Every finding on record at Pinnacle Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 out of 30 sampled residents, a resident's nasogastric (NG) tube feed did not have the formula bag labeled with the complete date and time of the administration. Resident identifier: 54.Resident 54 was admitted to the facility on [DATE] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/25/26, resident 54's physician ordered an Enteral Feed every shift continuous tube feeding Jevity 1.2 with a rate of 30 mL (milliliter) an hour continuously for 24 hours. On 1/26/26 at 12:10 PM, an observation was made of resident 54's tube feed. The tube feed bag was labeled, 1/26 [two letter initials]. On 1/28/26 at 9:51 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 54 was on a continuous tube feeding. RN 1 stated that the night shift nurses switched the tube feed bags and that they should be labeled with the date, the time the tube feed started, and initial the tube feed bag. RN 1 stated that if the tube feed bag was not labeled with all of the information then you would not know when the tube feed was actually started. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that tube feeding bags should be labeled with the complete date and time it was started and signed by the nurse who started it. The DON stated that she expected staff to label tube feed bags with all of this information.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 30 sampled residents, Enhanced Barrier Precautions (EBP) were not worn for a resident with a Nasogastric (NG) feeding tube and the end of the NG tube was uncapped and touching an intravenous pole. Resident identifier: 54. Resident 54 was admitted to the facility on [DATE] with diagnoses which included, cerebral palsy, unspecified dysphagia, unspecified severe protein-calorie malnutrition, and cachexia. Resident 54's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 11:39 AM, an observation was made of resident 54. Resident 54 had an EBP sign on the door. On 1/26/26 at 2:52 PM, an observation was made of resident 54. Resident 54's tube feeding was beeping with a status of inactive. One end of the feeding tube was attached to an Intravenous (IV) pole uncapped and touching the metal pole. On 1/26/26 at 2:55 PM, an observation was made of Registered Nurse (RN) 1. RN 1 entered resident 54's room and donned gloves. RN 1 was observed to pick up the end of the feeding tube from the IV pole and reattached to the nasogastric (NG) tube. RN 1 was observed to not don a gown while attaching the tube feed. On 1/27/26 at 11:17 AM, an observation was made of resident 54 and the Speech Therapist (ST). The ST donned gloves and knelt on the floor. The ST began to administer different fluids and foods to resident 54. The ST was observed to feed multiple fluids and foods to resident 54 and to adjust resident 54 in her bed. On 1/27/26 at 11:47 AM, the ST was observed to exit resident 54's room. It should be noted that the ST did not wear a gown during the period of time she was in resident 54's room. A review of resident 54's speech therapy notes on 1/27/26 documented, . Patient was seen upright in bed with good alertness and attention. Patient tolerated x8 [times 8]trials of L4 [level 4] yogurt with anterior loss of bolus on 100% of trials. Patient tolerated x6 [times 6] trials of LO [level O] apple juice with anterior loss of bolus on right side (patient head was tilted more that way throughout trials). Patient trialed x1 L6 peach (cut in half} with some success, however, difficult to determine safety d/t [due to] patient unable to hold bolus in oral cavity as compared to other PO [oral] trials. Patient refused PO trials with applesauce and chocolate ensure. On 1/28/26 at 9:51 AM, an interview was conducted with RN 1. RN 1 stated that resident 54 had a feeding tube that was a continuous tube feed. RN 1 stated that whenever she was dealing with the feeding tube she needed to wear a gown and gloves. RN 1 stated that she reconnected resident 54's feeding tube on 1/26/26 and did not wear a gown. On 1/28/26 at 11:16 AM, an interview was conducted with the Certified Nursing Assistant (CNA) Coordinator. The CNA Coordinator stated that any resident with wounds, catheters, feeding tubes, or anything indwelling required Personal Protective Equipment (PPE). The CNA Coordinator stated that the sign on the door indicated to staff what PPE they were required to wear and for what activities. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that EBP was to be followed when residents have any open area on the skin, a port, or a feeding tube. The DON stated that staff should be wearing gowns and gloves when they hooked up or handled a tube feeding. The DON stated that anytime resident 54 was being fed by the ST, a gown should be worn.

Based on interview and record review it was determined the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments during visits. Specifically, for 1 out of 30 sampled residents, the physician did not include an evaluation of the resident's condition and total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. A review of resident 53's progress notes revealed: a. On 12/4/25 at 3:23 PM, a nursing note documented, Resident was seen by [Name redacted]. b. On 1/13/26 at 5:26 PM, a nursing note documented, [Name redacted] in to see resident. MD [medical doctor] reviewed labs, medication and answered all questions. Will continue to monitor. It should be noted that the physician progress note for 1/13/26 was unable to be located in resident 53's medical record. On 1/29/26 at 8:06 AM, an interview was conducted with the Health Information Management (HIM) Director. The HIM Director stated that one of the facility physicians does not write or dictate any medical records for the residents that he sees. The HIM Director stated that she would have to call the physician's office and request resident progress notes. The HIM Director stated that it was hard to track the resident's records down because the physician did not write in the resident's medical record. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility would send a form with the resident and the physician would write what he did at that appointment. The DON stated if the facility required in-depth notes they would call the physician's office and ask for the progress notes. The DON stated that the physician would send a worksheet back with the resident that included orders. The DON stated that after they requested the physician notes they would then scan the records into the resident's medical record. The DON stated that it was hard to get progress notes from the physician.

Based on observation, interview, and record review, the facility did not ensure that residents who were continent of bladder received services and assistance to maintain continence unless his or her clinical condition was or became such that continence was not possible to maintain. Specifically, for 1 out of 30 sampled residents, the resident was given a PureWick external catheter without an order or directions for use. Resident identifier: 53. Resident 53 was admitted to the facility on [DATE] with diagnoses which included, unsteadiness on feet, difficulty in walking, and muscle weakness. Resident 53's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 1:44 PM, a concurrent interview and observation was made of resident 53 and her room. There was a suction canister on the bedside table with a suction tube that contained a dark amber fluid. Resident 53 stated that she was continent when she came to the facility, but was non-weight bearing for a few weeks and was given a PureWick catheter to use so she did not have to get up to use the toilet. Resident 53 stated that staff changed the PureWick device a few times a week. A review of resident 53's medical record did not contain an order for a PureWick device or directions for use. Resident 53's care plan did not include a PureWick device. On 1/28/26 at 10:21 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 53 was continent of urine when she was first at the facility, but now had a PureWick device. CNA 1 stated that she was told of resident 53 using a PureWick through a CNA report. CNA 1 stated that resident 53 wore briefs in addition to the PureWick, On 1/28/26 at 11:18 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that there was a resident that used a PureWick in the facility and that this was a newer thing. The CNA Coordinator stated that CNAs had been trained on how to use the device and if CNAs had questions they could ask. On 1/28/26 at 2:04 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 53 had a PureWick device and had been using it for a couple of weeks. RN 2 stated that resident 53 did not want to have brief changes and was non-weight bearing for a couple of weeks. RN 2 stated that resident 53 was now weight bearing and was in physical therapy. RN 2 stated that PureWicks should have a doctor's order. RN 2 stated that she had not received any training from the facility regarding the use of the PureWick. RN 2 stated that she was unsure how often the PureWick device should be changed. On 1/28/26 at 2:06 PM, an interview was conducted with RN 3. RN 3 stated that the PureWick device should be changed every 24 hours and that the canister was cleaned once a week. RN 3 stated that a resident should have the use of a PureWick care planned. On 1/28/26 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 53 had been using a PureWick for the past two weeks and it was a new thing for the facility to use. The DON stated that resident 53 was using the PureWick device for dignity as she had been bed bound and non-weight bearing for a short period of time. The DON stated that they had tried to use the bed pan for resident 53, but she did not like it. The DON stated that a PureWick device required a doctor's order and resident 53 did not have an order. The DON stated that the use of a PureWick should be care planned.

Based on observation, interview, and record review, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 30 sampled residents, staff were not monitoring changes in skin conditions with a resident or documenting bandage changes. Resident identifier: 50.Resident 50 was admitted to the facility on [DATE] with diagnoses which included, Type 2 Diabetes and restless leg syndrome. Resident 50's medical record was reviewed 1/26/26 through 1/29/26. On 1/26/26 at 2:31 PM, a concurrent interview and observation was conducted with resident 50. Resident 50 stated that he had open sores on his lower leg and that he had them for at least a week. Resident 50 stated that he had informed a nurse a week ago and she had put bandages on his legs, but that he was bleeding through the bandages onto his socks. It should be noted that there was no documentation regarding any leg wounds, or treatment for the wounds for resident 50. An observation was made of resident 50's lower right extremity. The right extremity below the knee was observed to be reddish-purple in color and had a large bandage that was covering a wound that was draining a serosanguineous fluid through the bandage and onto the resident's sock. There were two additional areas that were draining a serosanguineous fluid that were not covered. On 1/26/26 at 2:42 PM, an observation was made of resident 50 getting a dressing change by Registered Nurse (RN) 2. RN 2 was observed to tell resident 50 that she needed to make sure that his wounds were documented in the computer to be assessed every day. RN 2 was observed to apply bandages to 3 wounds. On 1/27/26 at 2:56 PM, an interview was conducted with resident 50. Resident 50 stated that the nurse had not assessed his legs or changed the bandages on his leg for today. [It should be noted that there was no order for wound care or a progress note that documented resident 50's skin condition located in the medical record.] A review of resident 50's care plan goal initiated on 8/6/25 revealed that resident 50 would have intact skin, free of redness, blisters or discoloration through the review date. Interventions for resident 50 included, daily body checks, notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. On 1/28/26 at 10:32 AM, an interview was conducted with RN 2. RN 2 stated that skin checks were done usually every shift. RN 2 stated that if she noted any abnormal skin condition then she would notify the doctor and the staff wound nurse. RN 2 stated that on 1/26/26 she was notified by resident 50 about his wounds. RN 2 stated that she had thought she had put in an order for wound care, but was unable to locate the order in resident 50's medical record. RN 2 stated that a different nurse should have documented that they had applied bandages to resident 50 before 1/26/26 when she had changed them. On 1/28/26 at 10:44 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that he was the wound nurse for the facility. The ADON stated that RN 2 had informed him about resident 50's legs on 1/27/26, but he had not assessed them yet. The ADON stated that if nurses noticed any skin changes on residents they would have to put in a risk management note which would alert him to assess the resident. The ADON stated that the nurses were supposed to notify the physician about any skin conditions changes, dress the wounds, and place a standard order for wound dressing changes in the resident's medical record. The ADON stated that he did not know why RN 2 had not put in an order for dressing changes or a risk management note for resident 50. On 1/28/26 at 11:59 AM, a follow-up interview was conducted with the ADON. The ADON stated that RN 2 had not completed the incident report correctly or put in a progress note about resident 50's legs. The ADON stated that there was no order put in for wound care for resident 50 on 1/26/26, but that RN 2 had put in a late entry progress note and order on 1/28/26. The ADON stated that he had put in a new wound order for resident 50 to have his dressings changed three times a week and updated resident 50's care plan. On 1/29/26 at 8:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that if a nurse found any skin abnormalities they should clean and dress the area, notify the family and the physician, and complete a risk management form. The DON stated the nurse should put in an order for dressing changes until the wound nurse assessed it and changed the order.

Based on the comprehensive assessment of a resident, the facility must ensure that a resident's abilities in ADLs do not diminish unless the resident's clinical condition demonstrates that diminution was unavoidable. This includes ensuring the resident is provided the necessary care and services to maintain personal hygiene. Specifically 1 of 30 residents sampled, the facility failed to provide timely incontinence care after staff were notified of a soiled condition, resulting in the resident remaining in soiled clothing for one hour and 44 minutes. Resident identifier: 13 Resident 13 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, muscle weakness, and dementia.On 1/26/26 at 11:55 AM, an observation was made of resident 13 with soiled pants being assisted into room [ROOM NUMBER]. A staff member talked into their earpiece stating the resident needed assistance with a brief change. A continuous observation of resident 13 was then initiated.On 1/26/26 at 12:02 PM, an observation was made of a certified nursing assistant (CNA) entering room [ROOM NUMBER], asking resident 13 if she wanted her lunch in the dining room or her room. The CNA exited. Resident 13 was sitting in her recliner. On 1/26/26 at 12:21 PM, an observation was made of a CNA walking by resident 13's room. The CNA did not enter resident 13's room to check on or or change the resident.On 1/26/26 at 12:55 PM, an interview was conducted with resident 13. This surveyor asked resident 13 if she had her brief changed yet. Resident 13 initially replied yes, then reached down and felt her brief area and stated, Oh no they haven't, but they will soon.On 1/26/26 at 1:23 PM, an observation was made of a CNA who knocked on the door for room [ROOM NUMBER], entered the room, placed a meal tray in front of resident 13 and exited.On 1/26/26 at 1:23 PM, an observation was made of a staff member knocking and entering room [ROOM NUMBER]. The staff member stated to resident 13 she was there making sure the correct activities calendar was posted. The staff member exited.On 1/26/26 at 1:28 PM, an observation was made of staff bringing resident 13's roommate into room [ROOM NUMBER]. A CNA took a Hoyer lift into the room and closed the door.On 1/26/26 at 1:38 PM, a CNA exited room [ROOM NUMBER] and then another CNA exited the room and stated, You're all good [resident 13].On 1/26/26 at 1:39 PM, an observation was made of resident 13 in her recliner and she had a different pair of pants on. The resident was in need of an incontinence brief change from 11:55 AM to 1:28 PM, a total of one hour and 33 minutes. Review of resident 13's medical record was completed on 1/26/26 through 1/29/26.An Annual Minimum Data Set (MDS) dated [DATE] revealed that resident 13 had a Brief Interview of Mental Status (BIMS) score of 7 which indicated severely impaired cognition. On 4/15/19, a Care Plan was developed for resident 13 with the focus that she has bowel/bladder incontinence related to impaired mobility and dementia. The goal for resident 13 was to remain free from skin breakdown due to incontinence. Interventions were for brief use, and to change the incontinence briefs every two hours and as needed.On 1/28/26 at 3:47 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that rounding on residents happened every one to two hours. CNA 2 stated that during rounding the CNAs were to ask residents if they needed their brief changed, make sure the call light was within reach of the resident, and ask the resident if they were in need of anything. CNA 2 stated that they did not go around and check on residents prior to meals being served unless it was during the round time frame. CNA 2 stated that when she was rounding on resident 13, she would ask to check her brief because the resident did not typically self-report the need for a change. On 1/29/26 at 9:33 AM, an interview was conducted with the Activities Director (AD). The AD stated that, during the activity, she offered and encouraged residents to drink fluids. The AD stated that it was very common for resident 13 to have a wet brief at the conclusion of the activity. The AD stated that, whenever a resident needed a brief change, she or her staff radioed the nursing team to request a brief change. On 01/29/2026 at 9:48 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she expected brief changes to be completed as soon as possible, or within approximately 10 to 15 minutes. The DON further stated that while earpieces sometimes did not transmit, she expected that if Activities or Physical Therapy staff brought a resident back to their room, they would also push the call light to ensure a double system was in place.

Based on interview and record review, it was determined, for 2 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not identify a change in condition for a resident prior to her death and TED (Thrombo-Embolic Deterrent) hose were administered without a physician's order. Resident Identifiers: 31 and 51. Findings include: 1. Resident 51 was admitted on [DATE] and readmitted on [DATE] with diagnoses of atherosclerosis of native arteries of left leg with ulceration of other part of lower leg, muscle weakness (generalized), cognitive communication deficit, weakness, metabolic encephalopathy, peripheral vascular disease unspecified, embolism and thrombosis of arteries of the lower extremities, malignant neoplasm of unspecified site of female breast, occlusion and stenosis of unspecified carotid artery, non-pressure chronic ulcer of other part of left foot with other specified severity, abnormal weight loss, acute kidney failure, tubulo-interstitial nephritis not specified as acute or chronic, acquired absence of spleen, hypothyroidism unspecified, essential hypertension, hyperlipidemia, and pain. Resident 51's medical record was reviewed [DATE] through [DATE]. A wound care noted dated [DATE] stated, Patient had revascularization procedure to left and right lower extremities approximately 3 weeks ago. Wounds on left food were stable for ,d+[DATE] weeks following. I consulted with [name of company removed] Vascular specialist as well as [name of company removed] Wound Clinic providers. Vascular specialist reported that the procedure was not successful as he hoped and was unable to clear extremely hardened plaque from blood vessels but did the best he could and wanted to give the patient several weeks to recover from surgery and offered a larger, more invasive procedure to follow if patient was up for it. Patient recovered from anesthesia and surgery slower than anticipated but wounds remained stable. The wound nurse at [name of facility] sent me a photo [DATE] that was very concerning for rapidly declining wound and possible gangrene to which I immediately recommended they contact the vascular surgeon for recommendations. Vascular advised patient go to [local hospital] emergency department where she had workup and consult that showed the only option for treatment would be above knee amputation to which patient and family declined. Patient was sent back to [name of facility] yesterday and patient will transition to palliative/hospice care. Wound orders as of today are meant to align with goals of palliative/hospice care. I spoke with patient and her niece who has been very involved in her care and they both feel like nothing could have been done better or different. Goals of treatment going forward are to manage pain and odor and prevent infection as best as possible. A nursing progress noted dated [DATE] stated, deceased note: CNA [Certified Nursing Assistant] [name removed] had called me back to the residents room to come assess something new. The LE [lower extremity] in the groin area had started to mottle and her breathing started to sound like [NAME] stokes so I gave resident some morphine 0.5 [milligram] to help with SOB [shortness of breath] and pain. Resident was diaphoretic, very clammy skin, very cold assessed her heart, very fluttery. Called in the charge nurse [name removed] and she assessed her as well. We called her time of death at 0128 [1:28 AM] [DATE]. She was comfortable at time of death. I called family before she had passed to let them know she was going fast, then I called the DON [Director of Nursing] and [name of physician]. CNA's cleaned her up, did post mortem care before family showed. Let family visit as long as they wanted, then called [name removed] mortuary. Will be about 45 minutes to come and pick her up. Family will be staying till then. Son [name removed] took her bracelet and they put her had [sic] and teddy bear with her. The most recent nursing progress note prior to this note was dated [DATE]. There was no information documented about palliative care in the note. A weekly Interdisciplinary Team Skin Review dated [DATE] stated that, .Resident still declining. Family and MD [Medical Doctor] aware. Being assessed for hospice. A weekly Interdisciplinary Team Skin Review dated [DATE] stated that, .Resident still declining. Family and MD aware. A weekly nursing assessment dated [DATE] stated that, Resident has had a decline in condition . On [DATE] at 3:42 PM, an interview was conducted with CNA 1. CNA 1 stated that to identify a change in condition in a resident, she observed for confusion, symptoms of urinary tract infection, unusual behaviors, skin tears, and weakness. CNA 1 stated if she suspected a change in condition, she informed a nurse. On [DATE] at 10:45 AM, an interview was conducted with CNA 3. CNA 3 stated that she remembered resident 51. CNA 3 stated that resident 51's legs bothered the resident frequently, and that she had to use a lift because she was unable to stand up. CNA 3 stated that resident 51 had been acting differently leading up to her death. CNA 3 stated that she was bed bound and in lots of pain, so she was put on comfort measures. On [DATE] at 10:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a resident was admitted to hospice, RN 1 made sure a resident had all of their correct medications, hospice performed an assessment, and hospice made changes to orders and medications as needed. On [DATE] at 10:50 AM, an interview was conducted with RN 2. RN 2 stated when a resident was admitted to hospice, the hospice performed an evaluation. RN 2 stated that sometimes hospice changed medications around, completed advance directive if the resident was experiencing a decline. RN 2 stated that she remembered resident 51. RN 2 stated that resident 51 had some sores on her foot and insufficient blood flow. RN 2 stated resident 51 had stents placed in her leg. RN 2 stated when resident 51 was readmitted to the facility after her surgery, she was placed on the short term hall for privacy. RN 2 stated that she was not sure if resident 51 was formally admitted to hospice, but she was receiving comfort care. On [DATE] at 8:21 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that when a resident was admitted to hospice, she faxed information such as the resident's medication list and face sheet to the hospice company the resident or resident's family has chosen. The RA stated that referral paperwork for resident 51 was sent to hospice on [DATE] and provided a copy of the fax referral. The RA stated that she did not document when she provides a hospice referral in the medical record unless a resident was leaving the facility to go home on hospice. On [DATE] at 11:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 51 had been at the facility for several years. Resident 51 started to develop sores on one of her legs. The DON stated prior to the sores on her legs, resident 51 had been wheelchair bound and did not ambulate. The DON stated the sores on resident 51's legs were slow to heal. The DON stated the facility ordered an ankle brachial index test, which checks for blood flow. The DON stated there was found to be no blood flow in her leg with the sores. The DON stated resident 51 was sent to undergo surgery to take an artery from her other left and graft it onto the other leg. The DON stated the surgery did not work and a second surgery was discussed, however resident 51's family decided not to have the surgery. The DON stated resident 51 was admitted for several days before her leg turned purple. The DON stated the facility staff talked to resident 51's family about comfort care. The DON stated resident 51 was not provided hospice services because her son was not ready and did not want to put her on hospice. The DON stated resident 51's daily skilled nursing assessments stopped once she was moved from a skilled stay to private pay for comfort care after [DATE]. The DON stated that decline was gradual, but that it was not a significant change. The DON stated since resident 51's decline was a gradual, there was no documentation regarding resident's decline or the comfort cares provided. 47431 2. Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, urinary tract infection, kidney failure, disorders of peripheral nervous system, acidosis, and hyperkalemia. Resident 31's medical record was reviewed on [DATE]. A review of physician's orders revealed no order for TED hose for resident 31. A Skin/Wound Progress Note date [DATE] at 12:06 PM stated .Swelling has come down to ,d+[DATE]+ edema. Will discuss with therapy about compression. An Interdisciplinary team progress note dated [DATE] at 9:28 AM stated .Orders were put in. Appears [NAME] hose had bunched up on feet causing pressure in areas. Will remove [NAME] hose. Talked with therapy, okay to wrap if needed for edema but no [NAME] Hose . A review of Nursing Care Plan dated [DATE] revealed on [DATE] New onset infection related to abscess on left lateral foot. The intervention was wrap feet if needed/no TED hose. Another care plan dated [DATE] revealed on [DATE] actual impairment to skin integrity on left Dorsal ankle related to TED hose bunching and pressure. An intervention initiated on [DATE], TED hose removed. May wrap if needed for edema. On [DATE] at 10:30 AM, an interview with the Wound Nurse (WN) was conducted. The WN stated that resident 31 was experiencing edema in his legs and physical therapy (PT) recommended TED hose be placed on both legs. The WN stated during treatment the TED hose on his left leg bunched up around the bend of the ankle causing a wound to form in that area. The WN stated the TED hose were discontinued at that time. On [DATE] at 4:21 PM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that therapy recommended TED hose and referred to the Minimum Data Set (MDS) coordinator to complete a physician's order in the resident's medical record. At 4:30 PM, a follow up interview was conducted with PT 1. PT 1 stated she was unable to locate the physician's order for the resident 31's TED hose. On [DATE] at 4:54 PM, an interview was conducted with the WN and the Director of Nursing (DON). The DON stated TED hose should be ordered by a physician with instructions on when to put the TED hose on and when to take them off. The DON stated staff were to check for skin break down when putting TED hose on and when removing the TED hose. The DON stated that TED hose tend to slip and bunch so staff needed to check for bunching to prevent skin breakdown.

Based on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's blood pressure medication was administered outside of the physician ordered parameters. Resident identifier: 35. Findings included: Resident 35 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, hypertension, musculoskeletal system, difficulty walking, major depressive disorder and atrial fibrillation. Resident 35's medical record was reviewed 11/27/23 through 11/30/23. A physician's order dated 9/14/23 revealed, Metoprolol Tartrate Oral tablet. Give 12.5mg [milligrams] by mouth two times a day related to essential (primary) hypertension. A physician's order dated 9/14/23 revealed Blood pressure to be checked during weekly nursing assessment. Hold any HTN [hypertension] medication if B/P [blood pressure] is less than 100 systolic and/or 50 diastolic. If B/P is out of parameters recheck twice a day until stable. A review of resident 35's blood pressures revealed the following outside of parameters: 1. On 9/23/23, 99/66 2. On 10/13/23, 97/73 3. On 10/22/23, 95/57 4. On 10/27/23, 91/65 5. On 10/28/23, 82/68 6. On 10/29/23, 97/57 7. On 10/30/23, 96/59 8. On 11/1/23, 91/63 9. On 11/3/23, 94/66 10. On 11/12/23, 85/45 11. On 11/20/23, 97/56 Resident 35's Medication Administration Record (MAR) for September, October and November 2023 were reviewed. Resident 35 was administered Metoprolol Tartrate twice daily on 9/23/23, 10/13/23, 10/22/23, 10/27/23, 10/28/23, 10/29/23, 10/30/23, 11/1/23, 11/3/23, 11/12/23, and 11/20/23. There were no nursing progress notes located in resident 35's medical record regarding why Metoprolol was administered when blood pressures were outside of parameters. There were no documented blood pressures twice daily until stable located in resident 35's medical record. On 11/29/23 at 10:18 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated physician's orders were obtained from the hospital and faxed to the pharmacy upon admission. RN 2 stated the nurse entered the physician's orders into the residents medical record. RN 2 stated blood pressure medications were held if the blood pressures was less than 100 for systolic and less than 60 for diastolic. RN 2 stated if there was a physician's order for parameters then the medication would be held according to those orders. RN 2 stated blood pressures were obtained by the Certified Nursing Assistant's (CNA's). RN 2 stated there was a daily list of resident that needed a blood pressures so the CNA's knew who's blood pressure to check. RN 2 stated the blood pressures were obtained between 6:00 AM and 7:00 AM. RN 2 stated that residents that were at the facility long term usually had weekly blood pressure checks unless there was an order. RN 2 stated if the blood pressure medication was not held with a low blood pressure, then the blood pressure could go lower and cause light headedness and dizziness. RN 2 was observed to review resident 35's blood pressures and stated it looked like the Metoprolol should have been held according to the physician ordered parameters. RN 2 stated resident 35 should have had blood pressures done twice daily until stable, but that was not documented. RN 2 stated there were no nursing progress notes regarding why the Metoprolol was administered with the low blood pressures and why the blood pressures were not rechecked. On 11/29/23 at 10:28 AM, an interview was conducted with RN 1. RN 1 stated blood pressures were always checked prior to blood pressure medication being administered. RN 1 stated CNA's checked blood pressures in the morning. RN 1 stated when she was passing medications, she obtained another blood pressure. RN 1 stated CNA's gave a paper form to the nurses with all the blood pressures and then the nurses documented the blood pressures in the medical record. RN 1 stated resident 35 should have a progress note if the medication was administered when the blood pressure was outside of the parameters. RN 1 stated there were no nursing progress notes regarding the blood pressures in resident 35's medical record. RN 1 stated there were no follow-up blood pressures documented in resident 35's medical record. RN 1 stated the Metoprolol should have been held and blood pressures rechecked. On 11/29/23 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that RN 1 and RN 2 informed her that resident 35 had received Metoprolol when the blood pressures were outside of parameters. The DON stated she was not aware that the order was to obtain a blood pressure and then recheck twice daily until stable. The DON stated the physician's order for the parameters should have been connected to the physician's order for the Metoprolol, so the nurse checked the blood pressure and then administered the medications.

Based on interview and record review it was determine, for 1 of 33 sampled residents, that the facility did not obtain radiology services only when ordered by a physician. Specifically, an x-ray was obtained without a physician order. Resident identifier: 28. Findings include: Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, history of falling, dementia, major depressive disorder. Resident 28's medical record was reviewed 11/27/23 through 11/30/23. An x-ray dated 7/7/23 was in resident 28's medical record. There was no physician's order located in resident 28's medical record. On 11/30/23 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that a physician's order was obtained for an x-ray but then it was sent with the resident to the hospital. The DON stated that the copy of the x-ray order was not kept in the residents medical record.

Based on observation and interview, it was determined for 22 of 33 that the facility did not treat each resident with respect and dignity. Specifically, the facility did not serve residents sitting at the same table in the dining room at the same time. Resident identifiers: 3, 4, 6, 10, 11, 13, 16, 22, 26, 27, 29, 31, 32, 34, 37, 38, 41, 42, 154, 156, 205 and 206. Findings include: 1. A dining observation was conducted on 11/28/23 at 10:21 AM. The following was observed: a. There were multiple tables placed together to make a large table in the middle of the dining room. Residents were observed to be served at different times. Resident 10 and resident 13 were served at 10:43 AM. Resident 31 and resident 11 were served at 10:49 AM. Resident 16 was observed to be served at 10:51 AM. Resident 29 was served at 10:52 AM. Resident 26 was observed to enter the dining room at 10:52 AM and was served at 10:54 AM. Resident 3 was observed to be served at 10:58 AM. It should be noted there was a 15 minute difference between the first resident served and the last resident at the same table. 2. A dining observation was conducted on 11/30/23 at 10:24 AM. The following was observed: a. There were multiple tables placed together to make a large table in the middle of the dining room. Residents were observed to be served at different times. Resident 22 and resident 3 were served at 10:44 AM, resident 10 was served at 10:45 AM, resident 6 was served at 10:46 AM, resident 38 and resident 11 were served at 10:49 AM, resident 156 was served at 10:48 AM, resident 26 was served at 10:51 AM, resident 34 was served at 10:52 AM, and resident 29 and resident 13 were served at 10:53 AM. It should be noted there was a 9 minute difference between the first resident served and the last resident served at the same table. b. Another table near the Christmas Tree was observed. Resident 32 was served at 10:28 AM and resident 42 was served at 10:31 AM. c. Another table near the music speaker was observed. Resident 27 was served at 10:30 AM and resident 41 was served at 10:32 AM. d. Another table near the television was observed. Resident 4 was served at 10:28 AM and resident 206 served at 10:41 AM. e. Another table near the vending machine was observed to have resident 205 served at 10:37 AM, resident 37 at 10:41 AM and resident 154 served at 10:46 AM. On 11/30/23 at 10:43 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that between 10:15 AM and 10:30 AM there were two CNAs from the halls that came to help residents that required assistance with eating. At 10:30 AM, two additional CNAs came to help pass drinks and put on clothing protectors. CNA 1 stated usually there was one staff member from the kitchen passing trays in the dining room. On 11/30/23 at 11:15 AM, an interview was conducted with Dietary Aide (DA) 2. DA 2 stated that at 10:00 AM, the hall meal carts were sent to the hallways. At 10:30 AM, the kitchen started to serve residents in the dining room. DA 2 stated residents that required assistance were fed first, then residents who tended to leave the dining room if they were not served quickly, and then any other residents last. DA 2 stated that two residents were served at a time. On 11/30/23 at 11:19 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that at 10:00 AM, the first hall meal cart went to the hallway, followed by the second cart at 10:10 AM. The DM stated the kitchen staff then started to serve residents that required assistance in the dining room. The DM stated the residents that tried to leave the dining room before being served were served next and then the other residents. The DM stated that all residents sitting at the same table should be served together. The DM stated that 2 residents were served at a time. The DM stated there was one dietary staff member that passed trays in the dining room. On 11/29/23 at 4:06 PM, an interview was conducted with resident 4. Resident 4 stated that it usually took until somewhere between 5:00 PM and 5:30 PM for dinner to be served. On 11/29/23 at 4:19 PM, an interview was conducted with resident 34. Resident 34 stated that meals should be ready and served at 4:00 PM, but almost everyday he had to wait until 5:00 PM or later to be served his meal. On 11/30/23 at 11:27 AM, a a follow-up interview was conducted with resident 34. Resident 34 stated that it made him anxious when he had to wait for his meal to be served. Resident 34 stated that the long table in the center of the dining room was usually served last. On 11/30/23 at 11:28 AM, an interview was conducted with resident 6. Resident 6 stated that the kitchen only serves two residents in the dining room at a time. 30563

Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically, a resident was observed to have medications on the bedside table and was not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 156. Findings included: Resident 156 was admitted on [DATE] with diagnoses which included osteomyelitis, Type 2 diabetes with foot ulcer, lymphedema, and cellulitis of right lower limb. On 11/27/23 at 12:57 PM, an observation was made of resident 156's room. There were three medication bottles observed on resident 156's bedside table. On 11/27/23 at 3:33 PM, a follow-up observation was made of resident 156's room. The three medications on resident 156's bedside table were the following: a. Bean-O b. Lactase Supplement c. Equate Gas Relief (simethicone 125 mg) Resident 156's medical record was reviewed on 11/27/23. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident 156 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated cognition was intact. On 11/28/23 at 9:50 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that none of the residents on her unit had medications at their bedside. RN 2 stated that if a resident were to have medications at their bedside the resident would need to be assessed and care planned to be able to self-administer. No documentation could be located in resident 156's medical record indicating that resident 156 had been evaluated to safely self-administer medications. No physician's order could be located for the three medications found on resident 156 bedside table. On 11/29/23 at 3:59 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that she noticed that resident 156 had medications on her bedside table on 11/28/23 and she informed the nurse about it. On 11/29/23 at 4:18 PM, an interview with RN 2 was conducted. RN 2 stated that she found medication on resident 156's bedside table on 11/27/23 or 11/28/23, that was the first time she had seen the medications. RN 2 stated she took the medications from resident 156 and instructed resident she can have them back when she was discharged from the facility. On 11/29/23 at 1:10 PM, an interview with resident 156 was conducted. Resident 156 stated that she went to take her medications she had kept on her bedside table this morning and noticed that they were no longer there. Resident 156 stated that she was unaware when staff came in and took her medications from her room. Resident 156 stated that she wished she had her medications since she was dealing with diarrhea that morning. On 11/29/23 at 6:12 PM, an interview was conducted with Director of Nursing (DON). The DON stated that upon admission to the facility none of the residents were allowed to self-administer medication. The DON stated that if a resident really wanted to have any medication to self administer, the staff did an assessment. The DON stated that if a resident was approved to self administer medications, the resident was required to keep medication out of site from other residents. The DON stated that RN 2 came to her on 11/27/23 regarding resident 156 having medication on the bedside table. The DON stated she talked with RN 2 and resident 156 about the medications needing to be ordered from physician and placed in possession of facility staff. The DON stated resident 156 was okay with this and asked nursing staff for the medications when needed. On 11/30/23 at 11:13 AM, an interview was conducted with resident 156. Resident 156 stated that she would really like to have some of her medications to self administer. Resident 156 stated that over the past two days she had gas, diarrhea, and was feeling uncomfortable. Resident 156 stated that she took the medications regularly prior to admission.

Based on interview, observation, and record review it was determined, for 1 of 33 sampled residents, the facility did not allow resident the right to request, refuse and/or discontinue treatment and to formulate an advanced directive. Specifically, a resident's Provider Order for Life-Sustaining Treatment (POLST) form did not match in their electronic medical record. Resident identifiers:156. Findings included: Resident 156 was admitted on [DATE] with diagnoses which included osteomyelitis, Type 2 diabetes with foot ulcer, lymphedema, and cellulitis of right lower limb. Resident 156's medical record was reviewed on [DATE]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented that resident 156 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated cognition was intact. The Physician Orders for Life Sustaining Treatment (POLST) dated [DATE] was reviewed and marked as Do Not Resuscitate (DNR). Resident 76's Medication Administration Record (MAR) was reviewed and indicated a code status of CPR (Cardiopulmonary resuscitation)/Full Code. An active physician's order for resident 156 dated [DATE] states, CPR/ FULL CODE with no directions specified. On [DATE] at 1:10 PM, an interview was conducted with resident 156. Resident 156 stated that she requested that she was a DNR. Resident 156 stated that the red wristband she had on was to alert staff she did not want to be resuscitated if her heart was to stop. Resident 156 stated that she already had heart failure so if it was to stop, she did not want CPR. On [DATE] at 1:10 PM, an observation was made of a red wristband was on resident 156's left wrist. On [DATE] at 5:05 PM, an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that upon admission residents can choose to have a wristband placed on their wrist. RN 2 stated the green wristband was to alert staff the resident requested to be full code status, and a red wristband meant the resident requested a DNR status. RN 2 stated that if the wristband was not present, she reviewed the electronic medical record. RN 2 stated for resident 156 had a red band requested to be a DNR. RN 2 stated if the wrist band was not on resident 156 since the physician had not signed the POLST, she would treat as a full code. On [DATE] at 6:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident admitted to the facility the advance directive was assessed and a POLST form was filled out and signed by the resident. The DON stated everyone came to the facility as full code status until the physician signed the POLST. The DON stated that the code status alert wristband should not go on until the order was signed and completed. The DON stated that a green wristband indicated a full code, and a red wristband was for a DNR.

Based on observation, interview, and record review, it was determined, the facility did not ensure that services provided met professional standards of quality. Specifically, for 1 of 33 sampled residents, orders were being checked off as completed for catheter care when a catheter had been discontinued. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, urinary tract infection, unspecified kidney failure, disorders of peripheral nervous system, acidosis, and hyperkalemia. On 11/27/23 at 12:54 PM, an observation was made of resident 31 laying in bed, there was no Foley catheter bag hanging on his bed or near resident. Resident 31's medical record was reviewed on 11/27/23. Review of resident 31's physician's orders revealed the following: a. Catheter care q (every) shift with a start date of 11/10/23. A review of resident 31's November 2023 Medication Administration Record (MAR) for Catheter care q shift order revealed the following: a. 11/27/23 Day shift marked as completed. b. 11/27/23 Night shift marked as completed. c. 11/28/23 Day shift marked as completed. d. 11/28/23 Night shift marked as completed. e. 11/29/23 Day shift marked as completed. On 11/29/23 at 4:12 PM, an interview with Registered Nurse (RN) 2 was conducted. RN 2 stated that resident 31 had his catheter discontinued on either 11/27/23 or 11/28/23. RN 2 stated that the Certified Nursing Assistants (CNAs) completed the care regarding catheters. RN 2 stated she followed up with the CNAs to verify the ordered care was completed and then check off the order as administered. On 11/29/23 at 6:12 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she discontinued and removed the catheter for resident 31. The DON stated that she forgot to discontinue the Catheter care q shift order. The DON stated that the nurse should take out any obsolete orders. The DON stated that nursing staff should be reading the orders prior to charting and marking the order as completed.

Based on interview and record review, it was determined that the facility did not conduct quarterly review assessments of the comprehensive care plans by the interdisciplinary team (IDT). Specifically, for 4 out of 30 sampled residents, the facility did not have quarterly review assessments of the comprehensive care plans by the IDT. Resident identifiers: 4, 5, 42, and 250. Findings included: On 2/24/22 a review of resident records was completed regarding care planning. 1. Resident 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 5's medical record indicated IDT-Care Plan Reviews were held on 7/6/21 and 10/21/21. Based on resident 5's medical record, resident 5 had not had an IDT-Care Plan Review since 10/21/21, which indicated resident 5 had not had an IDT-Care Plan Review in 4 months. 2. Resident 250 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 250's medical record indicated an IDT-Care Plan Review was held on 6/30/21. Based on resident 250's medical record, resident 250 had not had an IDT-Care Plan Review since 6/30/21, which indicated resident 250 had not had an IDT-Care Plan Review in greater than 7 months. 3. Resident 4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 4's medical record was reviewed on 2/22/22. Resident 4's medical record indicated IDT Care Plan Reviews were held on 8/14/20, 7/12/21, and 1/17/22, instead of quarterly. 4. Resident 42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident 42's medical record was reviewed on 2/22/22. Resident 42's medical record indicated IDT Care Plan Reviews were held on 7/16/21 and 12/15/21, instead of quarterly. On 2/24/22 at 10:45 AM, an interview was conducted with the Minimum Data Set (MDS) Registered Nurse (RN). The MDS RN stated that care planning meetings were held at least quarterly (every three months). She stated the Resident Advocate was responsible for scheduling the care planning meetings. On 2/24/22 at 11:30 AM, an interview was conducted with the Resident Advocate. The Resident Advocate stated that care planning meetings were held quarterly. She stated if the documentation was not in the Electronic Health Record (EHR) in the Standard Assessment tab under IDT - Care Planning Review type, the care planning meeting was not held. The Resident Advocate also stated that the EHR was supposed to alert staff that the care plan needed to be reviewed quarterly. The Resident Advocate stated she was unaware that the EHR was not alerting staff as it was supposed to, and this may have been the reason some of the care plans had not been reviewed in a timely manner.

Based on observation and interview it was determined, for 1 of 30 sample residents, that the resident was not able to make choices about aspects of her life in the facility that were significant to the resident. Specifically, the facility did not allow the resident the right to smoke cigarettes at times deemed desirable to the resident, instead only allowing the resident to smoke during the facility designated smoking times. Resident identifier: 27. Findings include: Resident 27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .On 2/22/22 at 1:09 PM, an interview was conducted with Resident 27. In the interview Resident 27 stated that she wished that the facility .would let me smoke when I like. Resident 27 expressed a dislike of the facility's smoking schedule and stated- I've been a smoker my whole life but here I am being told no I can't go smoke, I gotta wait for staff. On 2/22/22 at 2:22 PM, an interview was conducted with Registered Nurse (RN) 1 who stated that residents were allowed to smoke at this facility, but a smoking schedule was followed. RN 1 obtained a physical copy of the smoking schedule and stated that some residents try to push it and go out whenever they want, but we stick to the schedule. It makes everything run much smoother.On 2/23/22 at 12:39 PM, an interview was conducted with the facility's Resident Advocate (RA). The RA stated, All our residents are supervised when they go out smoking and nobody is allowed to go out to smoke unless it's during one of the scheduled times. They all know this, the times are posted.On 2/23/22 at 12:46 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3 who stated, Nobody is allowed to smoke without staff being there, it wouldn't be safe. Nobody can smoke on their own here-we have a schedule for that.On 2/23/22 a record review was conducted. Resident 27's smoking assessments from 12/20/21, 09/20/21, 06/20/21, and 03/20/21 indicated that Resident 27 was assessed as not having a need for assistance while smoking and assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/22 an interview was conducted with the Director of Nursing (DON). I stick to the scheduled smoke times we have, and we have six times. I do have residents that push it and I try to accommodate that, and we may have it start late sometimes, but we don't ever skip it. Only just a late start. I don't have a resident that is safe here to smoke by themselves. If someone is safe 100% then they can go out by themselves. On 2/23/22 a copy of the facility's smoking policy was reviewed. The policy stated that facility designated smoking times were at : 8 AM, 11 AM, 2 PM, 6 PM, 9 PM, and 11 PM. The policy also stated that, If it is determined that a resident is a safe smoker, smoking materials will still be retained by nursing staff and they may come and request 1 or 2 cigarettes at the time they desire to go out to smoke unsupervised.

Based on interview and record review, it was determined that for 2 of 17 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not adequately monitor and order laboratory tests for residents on [MEDICAL CONDITION] medication as recommended by pharmacists in the Pharmacy Consulting Report. Resident identifiers: 24 and 25. Findings include: 1. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/6/19 residents medical records were reviewed. A review of progress notes/labs showed that a [MEDICAL CONDITION] Stimulating Hormone (TSH) level was drawn in (MONTH) (YEAR). A review of resident 25's Pharmacy Consult Reports (PCR) revealed that in (MONTH) of 2019 the Pharmacist noted that he couldn't find a recent TSH level for resident 25 and recommended that a TSH level be checked with the next routine labs, because resident 25 was receiving a medication to treat her [MEDICAL CONDITION]. In (MONTH) of 2019 the Pharmacist noted that: there was not a recent [MEDICAL CONDITION] lab for resident 25 and that the last TSH on file done (MONTH) (YEAR). The recommendation was to check [MEDICATION NAME] (T4) and TSH with the next routine lab draw. In (MONTH) 2019 the Pharmacist requested that nursing follow up with the physician to see if yearly [MEDICAL CONDITION] labs (TSH, T4) should be ordered. In (MONTH) of 2019 the Pharmacist noted that he did not find a recent [MEDICAL CONDITION] lab report to monitor the [MEDICATION NAME] supplement that resident 25 was receiving. The recommendation was to check the TSH, T4 levels with the next routine lab draw. A review of resident 25's physician orders [REDACTED]. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/4/19. Resident 24's physician orders [REDACTED]. A review of resident 24's laboratory results revealed that the last [MEDICAL CONDITION] Stimulating Hormone (TSH) level was drawn on 3/1/18. The TSH level on 3/1/18 was within normal limits listed on the laboratory sheet. A review of resident 24's pharmacy recommendations indicated that in (MONTH) 2019, the pharmacist had recommended that resident 24 have a TSH level drawn again, as well as a Basic Metabolic Panel (BMP). Neither a BMP nor a TSH level could be located in resident 24's medical record after 3/1/18. On 11/6/19 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that in (MONTH) 2019, facility staff had identified that pharmacy recommendations had not been followed up on consistently, and they had since taken measures to correct this issue. The DON stated that she was under the impression that staff had gone back to insure that all pharmacy recommendations were acted upon. However, the DON confirmed that resident 24's TSH and BMP and not been drawn, even after the issue was identified in (MONTH) 2019. With regard to resident 25, the DON confirmed that the resident's TSH and T4 had not been drawn despite multiple recommendations to do so by the pharmacist. The DON stated that resident 25's physician had been contacted that day and had ordered a TSH to be drawn.

Based on interview and record review it was determined for 2 of 17 sample residents that the facility did not act upon pharmacy recommendations in a timely manner. Specifically, recommendations to draw blood levels for medication monitoring were not followed up for several months. Resident identifiers: 24 and 25. Findings include: 1. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/6/19 resident 25's medical records were reviewed. A review of progress notes/labs showed that a [MEDICAL CONDITION] Stimulating Hormone (TSH) level was drawn in (MONTH) (YEAR). A review of resident 25's Pharmacy Consult Reports (PCR) revealed that in (MONTH) of 2019 the Pharmacist noted that he couldn't find a recent TSH level for resident 25 and recommended that a TSH level be checked with the next routine labs, because resident 25 was receiving a medication to treat her [MEDICAL CONDITION]. In (MONTH) of 2019 the Pharmacist noted that: there was not a recent [MEDICAL CONDITION] lab for resident 25 and that the last TSH on file done (MONTH) (YEAR). The recommendation was to check [MEDICATION NAME] (T4) and TSH with the next routine lab draw. In (MONTH) 2019 the Pharmacist requested that nursing follow up with the physician to see if yearly [MEDICAL CONDITION] labs (TSH, T4) should be ordered. In (MONTH) of 2019 the Pharmacist noted that he did not find a recent [MEDICAL CONDITION] lab report to monitor the [MEDICATION NAME] supplement that resident 25 was receiving. The recommendation was to check the TSH, T4 levels with the next routine lab draw. A review of resident 25's physician orders [REDACTED]. 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 11/4/19. Resident 24's physician orders [REDACTED]. A review of resident 24's laboratory results revealed that the last TSH level was drawn on 3/1/18. The TSH level on 3/1/18 was within normal limits listed on the laboratory sheet. A review of resident 24's pharmacy recommendations indicated that in (MONTH) 2019, the pharmacist had recommended that resident 24 have a TSH level drawn again, as well as a Basic Metabolic Panel (BMP). Neither a BMP nor a TSH level could be located in resident 24's medical record after 3/1/18. On 11/6/19 at 9:15 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that in (MONTH) 2019, facility staff had identified that pharmacy recommendations had not been followed up on consistently, and they had since taken measures to correct this issue. The DON stated that she was under the impression that staff had gone back to insure that all pharmacy recommendations were acted upon. However, the DON confirmed that resident 24's TSH and BMP and not been drawn, even after the issue was identified in (MONTH) 2019. With regard to resident 25, the DON confirmed that the resident's TSH and T4 had not been drawn despite multiple recommendations to do so by the pharmacist. The DON stated that resident 25's physician had been contacted that day and had ordered a TSH to be drawn.

Based on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there was dust on the vents, lights and ceiling above the food preparation areas. In addition, there were foods not labeled or dated in the refrigerator, cracked tiles and peeling paint. Findings include: 1. On 10/22/18 at 9:23 AM, an initial tour was conducted of the facility kitchen. The following items were observed: a. There was a snack cart with a bag of trash tied onto the cart. The bag was hanging over the delivered food in the refrigerator. b. There was a container of Almond Breeze with an open date of 10/9/18. The container revealed to use within 7-10 days. c. There were 2 glasses of white liquid in the refrigerator with no date or label. d. There was an opened whipped topping with an open date of 9/10/18. The label revealed a shelf life of 2 weeks after thawed. e. There was brown splatter on the wall in they dry storage room by the sodas. f. There was peeling paint on the ceiling in the dishroom. g. There were cracked tiles with pieces of the tiles missing on the floor. h. There was dust on the light fixtures, ceiling, vents, and above the hood vent. The dust was above the food preparation area. i. There was a brown splatter on the wall above the hood vent. j. There was a vent above the coffee maker that had dust on it and around it. There was also a dark brown substance splattered on the ceiling above the coffee maker. 2. On 10/25/18 at 9:00 AM, a follow up tour of the kitchen was conducted. The following items were observed: a. There was dust on the light fixtures, ceiling, vents, and above the hood vent. The dust was above the food preparation area. b. There was a brown splatter on the wall above the hood vent. c. There was a vent above the coffee maker that had dust on it and around it. There was also a dark brown substance splattered on the ceiling above the coffee maker. d. There was brown splatter on the wall in they dry storage room by the sodas. e. There was peeling paint on the ceiling in the dishroom. f. There were cracked tiles with pieces of the tiles missing on the floor. On 10/25/18 at 9:25 AM, an interview was conducted with the Administrator. The Administrator observed the dust, peeling pain, and brown substance on the ceiling. The Administrator stated that the lights were replaced two weeks ago and all the dust was cleaned. The Administrator confirmed the cracked tiles were not sanitizable.

Based on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, medications were found in the medications room refrigerator that had been expired or were for residents who were no longer in the facility. In addition, nutritional supplements and powders were found in the facility medication room and were found to be expired. All medications and supplements were available for use by the facility nursing staff. Findings include: On [DATE] at 8:55 AM, an observation was made of the facility medication room and the medication room refrigerator. The facility medication room and facility medication room refrigerator revealed the following: a. One multi dose vial of [MEDICATION NAME] with an open date of [DATE]. b. Three [MEDICATION NAME] Injections for a resident who was no longer in the facility. c. One bottle of [MEDICATION NAME] with an expiration date of [DATE]. d. Two Ensure Nutritional Supplements with an expiration date of [DATE]. e. 25 packets of Juven Nutritional Supplement Powder with a best by date of [DATE]. On [DATE] at 8:55 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 verified the open date of the [MEDICATION NAME] and stated that it should have been discarded after 28 days. RN 2 verified the expiration date of the [MEDICATION NAME]. RN 2 verified that the resident was no longer in the facility. RN 2 verified the expiration dates of the supplements and stated that they should have been discarded. On [DATE] at 9:05 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that she had a question about the [MEDICATION NAME], and that it should have just been thrown out.

Based on interview and record review, it was determined for 3 of 32 sample residents, that the facility did not ensure that [MEDICAL CONDITION] drugs were not given unless the medication is necessary to treat a specific condition as diagnosed and documented in their medical records. Specifically, three residents, who were prescribed and received [MEDICAL CONDITION] drugs, did not have appropriate diagnoses documented in their medical record prior to 8/1/18. Resident identifiers: 12, 20, and 34. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses that include: hypertension, acute [MEDICAL CONDITION] infarction, asthma, pain, [MEDICAL CONDITION], dementia without behavioral disturbance, history of falling, difficulty walking, and muscle weakness. On 10/24/18 at 09:57 AM resident 20's medical record was reviewed. According to the diagnoses list for resident 20, resident 20's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. a. 5/29/18, [MEDICATION NAME] 25 milligram (mg) by mouth in the morning for impulse control and was discontinued on 8/1/18. b. 5/29/18, [MEDICATION NAME] 50 mg by mouth in the evening for impulse control and was discontinued on 8/1/18. c. 4/9/18, [MEDICATION NAME] 250 mg by mouth three times a day for behaviors and discontinued on 8/1/18. d. 8/1/18, [MEDICATION NAME] 25 mg by mouth in the morning for depression related to Major [MEDICAL CONDITION]. e. 8/1/18, [MEDICATION NAME] 50 mg by mouth in the evening for depression related to Major [MEDICAL CONDITION]. f. 8/1/18, [MEDICATION NAME] 250 mg by mouth three times a day depression related to Major [MEDICAL CONDITION]. According to the PASRR (Preadmission Screening and Resident Review) Level I dated 3/7/18 resident 20 did not have a serious mental illness and did not need to have a PASRR Level II completed The [MEDICAL CONDITION] Medication Review Form dated 3/28/18 revealed the following: a. [MEDICATION NAME] prescribed 3/16/18 for behaviors. The [MEDICAL CONDITION] Medication Review Form dated 5/31/18 revealed the following: a. [MEDICATION NAME] prescribed 3/16/18 for depression. b. [MEDICATION NAME] prescribed 5/29/18 for impulse control. The [MEDICAL CONDITION] Medication Review Form dated 8/23/18 revealed the following: a. [MEDICATION NAME] prescribed 5/28/18 for depression. b. [MEDICATION NAME] prescribed 4/9/18 for depression. The [MEDICAL CONDITION] Medication Review Form dated 9/25/18 revealed the following: a. [MEDICATION NAME] prescribed 3/6/18 for depression. b. [MEDICATION NAME] prescribed 5/29/18 for depression. No documentation indicating that resident 20's physician had completed an assessment leading to the new [DIAGNOSES REDACTED]. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses that include: hypertension, weakness, [MEDICAL CONDITION] without lower urinary tract symptoms, [MEDICAL CONDITION], hypo-osmolality and [MEDICAL CONDITION], altered mental status, [MEDICAL CONDITION] due to known physiological condition, [MEDICAL CONDITION] with delusions due to known physiological condition, [MEDICAL CONDITION] with behavioral disturbance, and difficulty walking. On 10/23/18 at 10:20 AM resident 34's medical record was reviewed. According to the diagnoses list for resident 34, resident 34's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. a. 7/18/18, [MEDICATION NAME] 200 mg by mouth daily for [MEDICAL CONDITION] related to [MEDICAL CONDITION] with delusions due to known physiological condition and was discontinued on 8/1/18. b. 7/18/18, [MEDICATION NAME] 300 mg by mouth at bedtime for behaviors related to [MEDICAL CONDITION] with delusions due to known physiological condition and was discontinued on 8/1/18. c. 8/1/18, [MEDICATION NAME] 200 mg by mouth daily for depression related to Major [MEDICAL CONDITION]. d. 8/1/18, [MEDICATION NAME] 300 mg by mouth at bedtime depression related to Major [MEDICAL CONDITION]. No documentation indicating that resident 20's physician had completed an assessment leading to the new [DIAGNOSES REDACTED]. On 10/24/18 at 3:05 PM an interview was conducted with the facility Director of Nursing (DON) and the facility Corporate Resource Nurse (CRN). The facility CRN stated that he completed an audit in (MONTH) (YEAR) on all residents with prescriptions for [MEDICAL CONDITION] drugs, to make sure there were appropriate diagnoses documented. The DON and CRN stated they contacted resident 20 and resident 34's physician, and informed them that resident 20 and resident 34 needed documented diagnoses indicating the appropriate use of the anti psychotic medications that were currently being prescribed. Diagnoses were suggested that fit resident 20 and resident 34's clinical condition and new anti psychotic medication orders were written. The new [DIAGNOSES REDACTED]. The CRN stated that when he added the new [DIAGNOSES REDACTED]. 3. Resident 12 was admitted to the facility on [DATE] with diagnoses which included [MEDICAL CONDITION], cerebral infarction, [MEDICAL CONDITION] arthritis, muscle weakness, and [MEDICAL CONDITION]. Resident 12's medical record was reviewed on 10/25/18. Resident 12's physicians orders revealed the following entries: a. On 11/17/17 and discontinued 8/1/18, [MEDICATION NAME] Tablet 100 MG Give 1 tablet by mouth at bedtime for dementia. b. On 8/1/18, [MEDICATION NAME] Tablet 100 MG Give 1 tablet by mouth at bedtime for Depression related to Major [MEDICAL CONDITION]. A review of resident 12's medical [DIAGNOSES REDACTED]. Resident 12's physician visits dated 10/5/18, 8/9/18, and 6/11/18 were reviewed and no [DIAGNOSES REDACTED]. No documentation indicating that resident 20's physician had completed an assessment leading to the new [DIAGNOSES REDACTED]. Resident 12's care plan dated 12/13/17 revealed, [MEDICAL CONDITION] medications use r/t (related to)Behavior management, Disease process cognitive deficit with Alzheimer's. Unsteady balance with wandering. The goal developed was, Will be/remain free of drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions developed were, Consult with pharmacy, MD (Medical Director) to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication. On 10/24/18 at 9:12 AM, an interview was conducted with the Medical Records Director. The Medical Records Director stated that she called the hospice agency and was told by the hospice agency employee that there were no changes to diagnoses documented. On 10/24/18 at 8:15 AM, an interview was conducted with the CRN. The CRN stated that the staff developer and he reviewed the diagnoses for residents that had ordered [MEDICATION NAME]. The CRN stated that they clarified diagnoses with the physicians but did not change the Preadmission Screening Resident Reviews (PASRR) and resubmit them. The CRN stated that dementia was not an appropriate [DIAGNOSES REDACTED]. On 10/24/18 at 8:40 PM, an interview was conducted with the DON. The DON stated that the CRN conducted an audit and changed the diagnoses for [MEDICATION NAME] and did not change the PASRRs and resubmit them. On 10/24/18 at 8:43 AM, a follow-up interview was conducted with the CRN. The CRN stated that the staff developer contacted the physicians regarding an appropriate [DIAGNOSES REDACTED]. The CRN stated that he did not know if the physician wrote a note about the new diagnosis. On 10/24/18 at 9:36 AM, a follow-up interview was conducted with the DON. The DON stated that she could not locate a physicians note related to a new [DIAGNOSES REDACTED]. According to the Nursing (YEAR) Drug Handbook by Wolters Kluwer. Philadelphia. Pages 1232-1234, and pages 1462-1465 revealed that the indicated use for [MEDICATION NAME] included Simple and complex absence [MEDICAL CONDITION], complex partial [MEDICAL CONDITIONS] migraine headache prevention. The indicated use for [MEDICATION NAME] included [MEDICAL CONDITIONS] Disorder with [MEDICAL CONDITION], depression associated with [MEDICAL CONDITION] Disorder, Major [MEDICAL CONDITION] and [MEDICAL CONDITION]. The black box warning for [MEDICATION NAME] revealed Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV (cardiovascular) disease or infection.

Based on observation, interview and record review, it was determined for 6 of 41 sample residents, that a resident who was unable to carry out activities of daily living received the necessary services to maintain. Specifically, 1) a resident did not receive timely services to maintain bowel continence and 2) five residents did not receive timely assistance with meals. Resident identifiers: 1, 4, 12, 34, 36, and 56. Findings include: 1. Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/6/14 at 1:12 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 34 had a pressure ulcer on his buttocks but was unsure of what stage it was. On 1/6/14 at 1:15 PM, an interview was conducted with RN 4. RN 4 stated that resident 34 had a wound on his testicles. RN 4 further stated resident 34's wound was healing and that it was not a pressure ulcer. RN 4 stated that the wound was caused from sitting in a soiled brief. On 1/6/14 at 3:31 PM, an interview was conducted with resident 34. Resident 34 stated that he would turn on his call light then the Certified Nursing Assistants (CNAs) would come in and turn off the call light, tell him they would return and then not come back. Resident 34 stated that the CNAs had explained to him that they did not have enough help and could not get to him right away. Resident 34 stated that he turned on his call light about a month ago at around 7:20 AM, the CNAs came in and turned off the light and told him that they would return. Resident 34 stated that his call light had not been answered for about 20 minutes. Resident 34 stated that he, "Had to let it go." Resident 34 stated that he had to, "Sit in my own filth" until approximately 8:20 AM. Resident 34 stated that he had developed sores on his scrotum approximately 3 months ago. Resident 34 further stated, "I got those because of sitting in my own filth. . . It's disgusting and belittling to have to sit in your own filth." On 1/7/14 resident 34's medical record was reviewed. A form titled "Comprehensive Resident Admission Assessment" dated 3/29/13 revealed that resident 34 was alert and oriented. The form further revealed that resident 34 was "always continent" of bowel. An initial Minimum Data Set ((MDS) dated [DATE] revealed that facility staff assessed resident 34 as being alert and oriented and was always continent of bowel. Resident 34's MDS dated [DATE] revealed that resident 34 alert and oriented to person place and time. Facility staff further assessed resident 34 as being frequently incontinent of bowel and required extensive assistance with toileting. Resident 34's care plan dated 5/7/13 revealed that resident 34 was "At risk for an ADL (Activities of Daily Living) self care performance deficit r/t (related to) recent decline." Resident 34's goals were, "Will maintain current level of function in (sic) through the review date. Will accept assist from the nursing staff for ADL cares." Interventions to achieve resident 34's goals were to "Monitor/document/report to MD (medical doctor) PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, (and) declines in function." On 1/7/14 at 9:00 AM, an interview was conducted with RN 2. RN 2 stated that resident 34 was an extensive 2 person assist with a hoyer lift. RN 2 stated that resident 34 had to wait when another resident was using the lift. RN 2 further stated that resident 34 experienced incontinent episodes waiting for assistance. RN 2 stated that resident 34 was continent of bowel if staff were able to toilet him in a timely manner. On 1/7/14 at 10:00 AM, an interview was conducted with CNA 2. CNA 2 stated that when she was alone on the hall, "a resident who requires the assistance of two people and a hoyer lift would have to wait even longer while staff found someone from another hall to help." On 1/7/14 at 10:50 AM, an interview was conducted with CNA 7. CNA 7 stated that residents were having accidents of bowel and bladder before getting the assistance that they needed. On 1/7/14 at 4:25 PM, an interview was conducted with CNA 5. CNA 5 stated that there had been times that they had not been able to get to resident 34 timely and that had resulted in resident 34 having a bowel movement in his brief. CNA 5 stated that if the staff could get to resident 34 timely then he would not have incontinent episodes. On 1/7/14 at 4:30 PM, an interview was conducted with CNA 4. CNA 4 stated that, "If you can get to (resident 34) timely, he can make it to the bathroom" and that he was continent of bowel and bladder. On 1/8/14 at 9:29 AM, an interview was conducted with CNA 1. CNA 1 stated that there had been times that resident 34 had been incontinent when the staff had not been able to get to him timely. On 1/8/14 at 9:40 AM, an interview was conducted with CNA 2. CNA 2 stated that if staff could get to resident 34 timely, he could get to the bathroom before having an accident. On 1/8/14 at 9:45 AM, an interview was conducted with CNA 7. CNA 7 stated that if "staff could get to (resident 34) timely, he is continent." 2. On 1/6/14 from 11:00 AM to 11:30 AM, the brunch service was observed. The meal cart arrived in the Special Needs Unit at 11:07. There was only one staff member to serve and assist the residents to eat until 11:30 AM. a. At 11:12 AM, resident 12 was served her meal. The facility staff did not assist resident 12 to eat until 11:19 AM, seven minutes after the meal was served. Review of the annual MDS assessment completed on 11/11/13 revealed that resident 12 required extensive assistance with meals. b. At 11:18 AM, resident 4 was served her meal. The facility staff did not assist resident 4 to eat until 11:27 AM, nine minutes after the meal was served. Review of the annual MDS assessment completed on 12/6/13 revealed that resident 12 required extensive assistance with meals. c. At 11:17 AM, resident 1 was served his meal. The facility staff did not assist resident 1 to eat until 11:26 AM, nine minutes after the meal was served. Review of the quarterly MDS assessment completed on 11/16/13, revealed that resident 1 required extensive assistance with meals. d. At 11:07 AM, resident 36 was served his meal. The facility staff did not assist resident 36 to eat until 11:29 AM, twenty two minutes after the meal was served. Review of the quarterly MDS assessment completed on 11/12/13, revealed that resident 36 required extensive assistance with meals. e. At 11:16 AM, resident 56 was served his meal. The facility staff did not assist resident 56 to eat until 11:29 AM, thirteen minutes after the meal was served. Review of resident 56's "Nutrition At Risk" care plan revealed that resident 56 was to receive assistance with meals when his wife was not in attendance.

Based on observation, interview and record review it was determined the facility failed to provide necessary care and services for 2 of 40 sampled residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, resident 74 was not treated in a timely manner for increased pain and was not treated in a timely manner for a stomach ulcer. Also, Resident 82 was not assessed and treated adequately for pain. Resident identifiers: 74 and 82. Findings include: 1. Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/16/12, resident 74 was discharged to the hospital for abdominal pain which resulted in a perforated bowel and surgery and reentered the facility. On 8/20/12 resident 74 had his gallbladder removed and came back to the facility. On 9/26/12 resident 74 went to the hospital for a port and fistula placement for [MEDICAL TREATMENT] and returned to the facility on [DATE]. The discharge Minimum Data Set (MDS) Assessment, dated 9/26/12, indicated resident 74 had a Brief Interview for Mental Status (BIMS) of 15, had constant pain at a level of 8, and needed extensive assistance with mobility and transferring. The admission MDS for the admission on 10/1/12 could not be located. A. A review of resident 74's medical record revealed resident 74 was not assessed and treated in a timely manner. Resident 74 had episodes of brown vomiting on 8/10/12. On 8/13/12, resident 74 was continuing with vomiting. There was no evidence that the physician was notified. On 8/16/12, resident 74 was transferred to the hospital for intense abdominal pain. Resident 74 was admitted for an acute perforated [MEDICAL CONDITION] ulcer. A review of Progress Notes for resident 74 revealed the following: a) On 8/9/12 resident 74's renal physician ordered a complete blood count with a differential and a renal panel before his next appointment. b) On 8/10/12: "Resident has had four episodes of vomiting this afternoon and evening. Physician was called and he ordered [MEDICATION NAME] 25 mg (milligrams) . . . every 4 to 6 hours. Resident was given [MEDICATION NAME] at 2000 (8:00 PM) but the resident vomited, brown in color, at 2130." c) On 8/12/12, a urinalysis was completed and indicated a urinary tract infection. The results were faxed to the physician. d) On 8/13/12 at 9:51 AM the note indicated resident 74 had laboratory results that included a red blood cell count of 4 (low), a hemoglobin of 11.4 (low) and a hematocrit of 34.7 (low). At 4:55 PM, the note indicated: "Resident having episodes of vomiting. Refuses nausea med (medication). Using cool wash cloths for comfort. Keeping head elevated. Offering fluids to prevent dehydration. Will continue to monitor." e) On 8/15/12: "Received lab results on UA (urinalysis): shows Staphylococcus Auricularis: Culture and sensitivity faxed to MD (medical doctor)." f) On 8/16/12 at 3:13 PM: ". . . Patient was referred to (hospital) for intense abdominal pain at 10 (AM). Follow up with hospital at 2:30 PM, patient's been admitted for possible perforated ulcer. Patients family notified at 2:50 PM." Resident 74's Medication Administration Record (MAR) and Weights and Vitals Summary were reviewed. They did not indicate vital signs were taken for resident 74 from 8/10/12 through 8/16/12. The hospital history and physical, consultation report, dated 8/16/12, indicated the primary [DIAGNOSES REDACTED]." On 10/24/12 at approximately 3:25 PM, Registered Nurse, (RN) 1 was interviewed. RN 1 was asked what he would do if a resident had a change of condition and was vomiting. RN 1 stated that vital signs would be taken and the change would be reported to the physician. RN 1 was shown his documentation on 8/10/12. RN 1 stated he was not sure if he took resident 74's vital signs that day. On 10/25/12 at 4:50 PM, the Director of Nursing (DON) was asked if she could provide further documentation that resident 74 had been assessed and treated before 8/16/12. The DON reported the facility was not aware that resident 74 had symptoms for six days prior to the perforated ulcer. B. On 10/22/12 at 3:37 PM, resident 74 was observed and interviewed. Resident 74 was favoring his left arm and holding it. Resident 74 was asked about his arm. Resident 74 reported he had a fistula put in several weeks ago and it had been hurting him "pretty much constantly". Resident 74 was asked what his pain level was. Resident 74 stated that it was "about a 6 right now, I can stand it if it's a 5." Resident 74 was asked if the pain medications helped him. He replied, "Not really, there is nothing they can do." Resident 74 reported he also had phantom pain in his right stump. Resident 74 was observed on 10/23/12, 10/24/12, and 10/25/12 at different times of the day. Resident 74 reported nothing was doing a very good job of relieving his pain. A review of resident 74's medical record revealed resident 74 was not reassessed for increased pain for 21 days after an arterial/venous fistula was placed in his left arm on 10/1/12. Prior to the placement resident 74 had a history of [REDACTED]. After the placement of the fistula, resident 74 complained of increased pain not only in the stump, but in his left arm. On the 24th day resident 74's pain medications were increased. The facilities Pain Risk Assessment for resident 74 were reviewed. An assessment, dated 6/4/12 revealed resident 74 scored 14, a high risk for pain. The assessment for 9/28/12, revealed a score of 11, a high risk for pain. (Note: The documentation on this assessment indicated the score was 13, however, the assessment added up to 11.) A review of resident 74's MAR for September 2012 and a review of physician orders [REDACTED]. a) [MEDICATION NAME] 25 micrograms per hour [MEDICATION NAME] every three days. This was initiated on 9/28/12. b) [MEDICATION NAME] 100 milligrams at bedtime for lower [MEDICAL CONDITION]. This was initiated on 8/23/12. c) An [MEDICATION NAME] 5 milligram every 3 hours as needed was initiated on 8/20/12. The care plan for chronic pain for resident 74 was dated 10/2/12. The goals were: a) "The resident will demonstrate pain relief through proper administration of [MEDICATION NAME] daily" b) "Resident will not experience any adverse side effects from medication daily." Interventions included: a) "Allow resident to vent concerns about living with chronic pain which includes anger, denial, sadness" b) "Evaluate residents verbal and nonverbal cues to assess the degree and severity of pain" c) "Observe resident for effectiveness from medication and obtain modifications as necessary in pain medication orders." The care plan did not mention the new pain from resident 74's fistula and did not include measures taken to reduce the pain, including diathermy, the [MEDICATION NAME], or the fact that the [MEDICATION NAME] was not effective in easing resident 74's pain. On 10/21/12 the physician was faxed the following: "Resident stated [MEDICATION NAME] 5 mg (milligrams) not effective in treating new pain since placement of [MEDICAL TREATMENT] fistula, chronic rating of pain 7-10 in left wrist, forearm, fingers. Resident also gets 25 mg of [MEDICATION NAME] (every) 72 hours and [MEDICATION NAME] 100 mg. Pt (patient) said it feels like nerve pain. Residents anxiety increases with pain levels as well. Please advise any changes". On 10/24/10 a fax from the physician indicated: "increase [MEDICATION NAME] to 5 mg 1 to 2 po (by mouth) q (every) 4 hours prn (as needed) pain." A review of the October 2012 MAR and Pain Rating Flow Sheet was made. Documentation of resident 74 receiving [MEDICATION NAME] October 1 and 2 could not be located. The Pain Rating Flow Sheet indicated resident 74 had a pain scale of 10 out of 10 every time [MEDICATION NAME] was given. From 10/3/12 to 10/23/12, resident 74 had [MEDICATION NAME] given as follows : a) Two [MEDICATION NAME] were given on one day. b)Two [MEDICATION NAME] were given two times on four days. c) One [MEDICATION NAME] was given two times a day on 10 days. d) One [MEDICATION NAME] was given each day on 8 days. Four doses of [MEDICATION NAME] that were documented on the Pain Rating Flow Sheet were reassessed for resident 74's response to the pain mediation. The rest did not have documentation. (Cross refer to F 281) Progress Notes were reviewed and revealed the following concerning resident 74's pain. The progress notes did not provide documentation that resident 74's pain medication had been effective or that resident 74's pain had been re-assessed. a)10/1/12: "Resident returned from (hospital), has a fistula placed in left arm dressing dry and intact. . . Resident c/o (complains of) pain 2 [MEDICATION NAME] 5 mg given. . . " b) 10/2/12: ". . . Medicated for pain as need (needed) and also has a pain patch. . . " c)10/4/12: ". . . resident takes [MEDICATION NAME] for pain with satisfactory results. . . " d)10/6/12, 10/7/12, 10/8/12: ". . . Medicate for pain as needed. . . . " On 10/20/12 an Interdisciplinary Team (IDT) meeting was held for resident 74. The IDT notes did not indicate that resident 74's pain was discussed. On 10/24/12 at 2:40 PM, Certified Nurse Assistant (CNA) 1 was interviewed concerning resident 74's pain. CNA 1 reported that pain made resident 74 not want to walk on his prosthetic leg. "He tells me it hurts like heck." CNA 1 reported, "Sometimes he calls for something for pain, usually his amputated leg hurts." CNA 1 was asked if resident 74 had anything else hurting him. CNA reported there was nothing else. On 10/24/12 at 3:00 PM, Registered Nurse (RN) 1 was interviewed concerning resident 74's pain. RN 1 reported resident 74 had [MEDICAL CONDITION] pain in his stump and increased pain in his arm since the fistula was placed. RN 1 reported that resident 74 had received a [MEDICATION NAME] for the pain in his arm, however, it "hasn't seemed to work". "We have tried it (the [MEDICATION NAME]) for three weeks. He is a quiet guy, just says it's hurting. I ask him if the pain has decreased and he tells me one pill helped, but is not enough." RN 1 was asked if residents were evaluated after the pain medication was given for effectiveness. RN 1 stated: "We are supposed to but sometimes I don't document it in the chart but I usually ask them." On 10/24/12 at 3:39 PM, RN 2 was interviewed concerning resident 74's pain. RN 2 reported resident 74 had intermittent pain and did not like to tell you if he was in pain. RN 2 reported she asked resident 74 if he was in pain when she did his blood sugar checks. RN 2 reported that resident 74 had more pain in the evening. RN 2 reported that resident 74 had told her that if his pain was over a 5 then he wanted a pain medication. RN 2 reported that resident 74 received [MEDICATION NAME] and it seemed to be working. RN 2 reported that resident 74 was not getting enough pain medication when he came back from the hospital for the fistula and it took a couple of days to get something for him. RN 2 reported that the effectiveness of the pain medication should be documented in the medical record. On 10/25/12 at 8:00 AM, Licensed Practical Nurse (LPN) 1 was interviewed concerning resident 74's pain. LPN 1 reported resident 74 had generalized pain and was receiving [MEDICATION NAME] ([MEDICATION NAME]), a pain patch and [MEDICATION NAME] that he took once a day. LPN 1 reported that she "sometimes asked the resident if the pain medication was effective." LPN 1 reported that the effectiveness of the pain medication should be documented in the medical record. 2. Resident 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 82 was not assessed and treated for [REDACTED]. A review of resident 82's medical record revealed resident 82 was not monitored and treated for [REDACTED]. The unrepaired [MEDICAL CONDITION] caused increased pain. On 10/8/12 resident 82 developed a pressure ulcer and later another pressure ulcer that caused resident 82 increased pain. (Cross refer to F 314) On 10/24/12 at 10:32 AM, a dressing change for resident 82's pressure ulcers was observed. When resident 82 was turned by facility staff, moaning was heard. When the pressure ulcers were cleaned, resident 82 gasped and cried out "it hurts." On 10/24/12 at approximately 1:30 PM, resident 82 was observed sitting in her wheelchair in her room. Resident 82 was insisting she be put to bed right away, because she hurt. On 10/25/12 at 8:05 AM, resident 82 was observed to be transferred from her wheelchair to her bed by CNA 1 and a physical therapist. Resident 82 cried out "it hurts, be careful". An admission MDS, dated [DATE], indicated resident 82 had a BIMS score of 7, verbal behaviors, resisted care, needed the extensive assistance of two people for bed mobility and transfers, was at risk for pressure ulcers, had a reducing device in her bed and chair and had pain frequently with a pain level of 3. A Pain Risk Assessment, dated 9/11/12, indicated resident 82 had a score of 11, at high risk for pain. The initial care plan for pain for resident 82, dated 9/11/12, indicated: "Pain related to fx L hip" (left [MEDICAL CONDITION]). Goal: "Will be free of pain". Interventions: "medicated as ordered. Assess and document response to each dose. Document effect in weekly/monthly summary Notify MD promptly if ineffective". Documentation that the facility followed this care plan could not be located. The DON initiated a new plan of care for pain for resident 82 on 10/23/12. Resident 82's care plan for pain had not been updated or revised for six weeks after admission. Documentation that resident 82's pain had been re-assessed was not located in the medical record. Resident 82's September and October 2012 physician orders [REDACTED]. A review of resident 82's MAR, Controlled Drug Record and Pain Rating Flow Sheet provided the following: The Pain Rating Flow Sheet indicated resident 82's pain level was 8 out of 10 on 2 days and the pain level was 10 out of 10 on 28 occasions that [MEDICATION NAME] was given. Resident 82's response or effectiveness of the pain medication was not documented. The Controlled Drug Record documented that 30, half tablets, or 15 [MEDICATION NAME] were provided by the pharmacy. Reviewing the Controlled Drug Record and the Pain Rating Flow Sheet, it was observed that the two were not the same. The Controlled Drug Record had different dates and times that [MEDICATION NAME] was given than the were on the Pain Rating Flow Sheet. All medications listed on the Pain Rating Flow Sheet should have been documented on the Controlled Drug Record. Between the two records resident 82 received [MEDICATION NAME] 7.5 mg for pain between 9/11/12 and 10/23/12: a) Resident 82 received a half of a 7.5 mg tablet on 7 days. b) Resident 82 received a half of a 7.5 mg tablet, two times, on two days. c) Resident 82 received 7.5 mg once a day for 24 days. d) Resident 82 received 7.5 mg two times a day for two days. The administration times and dosages were not consistent throughout the time with different times and doses. Medication was given in the morning or in the afternoon, however not consistently. Two faxes sent to the physician, dated 10/17/12 and 10/23/12 was reviewed. Also a progress note, dated 10/23/12, was reviewed. On 10/17/12 resident 82's physician was asked to review resident 82's pain medication due to the nurse's recommendation of increased pain caused by resident 82's pressure ulcers and hip. On 10/18/12, the physician was again asked for [MEDICATION NAME] as was discussed when the physician was in to see resident 82. A progress note, dated 10/23/12, written by the DON, indicated no order was ever received from the physician. Physician visit notes, dated 9/17/12 and 10/18/12 indicated: " . . . She (resident 82) indicates that she's not in any pain at this time. . . . " On 10/25/12 at 11:49 AM, the MDS coordinator reported she started a daily assessment for nurses to fill out on the electronic medical record. The daily assessment was started on 10/9/12. A daily assessment form was not completed before that time for resident 82. The daily assessment reports were reviewed and contained the following documentation concerning resident 82's pain and response to pain medication: (Note: The report is summarized and all days are not included.) a) On 10/9/12, 10/11/12, 10/12/12, 10/14/12, 10/15/12, 10/17/12,10/18/12, 10/22/12 and 10/23/12, the assessment indicated resident 82 had severe pain. b) On 10/16/12 and 10/19/12, the assessment indicated resident 82 had moderate pain. c) The daily assessments included the interventions of giving medication and turning and repositioning resident 82. The daily assessments did not include resident 82's response to the pain medication given. Progress Notes for resident 82 were reviewed for pain assessment or interventions. The following was found: a) "9/12/2012 21:00 (9:00 PM) Nursing Note Text: . . . Orders for PT (physical therapy) to increase [MEDICATION NAME] (sic) and endurance. Complained of pain this evening and was given pain medication with good results." b) "9/13/2012 14:19 (2:19 PM) IDT Note Text: Family here for initial IDT meeting. Discussed plan of care and what will be provided for her while she is here. She does state that she is in pain due to her hip Fx. . ." c) "9/13/2012 15:04 (3:51 PM) IDT Note Text: Family participated in IDT meeting today. (resident 82) stated that she did not want to go. My interactions with (resident 82) have always been positive she has stated to me that she wants to go home, but states that her hip really hurts. . . " d) "9/14/2012 12:41 (PM) Nursing Note Text: . . .resident is alert and oriented to self. has to be reoriented to place and time sometimes. is able to communicate and able to understand. her family (mostly her sons) are the decision makers for the resident. . . resident requires 2 person extensive assistance with bed mobility, transfers, dressing, personal hygiene, and bathing. resident does not ambulate or locomote (sic). she has a [MEDICAL CONDITION] that the family opted not to have surgically repaired. current treatment consists of pain medication and positioning the patient for optimum comfort. . . resident is very frequently in pain and is being medicated with one half to one [MEDICATION NAME] 7.5 every 4 to 6 hours as needed. . . . resident is very sweet, but is sometimes uncooperative with staff during cares because she is either in pain or afraid that she will be hurt during cares (turned onto hip or positioned the wrong way). resident takes no pyschotropic (sic) medications... " (Note: Resident 82 was not receiving [MEDICATION NAME], she was receiving [MEDICATION NAME].) e) 9/17/12, 9/18/12, " . . . medicated for pain as needed. . . " f) The note dated, 9/21/2012 11:15, is identical to the note on 9/14/12. g) "9/23/2012 11:34 Nursing Note Text: Medicare charting. . . Medicated x (times) one for pain. . . " h) "9/24/2012 13:28 Nursing Note Text: Medicare charting. . . Refuses to get out of bed R/T (related to) pain in left hip. Medicated to decrease pain. . . " i) "9/26/2012 15:44 Nursing Note Text: Medicare charting. . . Refuses to let aides move her very far and will not get out of bed. . . Pain controls also being worked on." j) The note dated, 9/29/2012 7:08 AM, is identical to the note on 9/14/12. k) The note dated, 9/30/2012 3:08 PM, is identical to the note on 9/14/12, except the following: ". . .resident frequently exhibits behavioral indicators of pain (however when asked if she is in pain she denies and states that she is "strong") and is being medicated with one half to one [MEDICATION NAME] 7.5 every 4 to 6 hours as needed. . . resident is very sweet, but is sometimes uncooperative with staff during cares because she is either in pain or afraid that she will be hurt during cares (turned onto hip or positioned the wrong way). . . " (Note: Resident 82 was not receiving [MEDICATION NAME], she was receiving [MEDICATION NAME].) l) "9/30/2012 15:08 Nursing Note Text: spoke with resident's daughter concerning the resident's PO (by mouth) intake. resident's daughter noticed that today when she was medicated for pain her PO intake increased greatly. resident was given 7.5 mg of [MEDICATION NAME] (1/2 tab at 9 am and 1/2 tab at 10 am.) resident will not ask for pain medication. medication was given based on behavioral indicators of pain. resident's daughter also noted that resident is much more calm and at ease since being medicated for pain. I will pass this on to the other nurses working with the resident." m) The note 10/5/12 is identical to the note on 9/30/12, indicating resident 82 was trying to tough it out and be "strong". Facility staff were interviewed concerning resident 82's pain assessment, treatment, and response to pain medication. On 10/25/12 at 8:50 AM, CNA 1 was interviewed. CNA 1 reported resident 82 did not complain of pain, "She just says I'm all right or leave me alone. She doesn't lay on her left side because of the pain in her hip. When she first came, she wouldn't let us touch her because of the pain, then pain meds were started." On 10/24/12 at 3:00 PM, RN 1 was interviewed. RN 1 reported that resident 82 had been in a lot of pain on admission. "It took two and a half hours to remove her from wheelchair to bed. She stated 'do not touch me or I will throw myself on the floor', finally she let us get her in bed. . . Up until the last few weeks she had been refusing brief changes and even dressing changes . . ." RN 1 reported that after giving pain medication the results should be evaluated and documented in the medical record. RN 1 stated it was supposed to be documented on the Pain Rating Flow Sheet or if not, in the progress notes. On 10/24/12 at 3:39 PM, RN 2 was interviewed. RN 2 reported she usually worked afternoon shifts at the facility. RN 2 stated that resident 82's granddaughters wanted resident 82 to have pain medication so she will be less anxious and want to have cares performed for her. RN 2 stated that resident 82's son wanted her up, but is most concerned about medicating his mother. RN 2 stated that the effectiveness of the pain medication should be documented in the medical record. On 10/25/12 at 8:30 AM, LPN 1 was interviewed. LPN 1 usually worked on the day shift with resident 82. LPN 1 stated she asked resident 82 about her pain every morning when LPN 1 gave her the food supplement. LPN 1 reported that if resident 82 had a frown on her face, she would ask her about pain. LPN 1 reported resident 82 had pain with turning. LPN 1 reported, if resident 82 had not had any pain medication during the night, LPN 1 would give resident 82 one tablet of [MEDICATION NAME] at about 10 AM. LPN 1 reported resident 82 hurt when she sat up and would not stay on her left side because her coccyx (pressure ulcer) or hip hurt. LPN 1 reported she usually documented resident 82's response to the pain medication in the medical record.

Based on record review and interview it was determined the facility did not notify the physician about a change of condition for 4 of 40 residents. Specifically, resident 47's physician was not notified of changed behaviors, resident 82's physician was not notified of the development of pressure ulcers, resident 52's physician was not notified of low blood pressures and resident 74's physician was not notified of symptoms of a [MEDICAL CONDITION] ulcer. Resident identifiers: 47, 52, 74, and 82. Findings include: 1. Resident 74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (Note: On 8/16/12, resident 74 was discharged to the hospital for abdominal pain which resulted in a perforated bowel with surgery then reentered the facility.) A review of resident 74's medical record revealed resident 74 was not assessed and treated in a timely manner. Resident 74 had episodes of brown vomiting on 8/10/12. On 8/13/12, resident 74 was continuing with vomiting. There was no evidence that the physician was notified. On 8/16/12, resident 74 was transferred to the hospital for intense abdominal pain. Resident 74 was admitted to the hospital for an acute perforated [MEDICAL CONDITION] ulcer. (Cross refer to F 309) On 10/24/12 at approximately 3:25 PM, Registered Nurse, (RN) 1 was interviewed. RN 1 was asked what he would do if a resident had a change of condition and was vomiting. RN 1 stated that vital signs would be taken and the change would be reported to the physician. RN 1 was shown his documentation on 8/10/12. RN 1 stated he was not sure if he took resident 74's vital signs that day and he did not call the physician. On 10/25/12 at 4:50 PM, the Director of Nursing (DON) was asked if she could provide further documentation that resident 74 had been assessed, the physician notified and treated before 8/16/12. The DON reported the facility was not aware that resident 74 had symptoms for six days prior to the perforated ulcer. 2. Resident 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (Cross refer to F 314) Resident 82's medical record was reviewed concerning assessment, notification of physician and interventions for resident 82's pressure ulcers. A Weekly/Monthly Skin Evaluation sheet indicated: On 10/8/12 skin intact "observing report of stage II dq (decubitus pressure ulcer) on coccyx red in crease of buttocks. " The picture on the evaluation indicated resident 82 may have had an old pressure ulcer site on the lower lumbar spine area and a pressure ulcer on the coccyx. On 10/24/12 at 3:39 PM, RN 2 was interviewed. RN 2 reported she usually worked afternoon shifts at the facility. RN 2 reported that resident 82 had a stage 2 hip pressure ulcer and the dressings were changed as needed. On 10/25/12 at 8:30 AM, LPN (Licensed Practical Nurse) 1 was interviewed. LPN 1 was the day shift nurse for resident 82. LPN 1 stated she believed the physician was notified of resident 82's pressure ulcers, but he was not notified by LPN 1. LPN 1 stated she was told by a night nurse that resident 82 had pressure ulcers. On 10/25/12 at 10:52 AM, the DON was interviewed. The DON reported she could not locate documentation that the physician was informed of resident 82's pressure ulcers or that orders were obtained. 3. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 52's medical record was reviewed on 10/24/12. October 2012 physician orders [REDACTED]. The medication was to be held if the blood pressure was less than 130/60. Resident 52's October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. From 10/1/12 through 10/22/12 resident 52's blood pressures were below 100/60 on ten occasions. On four consecutive days, with the 8:00 PM [MEDICATION NAME] dose, the blood pressures were as follows: On 10/19/12 the blood pressure was 89/43. On 10/20/12 the blood pressure was 76/48. On 10/21/12 the blood pressure was 95/41. On 10/22/12 the blood pressure was 85/56. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] was held. Documentation that the physician had been notified for the low blood pressures could not be located in the medical record. On 10/25/12 at 10:54 AM, the DON was asked how low blood pressures would have to be before the physician was notified. The DON reviewed the blood pressures for resident 52. The DON stated that if blood pressures were low, the blood pressure would be checked again in a few hours and would be documented in the electronic record and if the blood pressure was still low, the physician would be notified. The electronic vital sign summary was reviewed for resident 52. Blood pressures were not documented on the summary for the days and times resident 52 had low blood pressures. 4. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/22/12 resident 47's medical record was reviewed. Facility progress notes for resident 47 revealed the following: a) On 6/25/12 at 5:00 PM "Social Services . . . Resident has had some inappropriate sexual behaviors. Resident also has stated that he is thinking of harming himself. (Name of local mental health agency) called in (Name of therapist). He assessed pt (patient) (and) reported back that he does not believe he is a danger to himself and is responding to being confronted about those behaviors. Pt will be placed on 15 min (minute) checks. Notified nurse, DON (Director of Nursing), (and) Administrator." b) On 6/26/12 at 10:15 AM "Social Services . . . Pt has been on 15 min checks throughout the night. He is refusing to get up this am and is refusing meals. He states that he has thoughts of harming himself. He would take a bottle of aspirin if someone would give it to him. This seems to be related to him being confronted about sexually inappropriate behaviors which was (sic) reported to APS (Adult Protective Services) (and) PD (Police Department)." c) On 6/26/12 at 3:00 PM "Late Entry . . . Social Services . . . Pt was transferred to the (Name of Inpatient Psychiatric Hospital) for a psychiatric hospitalization r/t (related to) his suicidal ideation (and) sexually abusive behavior. He was transported by ambulance as (sic) when asked to go on the van he attempted to get out to the street to 'get in front of a car' and was seen trying to disassemble an electrical outlet in order to shock himself. Will continue to work with his daughter and the hospital staff to find an (sic) more appropriate placement for pt." No documentation could be located to indicate that resident 47's physician had been notified of the resident's change in condition, or the necessity to evaluate the resident for discharge. On 10/23/12 at 3:10 PM, an interview was conducted with the Medical Records Director (MRD). The MRD stated that at the time resident 47 was discharged from the facility, the resident's physician was on vacation. In addition, the MRD stated that she had contacted the physician's office, and verified that the physician had not been contacted regarding resident 47's change in condition or need for subsequent discharge. On 10/23/12 at 3:35 PM, an interview was conducted with the DON. The DON stated that she did not notify resident 47's physician regarding the change in condition, or need for subsequent discharge. On 10/23/12 at 4:00 PM, an interview was conducted with the facility Administrator. The Administrator stated that resident 47 was "being inappropriate with a female resident". The Administrator then stated that they had called the police regarding the incident, and that resident 47 "knew he was in trouble so that's when he started making suicidal statements." The Administrator stated that the Social Worker felt that it was essential that resident 47 be sent to the emergency room . The Administrator confirmed that the physician had not been notified regarding resident 47's change in condition, or need for subsequent discharge. The Administrator stated "We were trying to protect the resident and she (the Social Worker) forgot to tell the doctor."