further about follow-up actions taken by staff after the fall on 07/26/11. Employee #28A did not provide evidence that all applicable post-fall actions were taken as required by the Fall Management Program (as outlined above in Item #8 related to Resident #206). -- 3. Further record review for this resident found the Care Area Assessment (CAA) notes did not provide an additional assessment for the care areas that were triggered by the resident's most recent comprehensive MDS. The admission + Medicare 14-Day MDS, with an ARD of 07/31/11, indicated in Section C that Resident #214 had severely impaired cognition (Brief Interview for Mental Status score of "4") with impaired short-term recall. In Section J1700, the assessor recorded that Resident #214 had fallen in the month prior to ARD date and before the resident's admission to this facility. Documentation in Section V of the MDS indicated the care area of "falls" triggered and would be addressed in the care plan. This documentation also identified the location and date of the CAA information as "CAA WS (worksheet) dated 8/1/11". The CAA worksheet, dated 08/01/11, for the area of falls was reviewed. The CAA notes, dated 08/01/11, listed her medications, stated that she fell at home prior to coming to the facility, that she had a bed alarm to her bed and a high low bed with safety mats at bedside due to her poor safety awareness, and that she was unable to determine the edge of the bed. There was no information contained in the CAA notes to identify that this resident had fallen twice since her admission to the facility; both falls occurred prior to 08/01/11. The worksheet then provided a place to record an analysis of the findings; this analysis consisted of a paragraph restating the same information. There was no evidence of an in depth analysis of the find

Based on record review, staff interview, observation, and review interview, the facility failed to ensure the medication regimens for two (2) of forty-five (45) Stage II sample residents were free from unnecessary drugs. One (1) resident (#214) received medications to treat anxiety and [MEDICAL CONDITION] when the resident displayed signs / symptoms of pain, and she was not prescribed any medications to treat pain; this resulted in actual harm (e.g., untreated pain). Another resident (#159) received a medication without adequate indications for its use. Resident identifiers: #159 and #214. Facility census: 105. Findings include: a) Resident #214 1. Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or if she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident . A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (VAC) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. In Section 13.1a (integumentary / feet) of the admission nursing assessment, the assessor failed to mark a response to the following question: "Is there pain associated with the wound/skin condition?" - This section of the assessment was left blank. In Section 14.0 of the nursing admission assessment, the assessor responded as follows: - "At anytime during the last five (5) days has the resident: Been on a scheduled pain medication regimen?" = No - "Been on a PRN (as needed) pain medication?" = No - "Had pain or hurting?" = Yes (There was no follow-up documentation on the assessment to describe the pain or hurting the resident was experiencing.) -- 2. On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound VAC to measure and apply a new dressing. The wound VAC dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). On 07/20/11 at 5:00 p.m., a nursing note recorded the resident did not display any combativeness or other behaviors. On 07/21/11, the nursing notes stated that she did not display any behaviors on that day either. According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. on that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (According to her Medication Administration Record [REDACTED].) On 07/24/11, nursing notes stated: "S/p (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place." There was no documentation to reflect the resident had been exhibiting any behaviors at that time. A nursing note, on 07/25/11, recorded receipt of new orders for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 25 mg BID (twice daily) for [MEDICAL CONDITION]. There was no documentation to reflect the resident was exhibiting signs or symptoms of [MEDICAL CONDITION], nor was there evidence to reflect staff had assessed the resident for pain. - Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. On 07/27/11, the resident's medical record was reviewed to review the factors surrounding this resident's falls. There was no evidence that this fall had been recorded in the nursing notes, and there was no evidence that staff had conducted an investigation in an effort to identify internal and/or external factors that contributed to this fall. The incident / accident reports were reviewed for this time frame, and no report was found for the fall that occurred on 07/26/11. - On 07/28/11, a weekly nursing note stated: "... she rips off wound vac, combative, curses staff, she is currently receiving [MEDICATION NAME] 25 mg BID. ..." There was no evidence in the weekly interdisciplinary team (IDT) meeting note that pain was considered or ruled out as a reason for this resident's behaviors and pulling out her wound VAC. - Review of the resident's physician orders [REDACTED]. - The admission + Medicare 14-Day MDS, with an ARD of 07/31/11, indicated in Section C that Resident #214 had severely impaired cognition (Brief Interview for Mental Status score of "4") with impaired short-term recall. - During observations of this resident on 08/03/11 from 10:00 a.m. to 11:30 a.m., she was noted to be sleeping the entire time. Her lunch tray was provided to her, and at 1:15 p.m., this surveyor approached the resident. She was very lethargic, dozing off while she was eating. When interviewed by the surveyor about her meal, she reported she just wasn't very hungry. (Although ordered on [DATE], according to the MAR indicated [REDACTED].) Observation found the resident wrinkling her forehead and nose and grimacing. When asked if she was having pain, she stated "yes". When asked to describe her pain, she stated, "A deep pain that is real deep and sharp shooting down my leg and into my foot." When asked what treatment she received for pain, and she stated, "It is all right. I do not need any more pills. I take too many now." - At 1:30 p.m. on 08/03/11, two registered nurses (RNs - Employees #9 and #28A) were asked by this surveyor to assess this resident for pain. Employee #28A asked the resident if she was hurting anywhere, and the resident stated, "Yes. My leg hurts from here to here." (As she spoke, the resident pointed to the area surrounding the wound VAC on her left lower leg.) The RN asked her if she wanted some pain medication, and she said, "No. I don't think I need it." - On 08/03/11, the nurse practitioner (Employee #29A) wrote a note to follow-up with the wound center as soon as possible if not already seen, and to obtain a report from the wound center if she has already been seen. Employee #29A also wrote an order for [REDACTED]." - On 08/09/11 at 9:30 a.m., Employee #43 (a licensed practical nurse - LPN) was observed performing a treatment to Resident #214's leg. Throughout the procedure, the resident winced and gritted her teeth. At times, she covered her mouth with her sheet, and at other times, she covered her face with both hands, whimpering all the while. She repeated "golly, golly" time and time again. At one point, she asked the nurse to quit for a while and let her relax. It was apparent that this resident was in extreme pain, and this was confirmed by Employees #43 and #29A, who was also present at that time. Employee #29A said she would order something stronger for the resident. The treatment was stopped, and they said they were going to let the medication work before they finished the treatment. At 10:05 a.m., they administered [MEDICATION NAME] to the resident. - It was evident this resident was experiencing pain, and this untreated pain could have been the cause of her behaviors. There was no evidence that pain was considered as a causal or contributing factor prior to medicating the resident with antianxiety and antipsychotic medications for behaviors. There was inadequate monitoring of the resident's behaviors for the months of July and August 2011. No behavior monitoring sheet was found for July 2011. The behavior monitoring sheet for August 2011 indicated staff was to monitor her for the behavior of "fighting", and documentation on this sheet month-to date indicated she had no episodes of fighting. Additionally, no non-pharmacologic interventions were initiated in an attempt to reduce these behaviors prior to administering antianxiety and/or antipsychotic medications. During an interview with Employee #28A, she was made aware that there was no behavior sheet for July 2011 (when the antipsychotic and antianxiety medications were ordered and administered) and that no documentation was found to justify the use of either the antianxiety medication (e.g., evidence of increased anxiety) or the antipsychotic medications. There was also no evidence that the risks and benefits had been considered before using these medications. There was also no evidence that the facility had considered pain as a possible cause of the resident's combativeness (as she had exhibited combativeness when her wound care was done), nor was there any evidence that the facility considered the time of day that wound care had been done (at 4:00 a.m. - during hours of sleep) as a factor in the behaviors. The resident also suffered two (2) falls after these medications were initiated. The antianxiety and antipsychotic medications were administered without adequate indications for their use, without adequate monitoring, and in the presence of adverse effects (lethargy and falls), and the resident's pain (which was not identified as a possible underlying cause of her behaviors) was left untreated. -- b) Resident #159 On 08/09/11 at approximately 10:25 a.m., medical record review for Resident #159 revealed she received the medication [MEDICATION NAME] 1 mg po (by mouth) twice a day everyday for [MEDICAL CONDITION] since 08/18/10. Further medical record review found the resident did not have an active [DIAGNOSES REDACTED]. Interviews with Employee #27A (the director of nursing - DON) and Employee #28A (an RN consultant) revealed no supporting [DIAGNOSES REDACTED]. .

Based on medical record review and staff interview, the facility failed to ensure the medication regimen of one (1) of thirteen (13) sampled residents was free of unnecessary drugs. On 06/25/11, Resident #59 was admitted to the facility with orders for [MEDICATION NAME] (an anticoagulant) via subcutaneous (SQ) injection [MEDICATION NAME] to prevent the development of blood clots after having undergone surgical repair of a fractured femur. The resident continued to receive daily injections of [MEDICATION NAME] until 10/05/11, when the medication was not available for administration from the pharmacy. Staff notified the family nurse practitioner (FNP) about the lack of availability of the medication, and she ordered staff to hold the medication on 10/05/11; the [MEDICATION NAME] was subsequently discontinued on 10/06/11. Interview with staff revealed that the [MEDICATION NAME] was no longer needed after the resident had returned to his prior level of functioning, which he did on 09/15/11. The resident continued to receive this medication for an additional three (3) weeks without indications for its use. Resident identifier: #59. Facility census: 102. Findings include: a) Resident #59 Record review revealed this [AGE] year old male had been admitted to the facility for aftercare of a surgically repaired [MEDICAL CONDITION] on 06/25/11. He was ordered [MEDICATION NAME] 40 mg/0.4 ml solution SQ everyday for a personal history of venous [MEDICAL CONDITION] and embolism on 06/25/11. An order in the medical record revealed the administration of [MEDICATION NAME] was placed on hold on 10/05/11 due to the medication not being available from the pharmacy. It was then discontinued on 10/06/11. In an interview with the FNP on 10/27/11 at 2:05 p.m., she recalled the resident had done well after his surgery and was almost as mobile as he had been prior to the intervention. The facility had contacted her on 10/05/11 and explained the medication was unavailable from pharmacy, and she instructed them to put it on hold. The next day, on 10/06/11, it was discontinued. She reported that it was not going to hurt the resident if the medication was not available, since he was up and about and had done well in physical therapy. Review of physical therapy notes, dated 09/15/11, found Resident #59 had met all therapy goals and had returned to to his prior level of functioning. He was to participate in walk-to-dine program with staff, and staff was educated to ensure the resident wore his knee brace when ambulating. On 10/27/11 at 3:00 p.m., the director of nursing (DON - Employee #12) reported to the surveyors that she had had a conversation about Resident #59's [MEDICATION NAME] with the FNP. The DON related that the FNP had told her the [MEDICATION NAME] would have only been an unnecessary drug for no longer than the past three (3) weeks and that its continued use did not cause him any harm. Regarding the missed dose of [MEDICATION NAME] on 10/05/11, the DON stated the facility's policy directed staff to obtain the medication from the emergency drug box if a dose was not available in the medication cart for administration to the resident; the DON acknowledged that staff failed to do this for the 10/05/11 scheduled dose of [MEDICATION NAME]. Instead, staff contacted the FNP, who placed a hold on the medication. Staff did not retrieve a dose of [MEDICATION NAME] from the emergency drug box when there was still an active order for the drug's use at the time. .