Every finding on record at Putnam Center

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of two (2) shower rooms observed during the long-term care survey process. Facility Census: 115.Findings include: a) Genesis Policy OPS200 titled Safe and Homelike Environment states: Policy: The resident/patient has the right to a safe, clean, comfortable, and homelike environment that de-emphasizes the institutional character of the setting. Definitions: Orderly is defined as an uncluttered physical environment that is neat and well kept. Sanitary includes, but is not limited to, preventing the spread of disease causing organisms by keeping patient care equipment clean and properly stored. Patient care equipment includes, but is not limited to, equipment used in the completion of activities of daily living. Purpose: To provide a safe, clean, comfortable, and homelike environment. Process: The center must provide: A safe, clean, comfortable, and homelike environment, allowing the patient to use his/her personal belongings to the extent possible. This includes ensuring that the patient can receive care, and services safely and that the physical layout of the center maximizes patient independence and does not pose a safety risk. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. b) Observation of the two shower rooms located in the facility on 08/05/26 at 12:15 PM. The South Shower Room had the following concerns: The handwashing sink needed to have new caulking applied around it. There was two (2) clumps of human hair laying on a Geri chair. There was four (4) disposable razor guards that are made of hard plastic that was broken and laying in the floor in the right back stall. The floor drain in the right back stall had trash and human hair sitting on top of it. The fire safety damper vent located on the ceiling was dirty with lint and debris. The door sill on the inside of the shower room had lint and debris buildup. Interview with the Administrator at 12:40 PM. He verified the findings and stated I will get these concerns in TELS and have housekeeping come in here and clean this up. The Administrator stated I would say it is not acceptable and we are trying to remodel. I asked him how often housekeeping cleans the shower rooms? He stated I will have to check the policy.

Based on observation, record review, and staff interview, the facility failed to provide necessary care and services in accordance with professional standards of practice by not following physician orders for devices to aid in the prevention of pressure ulcers and abrasions. This deficient practice was found true for one (1) of two (2) residents reviewed for skin conditions. Resident identifier: #92. Facility Census: 115. Findings Include: a) Resident #92 A record review on 08/04/26 at 8:52 AM revealed an order for Resident #92 that read as follows: Left Leg: Leg Guard in place to prevent resident scratching self. Remove BID for skin checks. Further record review revealed an eInteract change in condition dated 05/12/26, indicating Resident #92 received an abrasion to the left lower leg from scratching herself. The preventive intervention for the abrasion was the leg guard to the left leg. Observations of Resident #92 on 08/04/26 at 11:17 AM, 12:30 PM, and 2:00 PM revealed no leg guard was in place on the left leg per the physician's order. During an interview on 08/04/26 at 2:10 PM, Licensed Practical Nurse (LPN) #41 showed the State Agency (SA) the leg guard, which he retrieved from Resident #92's dresser drawer. LPN #41 confirmed that the leg guard was not on the resident as ordered.

Based on food tray temperatures, observation and resident interviews, the facility failed to serve food to residents that was attractive, palatable and at a safe and appetizing temperature to prevent foodborne illness. The facility failed to ensure hot foods were served hot. This failed practice was true for one (1) of one (1) meal tray tested for food temperatures throughout the survey process. Residents Identifiers: #43 and #5. Facility Census 115. a) Healthcare Services Group (HCSG) policy #16 titled Food Preparation states: All foods are prepared in accordance with the FDA Food Code. HCSG policy #6 titled Food Quality and Palatability states: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. The Dining Services Director and Cooks are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. The Cooks prepare food in a sanitary manner utilizing the principles of Hazard Analysis Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code. b) Resident #43 During an interview on 08/04/26 at 11:30 AM, Resident #43 stated My meals are always cold, especially breakfast. c) Resident #5 During an interview on 08/03/26 at 11:58 AM, Resident #5 stated, F*&# no, the food isn't good here. d) Test Tray on 08/04/26The Director of Dining sent a test tray to North Front Hall at 12:43 PM. The temperatures of this test tray were taken by the Healthcare Services Group (HCSG) Director of Operations (DO) at 12:55 PM. The Director of Dining Services (DDS) was also present. The temperature was as follows: Garlic Tater Tots - 105.5 degrees Fahrenheit (F) It was confirmed that at the time of receipt by the resident, hot foods shall be at a temperature of no less than 120 degrees F

Based on observation and staff interviews, the facility failed to store food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen, small wares and the food preparation equipment. This practice had the potential to affect more than a limited number of residents. Facility census: 115Findings include: a) Healthcare Services Group (HCSG) Policy #16 titled Food Preparation states: All staff will practice proper hand washing techniques and glove use. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. HCSG Policy #18 titled Food storage: Dry Goods states: All dry goods will be appropriately stored in accordance with the FDA Food Code. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. HCSG Policy #19 titled Food storage: Cold Foods states: All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. HCSG Policy #27 titled Equipment states: All foodservice equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. All staff members will be properly trained in the cleaning and maintenance of all equipment. All food contact equipment will be cleaned and sanitized after every use. All non-food contact equipment will be clean and free of debris. HCSG Policy #28 titled Environment states: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. HCSG Policy #22 titled Ware Washing states: All dishware, service ware, and utensils will be cleaned and sanitized after each use. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. HCSG Policy #23 titled Manual Ware Washing states: All cookware, dishware and service ware that is not processed through the dish machine will be manually washed and sanitized. b) Initial walkthrough of the kitchen on 08/03/26 at 11:06 AM. The Director of Dining Services (DDS) completed the walkthrough with me. The findings were verified by the DDS. They were as follows: The toaster had old crumbs in the tray. 2. The outside of the exhaust hood in the kitchen had lint buildup that needed to be cleaned. 3. There was a black substance on the dish room wall. 4. The filters on the outside of the ice machine had lint buildup that needed to be cleaned. 5. The ice scoop holder had debris on it that needed to be cleaned. 6. There were eleven packs of hot dog buns that did not have a use by date on them. 7. There was a food container in the walk-in refrigerator that was soiled with food debris. 8. There was no paper towels at the hand washing sink located beside the reach-in refrigerator. 9. There was one drawer near the reach-in refrigerator that had measuring cups and used office supplies in it together. 10. The shelves in the reach-in refrigerator are rusted and need to be repaired or replaced. c) During the lunch meal service on 08/03/26 at 12:10 PM in the dining room. This surveyor noticed that the clear tumblers that were being used to serve the residents their cold beverages were stained a brown color. I asked Guest Services employee #118 if they looked to be stained to her and she stated they are stained and I will remove these and get new ones. Interview with the Director of Dining Services (DDS) on 08/04/26 at 12:15 PM. He stated that I cleaned the stained tumblers.

Based on observation, record review, and staff interview, the facilityfailed to establish and 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. The nurse touched medications with her bare hands during medication administration. This was a random opportunity for discovery during the medication administration facility task. Resident Identifier: #57. Facility Census: 115. Findings included:a) Resident #57 The facility's policy titled Medication Administration, dated January 2023, gave instructions to Pour the correct number of tablets or capsules into the medication cup, taking care to avoid touching any of the medication unless wearing gloves. On 08/04/26 at 9:05 AM, Licensed Practical Nurse (LPN) #59 was observed preparing morning medications for Resident #57. LPN #59 placed a tissue on top of the medication cart and placed the medication cup on top of the tissue. When popping medications out of the blister packet, two (2) medications, citalopram and Kapspargo, landed on the tissue instead of in the medication cup. LPN #59 used her bare hands to pick up the medications and place them in the medication cup. She then administered the medications to Resident #57. When questioned following the medication administration, LPN #59 confirmed she had touched Resident #57's medications with her bare hands.

After observation, interview and record review it was found the facility failed to develop and implement a care plan following doctor's orders for Resident #6 and Resident #9. Facility Census 115. Findings include: a) Resident #9 Findings were that Resident #9 physician's order stated for a nephrostomy bag to be wrapped with an ace bandage while Resident #9 was up. It was found that this was not documented in Resident #9 care plan. This deficient practice was verified with an interview with the Director of Nursing on 8/4/26 at 12:48 PM. b) Resident #6 Findings were that Resident #6 had a physician's order for a carrot brace to be placed in the left hand for one to three hours per day, this was not listed in Resident #6 care plan. This deficient practice was verified with the Director of Nursing on 8/4/26 at 12:20 PM. She stated that she would add this to the care plan.

Based on record review and staff interview, the facility failed to ensure the comprehensive care plan was revised when the resident had a change in condition. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of activities of daily living (ADL) decline. Resident Identifier: #107. Facility Census: 115. Findings included:a) Resident #107 Review of Resident #107 comprehensive care plan showed the following focus: Potential for decline in self-care abilities related to left above knee amputation, effects of stroke with left side paralysis, flaccid upper left arm, minimal left stump movement and pain - Currently independent with all aspects of care and mobility. The focus had been initiated on 05/14/18 and last revised on 07/02/25. Interventions included as follows:Resident is currently independent with bed mobility, transfers and w/c mobility at all times. This was initiated on 05/14/2018 and last revised on 09/04/20.Resident is currently independent with dressing, grooming, hygiene and bathing at all times (may occasionally require up to extensive assist with dressing and bathing on occasion). This was initiated on 05/14/2018 and last revised on 07/25/23.Resident #107's Minimum Data Set (MDS) assessments with Assessment Reference Dates (ARDs) 03/10/26 and 06/09/26 showed the following declines in functional abilities:Eating decreased from independent to set up/clean up assistance required. Oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, rolling from left and right, sit to lying, lying to sitting on the side of the bed, and bed-to-chair transfer decreased from independent to supervision or touching assistance required. On 08/05/26 at 12:00 PM, MDS Registered Nurse (RN) #22 confirmed Resident #107's comprehensive care plan no longer reflected the resident's functional abilities. She stated the care plan had been reviewed and revised by the intradisciplinary team (IDT) 06/03/26-06/10/26, but the focus and interventions for potential decline in self-care abilities had not been revised. She stated she would revise Resident #107's comprehensive care plan.

Based on record review, observation and staff interview, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that met their daily nutritional and special dietary needs. This failed practice was found true for one (1) of the three (3) residents reviewed for diet order accuracy during the Long-Term Care Survey Process. Resident identifiers: #5. Facility census: 115. Findings Include:a) Resident #5A record review on 08/04/26 at 11:30 AM, found the following diet order for Resident #5: Regular Texture, Standard Thin Liquids consistency, double protein/meat portions; Kennedy cup with meals, no bananas, tomatoes or potatoes related to End Stage Renal Failure.An observation on 08/04/26 at 12:45 PM, Resident #5 was served his lunch tray in his room. The resident's meal ticket indicated a renal diet, double protein meat portions, and 2 grilled turkey and cheddar sandwiches. The meal ticket also indicated the resident was to receive tater tots.During the observation it was noted that Resident #5 only received one (1) grilled turkey and cheddar sandwich, and the tater tots were served with ketchup.During the observation Registered Nurse (RN) #153 stated, I am not sure what the renal diet includes, but no he did not get his double portion of protein. RN #153 further confirmed that the ketchup condiment and tater tots were served to Resident #5.During an interview, on 08/04/26 at approximately 1:30 PM, the Regional Certified Dietary Manager (RCDM) stated, According to the renal diet for this meal he can have the tater tots. I talked to the kitchen staff and we are aware that he did not get the double portions. The State Agency (SA) pointed out to the RCDM that the physician's order specifically reads no bananas, tomatoes, or potatoes. The RCDM confirmed that tater tots are a potato and that the ketchup is a tomato product, which was contrary to the order.

Based on record review and staff interview. the facility failed to maintain a Physician Order for Scope of Treatment (POST) form that matched Resident #9's physicians orders. This was a random opportunity for discovery. Facility Census: 115. Findings include: A record review revealed Resident #9's physician order stated, Do Not Resuscitate when the POST form stated resident was a Full Code. This discrepancy was verified with the Director of Nursing (DON) on 08/04/26 at 11:15 AM. The DON stated that they had a correct POST form; however, it was sent out on an appointment with Resident #9 and not returned. The Medical Power of Attorney was contacted after surveyor intervention to complete a new POST form.

Based on record review and staff interview, the facility failed to ensure the pharmacist reported any irregularities to the attending physician, the facility's medical director and the director of nursing and the reports were acted upon. This failed practice was identified for three (3) out of three (3) residents with an NPO (nothing by mouth) order. Resident Identifier: #66, #93, and #8. Facility Census: 116. Findings included:a) The facility's Policy and Procedure for Medication Monitoring: Medication Regimen Review and Reporting stated, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regiment and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist by utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Sheet (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care.b) On 10/29/2025 at 12:24 PM, Pharmacist #138 was interviewed by a state surveyor via phone. The pharmacist reported the resident's ordered medications were reviewed for dosage and route and reported. Pharmacist #138 reported we look closely at the physician's order and if there is a discrepancy, we reach out to the facility or make a comment on our review. The pharmacist reported if she found documentation concerning discrepancies for Resident #66, Resident #8 and Resident #93's medication routes she would contact the state surveyor. c) The following orders and MARs were incorrect for the NPO (nothing by mouth) residents who were ordered medication by mouth:1. Resident #66:The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:- Xanax from 05/27/2025 through 06/24/2025.- Miralax Powder from 05/10/2025 through 06/26/2025.- Prozac from 05/30/2025 through 06/01/2025.- Vistaril from 05/24/2025 through 05/26/2025.- Potassium from 07/08/2025.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.2. Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.3. Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.

Based on resident interview, staff interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided to dependent residents. This was true for three (3) of three (3) residents reviewed during the survey process. Resident Identifiers: #93, #8, and #102. Facility Census: 116. Findings Include: a) Resident #93 An interview was held with Resident #93 on 10/30/25 at 10:35 AM. Resident #93 stated, I have been trying to get a shower since Monday (10/27/25) so maybe I will get one tomorrow. I have had problems before with getting my showers but I think they are getting it worked out. A review of showers from 09/01/25 through 10/30/25 was completed on 10/30/25 at 09/12/25-09/19/25 at 10:50 AM. The review found the following: No showers from 10/03/25 to 10/14/25 which was 11 days. No showers from 10/23/25 to 10/30/25 which was seven (7) days. On 10/30/25 at 10:45 AM, Nurse Aide (NA) #24 was assisting this Surveyor with the shower book and schedule. NA #24 stated, I know why she didn't get one on Monday .the NA left at 3:00 PM and the next NA coming on should have gave her a shower. On 10/30/25 at 11:00 AM, the Director of Nursing (DON) stated, I recently went around and asked the residents' preferences and redid the shower schedule. understand your concern .it looks like she went a long time without showers. On 10/30/25 at 12:03PM, the DON stated, we don't have a policy or procedure regarding how often showers or bed baths are to be given .we offer biweekly showers .if the resident wants less or more we will do that .if the resident refuses it should be documented. b) Resident #8 On 10/30/2025, Resident #8's shower care plan and tasks were reviewed. The resident's care plan indicated the resident was dependent for bathing. No showers were documented for the month of September 2025. and one (1) shower was documented for the month of October on 10/28/2025. On 10/30/25 at 11:03 AM, the Director of Nursing (DON) reported the staff should be documenting a bed bath everyday if no shower was given. It was their policy for a bed bath to be given everyday unless it is a shower day. On 10/30/2025 at 11:59 AM, the DON confirmed Resident#8 did not have showers and /or bed baths documented daily and reported there is no written policy for frequency of bed baths or showers, but residents are to be offered showers two (2) times a week and bed baths daily. Refusals would be documented under responses per the DON. Resident #8's shower days are listed as every Wednesday and Sunday. No documentation of bed baths and/or showers for September and October were found on the following dates.: 09/01/2025, 02/-2/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/12/2025, 09/13/2025, 09/15/2025, 09/16/2025, 09//29/2025, 09/30/2025, 10/01/2025, 10/02/2025, 10/03/2025, 10/04/2025, 10/05/2025, 10/06/2025, 10/07/2025, 10/14/2025, 10/16/2025, 10/19/2025, 10/21/2025, 10/22/2025, and 10/27/202. c) Resident #102 Interviews: During an interview with Resident's wife on 10/30/25 at 9:30 AM she reported the facility does not give resident enough showers. She stated that she had talked to staff about trying different times with him and they tell her he refuses. During an interview with Director of Nursing on 10/30/25 at approximately 12:30 PM she reported she had looked for documentation of shower refusals from Resident #102 and could not find any. Document Review: A review of Resident #102's Task section GG Bathing, Question 2 (two) for the month of October 2025, Resident had was given a shower on the following days: 10/01/25 10/08/25 10/28/25 On 10/30/25 review of resident's care plan he was up to dependent assist for bathing. Review of shower schedule on 10/30/25 reveals resident is scheduled to receive showers on Day Shift, Wednesdays and Saturdays.

Based on record review and staff interview, the facility failed to thoroughly investigate allegations of neglect This was true for two (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47 and #102. Facility census: 116. Findings Include: b) NeglectOn 10/27/25 at approximately 3:00 PM, a review of a FRI dated 07/19/25. The review of the FRI found the allegation of neglect was made by Resident #102 and #47. The allegation was that neither resident had received incontinence care since 5:00 AM on 07/19/25. The residents reported this to NA #116 upon delivery of the lunch trays. NA #116 got another NA #130 to assist with the incontinence care for both residents at 1:00 PM. The assigned NA #135 was noted to be on her personal phone at the nurses' station and was rounding on the other residents on her hall. NA #130 stated, I was told I had to go to the dining room before I finished my last residents. However, NA #130 did not notify the other NAs regarding the need for incontinence care for the residents. After the investigation was completed, NA #135 was terminated. However, the investigation was found to be unverified. Upon completing the review of the investigation, the witness statements as well as the resident statements, did verify the allegation of neglect.An interview was held on 10/28/25 at approximately 10:00 AM, with the Administrator. The Administrator stated, I see what you are saying.

Based on record review, observation and staff interview, the facility failed to ensure a clean, safe, comfortable, home-like environment by not preventing odors throughout the building. This was a random opportunity for discovery and this failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census:116.Findings included:a) On 10/27/2025, upon initial entrance to the building, the state surveyors observed a strong, unpleasant odor throughout the building. The odor was identified by the state surveyors during their initial tours and investigations in the facility. On 10/28/2025 at 09:35 AM, the state surveyor again smelled a strong odor throughout the facility when making rounds in the facility.b) On 10/27/2025 at 05:50 PM, the state surveyor interviewed the Corporate Registered Nurse nurse concerning odor/smell in the hallways observed by the state surveyors. The Corporate Registered Nurse confirmed the odor and stated, Almost smells like they have someone that's going somewhere. I'll have them look into it. c) The facility's policy and procedure for Resident Room Cleaning and Floor Care Policy stated, the Healthcare Services Group is committed to providing a safe, clean and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices.

Based on record review, staff interview, and resident interview, the facility failed to ensure continuity of care by not seeking order clarification from the physician regarding oral medication orders for a resident who was NPO (nothing by mouth) and failed to ensure respiratory equipment was obtained for a newly admitted resident. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #66, #93, #8 and #121. Facility Census: 116.Findings included:The facility's policy and procedure for Medication Administration stated, Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record. The Job Aid: Physician Review v2004, given to the state surveyor by the facility, stated the physician orders will be reviewed on a nightly basis to ensure accuracy, completeness: compliance with State, Federal and JACHO requirements and that they are accurate and true reflection of the plan of care. )n 10/29/2025, the Director of Nursing reported there is no monthly review of orders by the nursing staff and the orders are just left for the physician to sign.a) Resident #66:The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:1) Xanax from 05/27/2025 through 06/24/2025.2) Miralax Powder from 05/10/2025 through 06/26/2025.3) Prozac from 05/30/2025 through 06/01/2025.4) Vistaril from 05/24/2025 through 05/26/2025.5) Potassium from 07/08/2025.b) Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.c) Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.d) Resident #21:On 10/27/2025 at 01:55 PM during an interview conducted by phone, Resident #121 reported the facility couldn't hook up the (Continuous Positive Airway Pressure) CPAP machine until next day and that there were no orders for me to even be there per nursing staff. Orders were reviewed from the hospital consult from 07/04/2025: The orders stated: Obstructive sleep apnea - Continue patient's home CPAP. On 10/28/2025 at 10:15 AM, the Director of Nursing (DON) stated that she wasn't sure if there was an order for the CPAP machine in the resident's admission orders. The policy is to have the equipment here when the patient arrives. The DON reported she was going to look at the paper trail. The DON also stated, Sometimes they don't have the settings for the C-Pap because Lincare sends them to the facility preset according to order from the hospital. On 10/28/2025 at 11:26 AM, the DON reported Lincare did not send the CPAP nor did they have the order. On 10/28/2025 at 01:25 PM , the DON confirmed the resident was discharged back to the hospital before physician orders, diagnosis list and care plan were initiated.

Based on record review and staff interview, the facility failed to ensure the resident's medical record was accurate for physician orders for fall interventions and the medication route does not follow the physician's order for NPO (nothing by mouth). This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #66, #93, and #8. Facility Census: 116. Finding included:a) Resident # 66:On 10/27/2025 at 05:55 PM, an observation was completed for Resident #66. A low bed, fall mats to right side of the bed and the left side of the bed was against the wall. The resident was receiving 1:1 supervision initiated this date as reported by Nursing Assistant #51.The resident was ordered 1:1 for safety every day and night shift with a start date of 10/27/2025, floor mats x2 both right side of bed every day and night shift with a start date of 10:27/2025. No orders for low bed with parameter mattress was found. The only fall intervention on the care plan was for a low bed parameter mattress. The orders and care plan were confirmed by the Director of nursing and the Corporate Registered Nurse on 10/28/2025 at 12:15 PM.The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:1) Xanax from 05/27/2025 through 06/24/2025.2) Miralax Powder from 05/10/2025 through 06/26/2025.3) Prozac from 05/30/2025 through 06/01/2025.4) Vistaril from 05/24/2025 through 05/26/2025.5) Potassium from 07/08/2025.b) Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.c) Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.

Based on record review and staff interview, the facility failed to ensure residents were free from neglect, and verbal abuse. This was true for seven (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47, and #102. Facility Census: 116. Findings include: b) Resident #47 and #102 On 10/27/25 at approximately 3:00 PM, a review of a FRI dated 07/19/25. The review of the FRI found the allegation of neglect was made by Resident #102 and #47. The allegation was that neither resident had received incontinence care since 5:00 AM on 07/19/25. The residents reported this to NA #116 upon delivery of the lunch trays. NA #116 got another NA #130 to assist with the incontinence care for both residents at 1:00 PM. Asigned NA #135 was noted to be on her personal phone at the nurses' station and was rounding on the other residents on her hall. NA #135 stated, I was told I had to go to the dining room before I finished my last residents. However, NA #135 did not notify the other NAs regarding the need for incontinence care for the residents. After the investigation was completed, NA #135 was terminated. However, the investigation was found to be unverified. Upon completing the review of the investigation, the witness statements as well as the resident statements, did verify the allegation of neglect. On 10/30/25 at 9:30 AM an interview with Resident # 102's wife was held via telephone about an incident she reported on 08/04/25. She reported she walked into resident's room after lunch time on the morning of the incident. Resident's brief was so full it was crumbling and laying in pieces after having fallen apart. She stated a nurse was cleaning it up from the floor and cleaning her husband. She stated that he was red down there and the nurse was angry stating this was not acceptable. Resident's wife stated resident very rarely had redness in the groin area while living at home and they treated it but his skin was not red when he entered the facility. She stated no one told her the facility did not substantiate the complaint. She reported when she spoke with the administrator, he stated that he would take care of it and she has had no further complaints about her husband's care in that regard. She reported that he is not being bathed often. An Interview on 10/30/25 at 10:52 AM with Licensed Practical Nurse (LPN) #36 revealed the following LPN #36 reported she had been completing nursing duties earlier in the day and passing meds around 8:30 AM when she encountered Resident #102 who was covered with blankets. She did not check him or see anyone check him at this time, although she did see a nurse aide go into his room. She reported she took over nurse aide duties around 11:30 AM and was not given report before she took over the assignment. When she walked into Resident 102's room, he was wearing no brief, it smelled of foul odor of urine, parts of the brief all over the floor, and she had to ask housekeeping to help her clean it up. She stated that resident was a little reddened and she did not remember if the facility had already been giving him nystatin at that point or if he was prescribed a cream after. An interview with Administrator on 10/30/25 12:30 PM revealed: Administrator reported they do not always review the results of the incident investigations with the complainants unless they ask. He stated that he did try to take all sides into consideration and if there were other witnesses or if the alleged perpetrator was involved in any other investigations. Review of Documentation on 10/30/25 for Resident #102 found: Review of Progress Note dated 08/08/25 at 8:57 AM revealed a new, acquired in-house wound to the groin/genital area and describes it as Moisture Associated Skin Damage: Incontinence Associated Dermatitis MASD: IAD. Review of document titled Five-day Follow-up dated for 08/07/25 revealed an interview with alleged perpetrator, who is no longer employed by the facility, reported that she had checked to see if resident was dry twice on the day of the incident before 8:00 AM and once again at 9:30 AM.

Based on record review and staff interview, the facility failed to revise a care plan for a residents fall interventions. This failed practice had the potential to affect a limited number of residents . Resident Identifier: #66. Facility Census: 116.Findings included: Resident # 66:On 10/27/2025 at 05:55 PM, an observation was completed for Resident #66. A low bed, fall mats to right side of the bed and the left side of the bed was against the wall. The resident was receiving 1:1 supervision initiated this date as reported by Nursing Assistant #51.The resident was ordered 1:1 for safety every day and night shift with a start date of 10/27/2025, floor mats x2 both right side of bed every day and night shift with a start date of 10:27/2025. No orders for low bed with parameter mattress was found. The only fall intervention on the resident's care plan was for a low bed parameter mattress. Both floor mats to the left side of the bed, bed against the wall or 1:1 supervision were not documented in the resident's care plan. On 10/28/2025 at 12:15 PM, the orders and care plan were confirmed by the Director of Nursing and the Corporate Registered Nurse

Based on observation, record review and staff interview, the facility failed to provide an environment free of accident hazards due to medication being at bedside for Resident #60. This was a random opportunity for discovery. Resident Identifier: #60. Facility Census: 116. Findings Include:a) Resident #60On 10/27/25 at 5:40 PM, an observation was made of the medication Clotrimazole & Betamethasone % cream in a tube at bedside. At this time, Licensed Practical Nurse (LPN) #69 was notified and removed the medication from the nightstand.On 10/27/25 at 5:48 PM, the Corporate Registered Nurse # 132 was notified and stated, let me have them check that there is no other medications at bedside.

Based on observation, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to serve meals in a sanitary manner by serving a cup that had been dropped on the floor to a resident during meal time. This was true during a random opportunity of discovery for Resident #102. Facility Census 116.Findings Included: a) On 10/29/25 at 11:52 AM Registered Nurse RN #130 was observed walking out of the kitchen holding a cup can a lid. She dropped the lip the the floor of the dining room, bent down to pick it up. She then placed it on the counter as she filled the cup with ice and drink and handed it to Nurse Aide #81 who had just walked over to her. Nurse Aide #81 then placed the lid onto the cup and handed it to Resident #102. This Surveyor asked Nurse Aide to replace the drink before resident drank out of it as it had been dropped in the floor and Nurse Aide did so. b) Interview with Director of Nursing on 10/29/25 at approximately 1:20 PM who acknowledged failure to maintain sanitary eating environment for this resident. c) Interview with RN #130 on 10/29/25 at approximately 3:20 PM, when asked about giving resident the dropped cup she reported that she did not realize she had done it until after. She stated that it was stupid.

Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for the residents. This was a random opportunity for discovery. Resident Identifiers: Facility. Facility Census: 119Findings Included:a) Facility cleanlinessOn 09/18/25 at 12:25 PM observation found the floors in the facility to be cluttered with particles of paper, dust and spilled dried liquid in need of being swept and mopped. Trash cans were full and personal items were in the foor to the point of housekeeping not being able to sweep in some rooms. During a walk through with the Administrator he agreed, that in particular, the following rooms on that unit were the worst. room [ROOM NUMBER], 152, 153 and 154. On 09/18/25 at 12:45 PM he confirmed the faciity auto scrubber was down and the floors needed swept and mopped. b) Ceiling tilesOn 09/18/25 at 12:35 PM observation found that there were two (2) ceiling tiles outside the activity room that were dark in color as if something had leaked on them and they needed replaced. Also at the corner of the Nurses Station on the 100 unit there was a large ceiling trap door to the attic that was open. There was hot air coming into the facility from the attic. It was confirmed with the Administrator at this time that maintenance had been working in the attic on 09/17/25 and left the door open. He also verified the two ceiling tiles by the activity room needed replaced.c) LinensOn 09/18/25 at 12:50 PM observation found that several beds on the 100 hall were not made. Nurse Aide #1 stated Sorry, I would have made the beds but we are out of linen. When ask if this was a one time situation or if it happens often, she stated well, it happens sometimes. Observation of the clean linen closet found there were no fitted or flat sheets and no blankets. The Administrator verified the above and stated the laundry is working to get the back log out here.

Based on observation, record review, resident interview, and staff interview the facility failed to ensure a resident who has an indwelling urinary catheter receives the care and services needed to ensure the resident did not develop complications related to the indwelling urinary catheter. The facility staff failed to ensure an anchor device was on Resident #105's catheter to prevent it from becoming dislodged. In addition, the nursing staff failed to identify and/or address serious problems with Resident #105's catheter prior to surveyor intervention on two (2) separate occasions on 05/09/23 and again on 05/10/23. In addition Resident #105 suffered a change in mental status which was also not identified by nursing staff until it was pointed out by the surveyor. Also, nursing staff failed to follow all physician directives pertaining to Resident #105's catheter and his urinary status within a timely manner. Resident #105 suffered actual physical harm as the result of these failures. He was sent to the emergency room (ER) and returned to the facility with comfort measures in place and a referral to hospice services. When the resident returned to the facility, his diagnosis included: Septic Shock, Pyelonerhritis (an inflammation of the kidney due to a bacterial infection.). A CT (Computed Tomography) of his abdomen while at the hospital showed moderate bilateral hydroureteronephrosis (The swelling of a kidney due to build up of urine. This happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction.) The State Agency (SA) determined these failures posed an immediate risk to Resident #105 and placed him in an immediate jeopardy (IJ) situation in addition to the actual harm he had already suffered. The SA notified the facility of the IJ at 1:30 PM on 05/10/23. The facility submitted their first plan of correction (POC) at 4:17 PM. The SA requested changes to the POC. The second POC was submitted at 5:00 PM. The POC was accepted by the SA at 5:00 PM. This immediate Jeopardy began on the morning of 05/09/23. The facility Plan of Correction read as follows: F690 Resident #105 returned to the facility from the hospital at 2:00 PM on 05/10/23. The medical director assessed Resident #105 on 05/10/23 at 2:00 PM. All residents with indwelling catheters of the facility have the potential to be affected. The Unit Manager conducted an audit on all indwelling catheters at 1:50 PM on 05/10/23 to ensure all residents with an indwelling urinary catheter to ensure a secured device is in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and if medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) with any corrective action immediately upon discovery. Re-education was provided by the director of nursing (DON)/Designee to all licensed nurses on 05/10/23 at 2:30 PM to ensure all resident with an indwelling urinary catheter received the care and services to ensure the resident did not develop complications related to the indwelling catheter, including ensuring a secured devices was in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) . A post-test was done to validate understanding. Any licensed nurses not available during this time frame were provided re-education, including post test and return demonstration by DON/designee upon the beginning of their next shift to work. New Licensed nurses was provided education including post-test during orientation by the DON/designee. Annual in servicing was also provided to licensed nurses regarding the care of indwelling urinary catheters. The Unit managers (UM) /Designee conducted observations starting on 05/10/23 at 4:00 PM to ensure all residents with an indwelling urinary catheter received the care and services to ensure a secured device is in place, monitor urine output color and notify medical provider of abnormal changes and if orders were received for occlusion, they were followed ASP daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly there after. Results of observations were to be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or inservicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. After observation for implementation of the POC the IJ was abated at 6:00 PM on 05/10/23. It was at this time the IJ ended. After the immediacy was removed a deficient practice remained, therefore the scope and severity was reduced from a J to a G because of the actual harm suffered by Resident #105. A deficient practice also remained for Resident #110 related to a diagnosis of a Urinary Tract Infection and the staff failing to get the results of the Urinalysis Culture and Sensitivity to ensure Resident #110 was treated with the correct antibiotic. These failed practices were true for two (2) of three (3) residents reviewed for the catheter/UTI (Urinary Tract Infection) care area during the long term care survey process. Resident Identifiers: #105 and #110. Facility Census: 117 Findings Included: A) Resident #105 On 05/0923 at 11:10 am, Resident #105 was observed lying in his bed. His indwelling urinary catheter tubing was red in color and appeared to have dark blood toward the top of the tubing which appeared to be a blood clot. The resident on observation appeared to be uncomfortable. The surveyor entered Resident #105's room after obtaining his permission at 11:13 AM. Resident #105 was then asked how he was doing. Resident #105 stated, I am not doing too good. I was taking myself to the restroom this morning and my catheter pulled real hard. It felt like it was going to come out of me. Ever since then I have had a lot of pain and discomfort down there. Resident #105 was asked if he had told the staff about this incident. He stated, I told them, but they have not done anything yet. He further stated It felt like that ball just pulled right out of me but I can still feel it so I know it didn't. At 11:15 AM on 05/09/23 Licensed Practical Nurse (LPN) #126 was asked to accompany the surveyor to Resident #105's room. LPN #126 stated she was aware of Resident #105 pulling his catheter this morning and there was minimal bleeding and she notified the nurse practitioner of the incident. Upon entering Resident #105's room, LPN #126 was asked to observe Residents #105's catheter tubing with Nurse Surveyor 39751 present. She agreed there was a blood clot in the tubing below the Y- point of the catheter which was blocking urine flow. She stated, We will have to get an order to change the catheter. Again Resident #105 voiced to LPN #126 he was experiencing pain related to his catheter and the incident which happened this morning. LPN #126 confirmed at this time the resident did not have an anchor device on his leg to anchor the tubing to keep it from pulling and dislodging upon movement. Nurse Surveyor 39751 noted the Y-point of the catheter tubing was down to Resident #105's knee. This would indicate the catheter had dislodged from it previous location because the Y-Connecter is usually located in the upper thigh region. A review of the medical record found the following progress notes related to Resident #105's condition from 11:15 am on 05/09/23 until the surveyors returned to the facility on [DATE]: -- Note dated 05/09/23 at 9:00 am written by LPN #126 read as follows: Resident reports pain to Foley catheter site, blood tinged urine noted to catheter tubing and BSD (Bed side Draining) bag. Reported to NP (Nurse Practitioner). N/O (new order) to monitor Foley catheter for increased bleeding/pain. RR (responsible party) aware. --Note dated 05/09/23 at 10:00 am written by LPN #126 read as follows: Foley Catheter patent with blood tinged urine draining to BSD (Bed Side Draining) bad [SIC]. The notes with the times of 9:00 am and 10:00 am were both entered into the EMR (Electronic Medical Record) after the nurse was requested in the Room of Resident #105 by the surveyors. -- Note dated 05/09/23 at 11:15 am written by LPN #126 read as follows: Resident c/o increased pain to Foley catheter site, catheter not draining, increased bleeding/blood clots noted to tubing. Reported to NP. N/O to change Foley Catheter. -- A note written by the Nurse Practitioner dated 05/09/23 signed at 11:59 AM read as follows: .Chief complaint /nature of presenting problem Seen today to evaluate hematuria per nurse request. History of present illness: Resident with urinary retention, Foley placed in hospital. Now with hematuria, with some small clots after pulling on Foley, causing some urethral pain as well. Medications reviewed, currently taking aspirin 81 mg daily. Resident with poor safety awareness and some confusion related to dementia Plan: Discontinue Foley today, monitor for voiding. If unable to void, replace per urologist orders. Follow up with urologist as scheduled. Hold aspirin 81 mg X 5 days, monitor hematuria. -- Note dated 05/09/23 at 1:14 PM written by LPN #126 read as follows: New order to D/C Foley catheter. Resident tolerated well, small amount of blood discharge noted to urethra. Resident has no complaints of pain or discomfort at this time. Will monitor urine output. -- Note Dated 05/09/23 at 5:51 PM written by LPN #94 read as follows: New orders noted: Straight cath X 1 if resident unable to void after 8 hour (7:45 PM) If resident does not void within 8 hours after straight cath, Approx 3:45 am (on 05/10/23) reinsert indwelling Foley cath. -- Note dated 05/09/23 at 6:00 PM written by LPN #126 read as follows: Resident has not voided this shift, order obtained to straight cath X 1 if resident is unable to void after 8 hours (7:45 PM) if resident does not void within 8 hours after straight cath, 3:45 am reinsert indwelling Foley cath. -- Note dated 05/09/23 at 6:25 PM written by LPN #126 read as follows: LATE ENTRY:Resident stated to this nurse that he felt like he needed to void, urinal given to resident. Resident stated that it will take him a few minutes. This nurse passed on to night shift that resident is attempting to void in urinal at this time and if not voided by 7:45 am to straight cath per order. Night shift nurse verbalized understanding. -- Note dated 05/09/23 at 8:58 PM written by LPN #47 which read as follows: Resident was not able to void during straight Cath only blood was showing. This nurse contacted (Name of Tele health Service Name of Specific Dr.) ordered to discontinue straight cath and to Foley cath and irrigated bladder to flush out any blood. -- Tele health Evaluation note dated 05/29/23 at 9:11 PM written by Tele health Doctor read as follows: Primary chief complaint: GU Hematuria. : History of present illness: Patient is a [AGE] year old male inadvertently pulled out his Foley Yesterday and Foley was not put in but orders were given to straight cath patient if unable to void. Patient was straight catheterized and thick blood clots mixed with urine was obtained. Patient continues having problems voiding. He has no fever or chills. Diagnosis, assessment plan: Urinary retention, retention of urine, The patients condition is worsening. Put in Foley at this time because of thick clots and repeated straight cath is just damaging urethra more. Obtain UA and culture. Once Foley placed irrigate bladder with saline until clear. ** Please note the medical record was void of any indication the Urine was obtained for the UA C&S as ordered by the tele health physician. The nurse also noted that she got back blood tinged urine. There was no indication in the record she irrigated the bladder until clear as directed by the Tele health physician. -- Note dated 05/10/23 3:45 am written by LPN #47 read as follows: This nurse inserted 16' Foley catheter return yielded a bright red blood and urine mix at 350 cc's of urine. Cath bag in place with leg strap on left leg. Resident Denies pain will continue to monitor. An observation of Resident #105 on 05/10/23 at 9:00 am found the resident had an Indwelling catheter. There was a bedside drainage bag which contained less than 5 cc's of blood. The tubing of the catheter again was full of blood and appeared to be clotted. The resident was not responding to verbal stimuli as he had on the previous two (2) days. When the surveyor said his name multiple times the resident just stared at the ceiling and showed no response. LPN #126 was Resident #105's assigned nurse at this time. The surveyor requested she come to Resident #105's room with this surveyor and Nurse Surveyor #39751. Upon entering the room LPN #126 stated I know about the blood in the tubing I told the Nurse Practitioner and have an order to irrigate it I just have not got to it. Please note when the surveyor approached LPN #126 to enter resident #105's room she was preparing medications for other residents and was not in the process of gathering supplies to irrigate Resident #105's catheter which was obviously obstructed with blood clots. Her own admission revealed she knew about the blood clots but had not done anything to resolve the issue. LPN #126 was then asked about Resident #105 not responding to verbal stimuli. She stated, I was not aware he was not responding to verbal stimuli. When asked if this was normal for him she stated, No I guess that is a little bit of a change for him. She was then asked if she could irrigate the residents catheter. She left the room at 9:15 am to gather supplies to perform the irrigation. LPN #83 entered Resident #105's at 9:25 am on 05/10/23 to obtain a set of vitals for the resident. LPN #83 said Resident #105's name loudly several times which warranted no response from the resident. She then performed a sternal rub which also warranted no response from the resident. She then placed her hand under his and asked him to squeeze her hand which he did not do. LPN #83 was asked if this was normal for this resident, She stated no it is not. I have never seen him like this even when he was here previously he was never like this. I think we need to send him to the emergency room . LPN #83 obtained the following vital signs for this resident: Blood Pressure was 176/81, Temperature was 98.2 degrees Fahrenheit, his oxygen saturation was 86. LPN #83 stated, We need to get him on some oxygen. LPN #83 was then asked to palpate Resident #105's bladder to determine if it was distended. LPN #83 then began pushing on Resident #105's pelvic bones. Nurse Surveyor #39751 then instructed LPN #83 the proper way to palpate the bladder. When LPN #83 performed the palpation correctly she determined Resident #105's bladder was distended. The proper procedure to palpate the bladder is to gently palpate from the umbilicus downward toward the pelvis, feeling for a full bladder. At 9:40 am on 05/10/23 it was noted LPN #126 had not returned to irrigate Resident #105's bladder. The Director of Nursing was asked to assist LPN #126 in gathering her supplies so Resident #105 could have his catheter irrigated. At 9:45 am on 05/10/23 thirty minutes after she left the room to gather her supplies, LPN #126 returned to the room to irrigate the catheter. Nurse Surveyor #39751 observed LPN #126 irrigate the catheter. Upon irrigation she flushed in 50 ml (milliliters) of water and only received 5 ml of water on return which was blood tinged. LPN #126 received no urine in return. This indicates the catheter is possibly occluded or not in the bladder. LPN #126 stated, We got orders to send him to the emergency room . An interview with the Nurse Practitioner at 9:55 am on 05/10/23, revealed she had not completed a head to toe assessment on Resident #105. She stated, About 8:05 am this morning I stuck my head in and the resident was awake and moving. She noted nothing specific to his catheter at this time. When asked what it meant when the nurse only received back 5 ml of the 50 ml or saline she flushed into the catheter she stated, It is probably occluded. She stated, I am going in to see the patient right now. That's what I do. At 10:10 am on 05/10/23 Resident #105 was observed being loaded onto an ambulance to go to the hospital. At approximately 2:00 PM on 05/10/23 the Nursing Home Administrator stated, I noticed his catheter had blood in it this morning at about 8:30 am. I told the Nurse about it and she said she would let the Nurse Practitioner know about it. At 2:14 PM on 05/10/23, the director of nursing entered the following note, Spoke with (Name of Nurse) at (Name of Hospital) taking care of resident. Residents son is at bedside, son wants to keep resident as comfort measures. Residents lactic acid was 12, troponin was 53, D-dimer 58, CT evaluation, lesions on liver, fluid filled esophagus, No urine output at this time, the little bit they had in the tubing was nothing but blood. They are giving morphine for comfort. A nurses note dated 05/10/23 at 2:17 PM, written by LPN #126 read as follows: Resident arrived to facility via EMS (Emergency Medical Services) from (Name of Local hospital) Resident was discharged with orders to be comfort care only, resident diagnosed with septic shock, pyelonephritis, acute emphysematous cystitis. NP and MD notified. New orders to d/c maintenance medications and start end of life medications. Resident lethargic, unable to verbally respond or follow commands. Blood noted to Foley catheter tubing and BSD bag. A review of the emergency room report for Resident #105 was reviewed in the evening of 05/10/23 and the following was revealed. Resident #105 was returned to the facility with the following assessment/plan 1. Comfort Measures Only. 2. Septic Shock (life threatening condiiton caused by severe localized or system-wide infection that requires immediate medical attention). 3. Pyelonephritis (inflammation of the kideny). 4. Acute emphysematous prostatis (gas collection and purulent exudates within the prostate). 5. Acute emphysematous cystitis (a potentially life threatening infection characterized by gas within the bladder wall and lumen due to gas forming bacteria). Orders: Morphine As needed for pain. The resident had a CT of the abdomen pelvis with contrast which yielded the following results: 1. Acute emphysematous cystitis, acute emphysematous prostatis and acute bilateral pyelonephritis. 2. Moderate bilateral hydroureteronephorosis. 3. Acute diffuse colitis and proctitis. 4. Abnormal low density lesion on hepatic dome could represent a hemangioma or other begnin etiology are not excluded. MR exam of the liver without and with intravenous contrast is recommended for further evaluation, which could be performed non emergently depending on clinical scenario. Further review of the record found the facility staff talked to the son about a hospice referral for this resident. The son agreed and hospice is to evaluate the resident on 05/11/23. b) Resident #110 A record review of Resident #110's medical record found she had an outside appointment on 04/13/23 and returned to the facility with an order from that Physician for an antibiotic. While at this appointment the office obtained a urinalysis and urine culture. The script was for Cipro 500 mg bid (twice a day) x (times) 10 days d/t (due to) bacteria found in urine. Awaiting urine culture. When Resident #110 returned to the facility on [DATE], the nurse on duty entered the following progress note: (as copied) 04/13/2023 11:04 General Late Entry: Note: Resident returned from radiology appointment with orders for Cipro 500 mg BID x 10 days d/t bacteria found in urine. Awaiting culture at this time. NP aware. RP aware. According to documentation on the Medication Administration Record (MAR) the resident did receive all twenty (20) doses of the antibiotic from 04/13/23 through 04/23/23. A urine culture was needed to confirm if there is a need for an antibiotic and if the urine bacteria is susceptible to specific antibiotics. On 05/10/23 at 5:52 PM the Director of Nursing confirmed the facility never obtained the results of the urine culture to confirm if Resident #110 needed the antibiotic or if the resident was on the correct antibiotic for the infection. 45171

Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #93 was hoisted in a lift in the hall way outside of his room and then transported in the lift from the hallway to his room where he was placed in his bed by the window. Mechanical lifts are transfer devices only and are not to be used as transport devices due to the risk of serious harm and/or death to residents. The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #93 at risk for serious harm and/or death. The facility was notified of the IJ at 3:41 pm on 02/08/22. The facility submitted a Plan of Correction (POC) at 5:24 pm on 02/08/22 at which time it was accepted by the SA. The plan of Correction read as follows: The Registered Nurse re educated Nurse Aide #36 and #98 on the appropriate use of the total lift with return demonstration on 02/28/22 at 1445 (2:45 pm). All resident of the facility have the potential to be affected. The Registered Nurse (RN) conducted an observation round on 02/08/22 at 1656 (4:56 pm) to ensure dependent residents who require a total lift are being transferred appropriately with corrective action upon discovery. Reeducation will be provided by the Director of Nurses (DON)/designee to all nursing staff on 02/08/22 at 5:00 pm to ensure residents who are dependent for transfers using a total lift are being transferred according to manufacturer guidelines. Posttest with return demonstration completed to validate understanding. Any nursing staff not available during this time frame will be provided reeducation, including posttest and return demonstration by DON/designee upon the beginning of next shift to work. New nursing staff will be provided education, including posttest during orientation by the DON/Designee. The unit managers (UM)/designee will conduct observations starting on 02/08/22 at 11:00 pm to residents who are dependent for transfers using a total lift are being transferred appropriately and in accordance with manufactures guidelines, appropriately daily across all shifts for 2 weeks including weekends and holidays then 3 times a week for 2 weeks then randomly thereafter. Results of observation will be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and our in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. After observation of implementation of the POC the IJ was abated on 02/09/22 at 6:00 pm at which time a deficient practice remained and the scope and severity was decreased from a J to a G. A deficient remained for Resident #55 who sustained a [CONDITION(S)] when she rolled from bed during Activities of Daily Living (ADL) care. The residents care plan did not direct the Nurse Aide (NA) to have two (2) staff members present during bed mobility therefore when the resident rolled away from the NA she rolled unto the floor fracturing her hip. This failed practice resulted in actual harm for Resident #55. Resident #93 was a random opportunity for discovery. For Resident #55 this was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifiers: #93 and #55. Facility Census: 118. Findings included: A) Resident #93 Resident #93 was observed laying on a shower bed which was parked in the hallway outside of his room at 11:06 am on 02/08/22. Nurse Aide (NA) # 36 (who was wearing a name badge indicating she was a new employee) and NA #98 was observed approaching with a full body lift. They proceeded to lift Resident #93 in the lift while still in the hall way. Once he was hoisted above the shower bed in the lift they pushed the shower bed out of the way and proceeded to push the lift with Resident #93 still hoisted in the air into his room to place him in the bed which was placed on the far side of the room. An interview with NA #36 at 11:18 am confirmed she was the NA assigned to Resident #93. She agreed she and NA #98 had transferred Resident #93 from the shower bed to his bed. When asked why they hoisted Resident #93 in the lift while he was still in the hallway she replied, Its really a tight fit to get the shower bed into his room. So we put him in the lift and pushed him in his room while in the lift. She proceeded to say, Is this a FUBAR ([OBSCENITY] ed Up Beyond all recognition). What is this going to fall under a dignity issue. An interview with NA #23 at 11:13 am on 02/08/22, revealed when she showers Resident #93 she places the shower bed at the foot of his bed and transfers him from surface to surface with both beds in the room. She stated, I don't have any trouble getting the shower bed in his room. An interview with the Center Nurse Executive (CNE) on 02/08/22 at 11:22 am confirmed the lift should not be used to transport a resident. It is to be used to move the resident from one surface to another surface. She indicated the shower bed should have been placed in the resident's room and the resident should not have been hoisted in the lift while in the hall way. The CNE was then asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. On 02/08/22 at 1:35 pm the CNE stated they do not have any evidence to show NA #36 and NA #98 was evaluated for competency to operate the lift. At 3:00 pm on 02/08/22 all competencies for all NA's was provided, and the following information was found. There was a total of 42 NAs currently working at the facility there were 4 NA's who had their competencies evaluated in the last year those included NA #12 who was evaluated on 05/25/21, NA #35 who was evaluated on 04/20/21, NA #72 who was evaluated on 05/25/21, and NA #119 who was evaluated on 05/19/21. There were seven (7) other NAs who were evaluated on the following dates: --NA #44 evaluated on 08/11/20. -- NA # 23 evaluated on 08/19/20 -- NA #19 evaluated on 08/13/20 -- NA #84 evaluated on 08/11/20 -- NA #65 evaluated on 08/19/20 -- NA #98 evaluated on 08/19/20 -- NA #122 evaluated on 08/13/20. The competencies should be completed yearly. The following NA's had no competency evaluations related to lifts at all NA #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95. At 2:13 pm on 02/08/22 the CNE provided a list of residents who require a total lift for transfers. There were a total of 54 residents who required the use of a total lift residing in the facility. A review of Resident #93's medical record found he has a required the use of a total lift since 05/10/17 according to his lift assessments. NA #36 has been an employee at this facility since 05/17/21. She was wearing a new employee badge with no name on it because she forgot her name badge at home. She has been an employee with the corporation who owns this facility since 07/29/18. A review of the Invacare Reliant 450 and 600 Battery Powered Patient Lift manual found the following information: On Page 5 of the manual the following was contained: 1.1 Symbols Warnings Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. See the information below for definitions of the signal words. DANGER: Danger Indicates an imminently hazardous situation which, if not avoided, will result in in death or serious injury. Warning: Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. Caution: Caution Indicates a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both . On Page 7 of the manual the following was contained: Warning: The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair). Review of the facility's policy titled, Safe Resident Handling/Transfer Equipment. the following was found, . Due to the variety of lifts used in centers, manufacturers's instructions will be used. If manufactures' instructions are not available in the center, Contact Risk Management for assistance. b) Resident #55 A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information: Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor. Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility. Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following: Focus Statement: Self care deficit related to recent hospitalization with left [CONDITION(S)] s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis. The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review. The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14. An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist. Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction ([CONDITION(S)]). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm. Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired. By failing to ensure the care plan which guides the residents care was accurate. The NA providing care on 11/16/21 was doing so by herself when the resident required a two (2) person assist for bed mobility. As a result Resident #55 fell from bed and fractured her left hip causing her to be hospitalized for a surgical repair of the hip which is actual harm.

Based on resident interview, observation, medical record review, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two (2) of forty-two (42) sample residents. Resident #37 was not provided insulin as ordered. Resident #87 was not sent to an oral surgeon for extraction of all remaining natural teeth due to severe periodontal disease. The deficit regarding Resident #87's dental needs resulted in an immediate jeopardy as described below: A medical record review revealed a progress note from the oral surgeon dated 02/17/14, which contained the following statement, " ... We will try to obtain clearance from his physician, coordinate his care and see if he is a candidate for either mach (Monitored Anesthesia Care) or general anesthesia in a hospital setting." The facility failed to provide evidence of any attempts made to obtain medical clearance from any physician. Further medical record review revealed a discharge summary from a local hospital dated 07/17/14, which contained the following statement, "... During his stay at (Name of Hospital), it was deduced that the reason behind the patient's multiple recurrent episodes of aspiration pneumonia was secondary to his severe periodontal disease." Additionally, another progress note from the oral surgeon's office contained the following text, "7/23/14 no response from medical clearance sent letter to pt. (patient)." Based on theses findings, Resident #87 was found to be in an immediate jeopardy situation (IJ). The facility's Administrator (NHA) was notified of the immediate jeopardy on 10/15/14 at 6:30 p.m. The facility submitted a plan to abate the immediacy of the IJ at 8:30 p.m. on 10/15/14. This plan was accepted by the State agency at 8:30 p.m. on 10/15/14. It contained the following information (typed as written), "On 10/15/14 ADNU (Assistant Director of Nursing Unit) spoke with (Name of Oral Surgeon Office) to request the forms for medical clearance for oral surgery for [REDACTED]. Medical clearance was reviewed by Medical Director on 10/15/14, medical director requested resident to be sent for consult to (Name of Pulmonologist) for a pulmonologist to evaluate medical clearance for oral surgery for [REDACTED]. ADNU will call on 10/16/14 and schedule an appointment with (Name of Pulmonologist)." The facility submitted an amended plan of correction (POC), which was accepted by the State agency at 1:00 p.m. on 10/16/14: (typed as written) "On 10/15/14 ADNU (Assistant director of Nursing Unit) spoke with (Name of Oral Surgeon Office) to request the forms for medical clearance for oral surgery for [REDACTED]. Medical clearance was reviewed by Medical Director on 10/15/14, medical director requested resident to be sent for consult to (Name of Pulmonologist) for a pulmonologist to evaluate medical clearance for oral surgery for [REDACTED]. ADNU will call on 10/16/14 and schedule an appointment with (Name of Pulmonologist). Oral assessments were completed on 09/19/14 and 09/20/14 on current residents. Currently one resident has been identified for medical clearance for removal of teeth. The resident's pre-appointment packet was received 10/15/14 to be completed with the resident on 10/16/14 by the ADNU. Documents will be faxed to (Name of Oral Surgeon) and they will give the resident an appointment. This has the potential to affect residents in need of medical clearance for dental procedures. Reeducation of current licensed nurses will be provided by the Nurse Practice Educator (NPE) on or before 10/22/14 regarding need to document in nurses' progress note when a resident needs surgical clearance to allow for continual follow up until appointment obtained or no longer needed. In morning clinical meeting Monday-Friday the Director of Nursing/designee, will follow up on all dental appointments for medical clearance for the next 90 days with corrective action if indicated then as recommended by the monthly Quality Improvement Committee. Findings will be reported to the Administrator. Any trends identified will be reviewed by the Director of Nursing/designee at the monthly Quality Improvement Committee for further follow up and recommendations." As of the survey team's exit from the facility at 4:00 p.m. on 10/21/14 the IJ had been removed and a scope and severity of G (actual harm) remained in effect. Resident identifier: #87. Facility census: 115. Findings include: a) Resident #87 Observation of the resident, at 8:25 a.m. on 10/14/14, during Stage 1 of the QIS, found the resident's natural teeth were discolored, broken and decayed. Interview with Resident #87, on 10/14/14 at 8:25 a.m., revealed the resident had been having pain from his teeth. He further explained he had been waiting for extraction of all of his remaining teeth. A review of Resident #87's medical record, on 10/15/14 at 10:10 a.m., found Resident #87 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. On 10/08/13, Resident #87 requested a dental appointment due to tooth pain. On 10/09/13, the resident was seen by a dentist who diagnosed him with rampant caries (which is defined as a wide spread extensive form of caries that occur in teeth that are usually immune to decay and involves pulp) and non-restorable teeth. The plan was to extract the remaining 28 erupted teeth. A referral was made to an oral surgeon and a request was made for the nursing home to obtain medical clearance for the extraction of the resident's teeth with intravenous (IV) sedation. The medical director/attending physician, on 10/16/13, wrote a progress note: (typed as written) "May have teeth extractions with local or minimal twilight sedations only." A discharge summary, dated 11/29/13, by a local hospital read: (typed as written) "Also, the patient needs full dental extraction because he has multiple infected teeth." Further medical record review revealed a request from the oral surgeon which was faxed to the facility on [DATE] at 1:04 p.m. This form requested the completed health history (front and back), medical clearance from the attending physician, and Medical Power of Attorney documents. On 02/17/14, Resident #87 had an appointment with the oral surgeon, with progress notes by the nurse present during the exam: (typed as written) "02/17/14 Consult only for ext. (extraction) of all remaining teeth. Pt. (patient) poor medical health. Hx (history) [MEDICAL CONDITION] intubation for chronic pneumonia. Has a PICC (peripherally inserted central catheter) in RUE (right upper arm), PEG (percutaneous [MEDICAL CONDITION] gastrostomy) tube, O2 (oxygen) continuously via NC (nasal cannula), A. Fib ([MEDICAL CONDITION]) and DM (diabetes mellitus). Nursing home patient. A&O x3 (alert and oriented to time, place and person) and able to sign consents. Paper consents signed per exam by (Name of Oral Surgeon). Review of PMH (past medical history) and plan of operation. This will be done at hospital. Pt. and NH (nursing home) attendant instructed will schedule after medical clearance approval and will need PAT (preadmission testing) with Anesthesia prior. Est (estimates) given." A consult by the oral surgeon read: (typed as written) " 02/17/14-Discussion: Today, I went through the surgery, anesthesia, complications, risks, benefits, and alternatives of removing all remaining maxillary and mandibular teeth; emphasizing temporary or permanent paresthesia of the cheeks, lips, gums and tongue due to the proximity of the neurovascular bundle to the teeth structure; swelling, discomfort, bleeding, fracture, infection and possible sinus perforation. Consents were signed. Pre-estimates are given. NPO (nothing by mouth) instructions given. We will try to obtain clearance from his physician, coordinate his care and see if he is a candidate for either mach or general anesthesia in a hospital setting." The medical record also contained a progress note written by the oral surgeon's nurse, dated 07/23/14: (typed as written), " No response from medical clearance sent letter to pt. (patient)." Review of the medical director/attending's progress notes, after the consult with the oral surgeon on 02/17/14, found no indication of medical clearance for oral surgery. An interview with the director of nursing (DON) and the attending physician, on 10/15/14 at 3:45 p.m., revealed the attending physician had given medical clearance in October 2013 after the first oral surgeon visit. He further stated he was not notified of the need for medical clearance in February 2014 after the second visit to the oral surgeon. The physician also stated the medical clearance should be obtained from the resident's pulmonologist. The DON could not provide any noted attempts to assist the resident in getting medical clearance for the extraction of the resident's remaining natural teeth. They both confirmed they had knowledge the resident had pain from his teeth. Resident #87's need for medical clearance for the removal of his remaining natural teeth due to severe periodontal disease and continuing pain and discomfort from his broken and decayed teeth was not addressed until brought to the attention of the facility during the survey. Based on theses findings, Resident #87 was found to be in an immediate jeopardy situation (IJ). The facility's Administrator (NHA) was notified of the immediate jeopardy on 10/15/14 at 6:30 p.m. An acceptable plan for immediate correction was accepted and the IJ was removed with a scope and severity of G (actual harm) remaining in effect. . b) Resident #37 Observation during medication pass, on 10/20/14 at 2:14 p.m., revealed licensed practical nurse (LPN) #99 reviewed the lunch meal percentage for Resident #37 in order to know whether the resident should receive [MEDICATION NAME] insulin ten (10) units subcutaneously. The LPN stated the resident goes to the dining room to eat lunch at 12:00 p.m. She looked at the percentage of meal intake record for Resident #37, and stated the resident consumed 100% of her meal. The LPN said Resident #37 should receive the ten (10) units of [MEDICATION NAME]subcutaneously. She stated, "We do not administer the insulin if the resident eats less than fifty (50) percent of her meal." LPN #99 was then observed administering Resident #37 ten (10) units of [MEDICATION NAME] insulin. A review of Resident #37's physician's orders [REDACTED]." Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] insulin is to be administered at 11:30 a.m." In an interview, on 10/20/14 at 2:30 p.m., with LPN #99 and nurse-unit manager director #86, they both were asked, why is the [MEDICATION NAME] Insulin on the MAR indicated [REDACTED]. .

Based on medical record, resident interview,resident observation, and staff interview, the facility failed to obtain needed dental services for one (1) of one (1) Medicaid resident who triggered dental status in Stage 2 of the Quality Indicator Survey (QIS). Resident #87's need for dental care and services was identified, but was not addressed. This resulted in actual harm due to severe periodontal disease which caused the resident pain. Resident identifier: #87. Facility census: 115. Findings include: a) Resident #87 Observation of the resident, at 8:25 a.m. on 10/14/14, during Stage 1 of the QIS, found the resident's natural teeth were discolored, broken, and decayed. Interview with Resident #87, on 10/14/14 at 8:25 a.m., revealed the resident had been having pain from his teeth. He further explained he had been waiting for extraction of all of his remaining teeth. A review of Resident #87's medical record, on 10/15/14 at 10:10 a.m., found Resident #87 was admitted to the facility on [DATE] with the medical [DIAGNOSES REDACTED]. On 10/08/13, Resident #87 requested a dental appointment due to tooth pain. On 10/09/13, the resident was seen by a dentist who diagnosed him with rampant caries (which is defined as a wide spread extensive form of caries that occur in teeth that are usually immune to decay and involves pulp) and non-restorable teeth. The plan was to extract the remaining 28 erupted teeth. A referral was made to an oral surgeon and a request was made for the nursing home to obtain medical clearance for the extraction of the resident's teeth with intravenous (IV) sedation. The medical director/attending physician, on 10/16/13, wrote a progress note: (typed as written) "May have teeth extractions with local or minimal twilight sedations only." A discharge summary, dated 11/29/13, by a local hospital read: (typed as written) "Also, the patient needs full dental extraction because he has multiple infected teeth." Further medical record review revealed a request from the oral surgeon which was faxed to the facility on [DATE] at 1:04 p.m. This form requested the completed health history (front and back), medical clearance from the attending physician, and Medical Power of Attorney documents. On 02/17/14, Resident #87 had an appointment with the oral surgeon, with progress notes by the nurse present during the exam: (typed as written) "02/17/14 Consult only for ext. (extraction) of all remaining teeth. Pt. (patient) poor medical health. Hx (history) [MEDICAL CONDITION] intubation for chronic pneumonia. Has a PICC (peripherally inserted central catheter) in RUE (right upper arm), PEG (percutaneous [MEDICAL CONDITION] gastrostomy) tube, O2 (oxygen) continuously via NC (nasal cannula), A. Fib ([MEDICAL CONDITION]) and DM (diabetes mellitus). Nursing home patient. A&O x3 (alert and oriented to time, place and person) and able to sign consents. Paper consents signed per exam by (Name of Oral Surgeon). Review of PMH (past medical history) and plan of operation. This will be done at hospital. Pt. and NH (nursing home) attendant instructed will schedule after medical clearance approval and will need PAT (preadmission testing) with Anesthesia prior. Est (estimates) given." A consult by the oral surgeon read: (typed as written) " 02/17/14-Discussion: Today, I went through the surgery, anesthesia, complications, risks, benefits, and alternatives of removing all remaining maxillary and mandibular teeth; emphasizing temporary or permanent paresthesia of the cheeks, lips, gums and tongue due to the proximity of the neurovascular bundle to the teeth structure; swelling, discomfort, bleeding, fracture, infection and possible sinus perforation. Consents were signed. Pre-estimates are given. NPO (nothing by mouth) instructions given. We will try to obtain clearance from his physician, coordinate his care and see if he is a candidate for either mach or general anesthesia in a hospital setting." The medical record also contained a progress note written by the oral surgeon's nurse, dated 07/23/14: (typed as written), "No response from medical clearance sent letter to pt. (patient)." Review of the medical director/attending's progress notes, after the consult with the oral surgeon on 02/17/14, found no indication of medical clearance for oral surgery. An interview with the director of nursing (DON) and the attending physician, on 10/15/14 at 3:45 p.m., revealed the attending physician had given medical clearance in October 2013 after the first oral surgeon visit. He further stated he was not notified of the need for medical clearance in February 2014 after the second visit to the oral surgeon. The physician also stated the medical clearance should be obtained from the resident's pulmonologist. The DON could not provide any noted attempts to assist the resident in getting medical clearance for the extraction of the resident's remaining natural teeth. They both confirmed they had knowledge the resident had pain from his teeth. Resident #87's need for medical clearance for the removal of his remaining natural teeth due to severe periodontal disease and continuing pain and discomfort from his broken and decayed teeth was not addressed until brought to the attention of the facility during the survey. .

Based on record review, facility policy review, observations and staff interviews, the facility failed to prevent avoidable falls and fracture for 2 of 4 residents reviewed out of 5 residents with concerns related to accidents (Resident #123 and Resident #97). Findings include: 1. Review of resident #123's clinical record revealed an initial admission date of [DATE] and [DIAGNOSES REDACTED]. On the most recent comprehensive Minimum Data Set assessment dated [DATE], Section C, Brief Interview for Mental Status, the resident scored a 1, indicating severely impaired cognition, triggering a Care Area Assessment (CAA) to be completed for cognition. Review of the CAA worksheet revealed the resident had dementia with confusion, short and long term memory loss and poor safety awareness. The resident was assessed to have decreased ability to make self understood or to understand others, and presented with confusion, disorientation, and forgetfulness. Review of Section G, Activities of Daily Living, documented the resident required extensive assistance of one staff member for bed mobility, transfers, and walking. Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. Under Mobility Devices the resident was assessed to use a wheelchair and a walker. Resident #123's care plan dated 12/21/2012, revealed the resident was at risk for falls with injury related to weakness, unsteady gait, impaired balance, dementia with confusion, decreased safety awareness, use of psychotropic medications, use of cardiac medication, use of blood thinning medication and the presence of a cardiac pacemaker. The interventions included the use of a clip alarm at all times, check placement and function every shift, remind resident to use call light to prior to ambulating or transfer, reinforce need to call for assistance, place call light within easy reach, encourage resident to transfer and change positions slowly, encourage resident to communicate needs/ask for assistance. The resident received Physical and Occupational therapy from 12/20/2013 through 01/25/2013. Review of a Physical Therapy Evaluation form dated 01/25/2013 revealed the resident was discharged from Physical and Occupational therapy and referred to Restorative Nursing for an ambulation program to maintain current mobility status. Review of Resident 123's fall investigations, revealed that from 01/05/2013 through 05/24/2013, resident #123 experienced 12 falls. The resident's fall investigations were as follows: On 01/5/2013 at 3:30 a.m., the resident attempted to stand from his/her wheelchair with breaks unlocked and fell to the floor. The resident was assessed to have three skin tears to his/her right forearm. A new intervention for the use of a wheelchair alarm was initiated at that time. On 01/05/2013 at 9:15 a.m. the resident was found on the floor beside his/her bed. The resident complained of left hip pain and headache. The resident was sent to the emergency room for evaluation and returned that day with no injury noted. A new intervention for the use of a bed alarm was initiated at that time. On 01/11/2013 at 6:54 a.m., the resident fell from his/her wheelchair. The resident was assessed to have a hematoma to his/her posterior head. The interventions listed were to continue Physical Therapy for strengthening and to encourage the resident to comply with remaining in his/her wheelchair until assistance is available. On 01/17/2013 at 5:33 a.m., the resident's wheelchair alarm sounded and the staff found the resident seated in his/her bathtub, the resident stated he/she lost his/her balance and landed in the bathtub. The resident was assessed to have no injuries at that time. The new intervention at that time was to monitor for signs of toileting needs. Review of a Physical Therapy Evaluation form dated 01/25/2013, revealed the resident was discharged from physical therapy and referred to a restorative nursing program to maintain current mobility status. A physician order [REDACTED]. The clinical record was silent for initiation of the order. Review of physician order [REDACTED]. An interdisciplinary team (IDT) note dated 2/14/2013 at 2:40 p.m., revealed the alarm was discontinued due to the residents multiple attempts to ambulate unassisted. In addition at that time the residents Trazodone dosage was increased to 50 mg and Ativan 1 mg as needed every 6 hours was initiated. Review of the resident's plan of care for the use of Trazodone indicated side effects including sedation, drowsiness and blurred vision, and for Ativan side effects included sedation, drowsiness and blurred vision, placing the resident at an increased risk for falls. However, the clinical record was silent for the development of any new fall interventions to prevent further falls at that time. On 02/14/2013 at 1:20 a.m. the resident fell out of his/her wheelchair. The resident was assessed to have a large hematoma above his/her left eye and a skin tear to his/her left elbow. The resident became less alert and was sent to the emergency room for evaluation. The new fall interventions initiated at that time were to encourage resident to sort mail, remove from loud areas and referenced that his/her Trazodone dosage was increased. On 02/16/2013 at 12:30 a.m. the resident was ambulating with a walker, became unsteady and fell backwards. No injury was noted at that time. The new fall intervention was to continue to offer assistance and check the resident frequently. On 02/16/2013 at 3:45 a.m. the resident was found on the floor next to his/her bed. The resident was assessed to have a large hematoma and small abrasion to his/her right eye and was sent to the emergency room for evaluation. The new fall interventions initiated at that time were to encourage assistance, offer snacks, and mail sorting activity. On 02/19/2013 at 12:55 p.m. the resident was found on the floor in the hallway. The resident was assessed to have a small laceration to the left side of his/her head above the eyebrow and complained of left hip and left shoulder pain. The resident was sent to the emergency room where he/she received 4 sutures to close the wound. The new fall interventions initiated at that time were to refer the resident to Physical and Occupational therapy for device use. Review of the clinical record was silent for the aforementioned Physical and Occupational therapy referral and evaluation for device use. On 02/20/2013 a physician order [REDACTED]. On 02/22/2013 at 3:00 p.m., the resident fell out of his/her wheelchair striking his/her head on a door resulting in an abrasion to the top of his/her head. The resident had removed the clip and alarm and placed it in his/her pocket. The new fall intervention initiated at that time was to encourage the resident to ask for assistance and to toilet frequently. On 02/27/2013 at 9:15 p.m. the resident fell out of his/her wheelchair. The resident was not injured. The new fall intervention was to keep the resident in a high traffic area. On 03/11/2013 at 8:10 a.m. the resident was found on the floor in front of his/her toilet. The resident was not injured. The new fall intervention was to have the resident's medications evaluated by his/her physician. On 05/24/2013 at 10:00 p.m. the resident slid out of his/her wheelchair. The resident was not injured. The new fall intervention was to encourage resident to seek assistance with transfers and ambulation. On 06/18/2013 at 3:41 pm the resident was observed in bed asleep with bed alarm in place. On 06/18/2013 4:30 pm the resident was observed up in his/her wheelchair with alarm in place. The resident was wearing non-skid socks. On 06/19/2013 at 8:37 am the resident was observed in bed with personal alarm in place. During interview on 06/20/2013 10:41 a.m., staff member #136 verified the resident received Occupational therapy from 12/20/2013 through 01/25/2013. Stated the resident was re-evaluated 02/07/2013 as a re-admit, however was not picked up for Occupational therapy services at that time. Staff further stated the resident was screened again on 03/12/2013 and was unsure if it was a quarterly screen or hospital readmission screen, however the resident refused to participate in the evaluation at that time. Staff verified no referral was made by nursing on 02/19/2013 as indicated on the fall investigation report dated 02/19/2013 in regards to device use related to falls. During an interview on 06/20/2013 at 3:31 p.m., staff member #59 upon review of the aforementioned incident reports, stated the fall intervention initiated on 01/11/2013, to encourage the resident to comply with remaining in his/her wheelchair until assistance was available, was not an appropriate or effective intervention due to the resident's cognitive status. The staff member stated the resident was very spontaneous and could not follow that type of direction. In regards to initiation of the physician order [REDACTED]. Staff further stated the resident was hospitalized from [DATE] till 02/06/2013 for a psychiatric evaluation and verified the previous recommendation and physician order [REDACTED]. In regards to the physician order [REDACTED].#59 stated it was discontinued due to not being an effective fall intervention and verified no new interventions were initiated at that time to prevent another fall. In regards to the fall interventions initiated on 02/16/2013 to continue to offer assistance and check the resident frequently, staff member #59 verified these were not formal interventions and the clinical record was silent for initiation of the interventions. In addition staff member #59 verified the resident was not referred to Physical and Occupational therapy for device use as indicated on the 02/19/2013 incident report. In regards to the fall interventions initiated on 02/22/2013, to encourage the resident to ask for assistance, staff member #59 stated due to the residents cognitive status he/she could not remember to ask for assistance and verified this was not an appropriate intervention to prevent further falls. In regards to the fall intervention initiated on 05/24/2013, to encourage the resident to seek assistance with transfers and ambulation, staff member #59 again verified due to the resident ' s cognitive status this was not an effective or appropriate intervention to prevent further falls. During an interview conducted on 6/21/2013 at 9:39 a.m., staff member #13 verified the plan of care located in the resident's chart was used by the staff to guide the care the resident received. Staff member #13 verified on 02/16/2013, there were no other interventions developed other than what was listed on the fall report. Staff member #13 stated on 02/19/2013 no new interventions were developed to prevent further falls. Staff member #13, verified on 02/13/2013, the resident's alarms were discontinued and stated the resident's Trazodone was increased and Ativan was initiated and verified known side effects of the psychoactive medications increased the resident's risk for falls, however no new formal interventions to prevent falls were developed at that time. Staff member #13 verified on 02/22/2013, the toileting intervention was in place prior to the resident's fall, and verified no formal intervention was developed at that time. Staff member #13 stated due to the resident's impaired cognitive status, to encourage the resident to ask for assistance was not an appropriate or effective fall intervention. Staff member #13 stated on 2/27/2013 the intervention documented on the fall investigation to place the resident in a high traffic area was not part of the formal care plan to direct resident care in order to prevent further falls. Staff member #13 stated that on 5/24/2013 the intervention to ensure the resident's wheelchair is locked before attempting to stand, was not an appropriate intervention due to the resident's impaired cognitive status. The facility's "Problem Management" policy, noted "Develop a plan of care including general and specific interventions to reduce falls risk" and "Refer to the following tools to develop an individual plan of care which addresses environmental modifications, sensory capacity, functional deficits, orthostatic hypotension, medications that affect balance or level of consciousness, and appropriate restorative/rehabilitation services". In addition the policy noted to "Update care plan with new interventions as appropriate " . 2. Resident #97 was originally admitted to the facility on [DATE] and had multiple [DIAGNOSES REDACTED]. A review of the resident's admission minimum data set (MDS) assessment dated [DATE] was conducted. The MDS assessment revealed under the section entitled "Functional status" that Resident #97 was coded as 3/3 under self performance and support as requiring "extensive assistance" with transfers indicating the resident was involved in the activity and that staff provided weight bearing support. The resident was also coded as requiring the support of two plus person's physical assistance with transfers. The same assessment also had the resident coded as 3/3 for self performance and support for toileting, indicating that the resident required extensive assistance from staff with two plus person's physical assistance. Under the section entitled "Balance during Transitions and Walking" the resident was coded as "not steady, only able to stabilize with staff assistance with moving on and off toilet, and was also coded as not steady with moving from a seated to a standing position." A review of the care area assessment (CAA) worksheet dated 3/14/2013 revealed that the resident was coded as having impaired balance during transitions. The resident was also noted to have an unsteady gait. A review of the plan of care dated 3/07/2013 revealed in part, the following problem area of focus: 1. Self-care deficit and mobility deficit status related to right femur fracture with surgical repair requiring extensive assistance X (times) 2 with transfers. The goal included: will continue to transfer with no more than extensive assist times 2 at all times q (every) shift through next review. The care plan included the following intervention: Non-weight bearing right lower extremity with and initiated date of 3/19/2013. A separate care plan entry also had the resident's non weight bearing (NWB) status for the RLE dated as effective 3/21/2013. A review of the facility's policy regarding Resident/Patient Lifting/Transfer was reviewed. The policy listed in part, a section entitled "Communication of Policy and Resident/Patient Needs. A. Residents and family members are advised that this is a "Safe Lift" center and residents/patients that cannot bear weight must use the mechanical lift and transfer equipment. B. Immediate communication to the caregiver regarding the resident's patients transfer/mobility needs is essential in ensuring our residents/patients are properly handled without injury to the resident /patient or employee. physician's orders [REDACTED].#97 originally had an order for [REDACTED]." Those orders were discontinued on 3/21/2013 after the resident's follow up appointment with the orthopedic surgeon. On 3/21/2013, the orthopedic surgeon changed the order from toe touch status "Non-weight bearing RLE." A review of the physical therapy weekly progress note dated 3/21/2013 revealed in part, "pt (patient) had an appointment this morning and returned with an order stating pt is now Non-weight bearing RLE (right lower extremity). A review of a change in condition report dated 3/28/2013 at 11:45 AM was conducted. Under the section entitled assessment, the resident was coded as having an injury/accident and was also coded under the section entitled "other" as having "deformity /pain right leg." Under the section entitled " Reason you are calling the physician" was the following entry: "Injury to right (symbol for arrow pointing up) upper leg, during transfer with deformity, right upper leg." Under the section entitled, "Nursing Progress Note" was the following entry which read in part, "Called to resident's room by CNA. Resident sitting on toilet, yelling, stating her leg hurts. Per CNA 2, CNA's training resident to toilet. CNA states they were pivoting resident and right leg did not turn. CNA's heard pop on right leg. Note deformity to right upper leg with bulge outward. Resident states pain 8-9 ...Brace is in place to right leg....Dr. ___ notified ...send to ER for eval... Resident admitted to ___ (local hospital), R leg fx (fracture)." On 3/28/2013 further review of the physician's orders [REDACTED]. "May send to local hospital ER (emergency room ) for eval (evaluation) of pain and deformity right upper leg." Upon admission to the hospital on [DATE], the dictated History and Physical listed the primary [DIAGNOSES REDACTED]. The history and physical report also noted in part, "...The patient did well postoperatively until today in a nursing facility, apparently was in the bathroom according to the nurse and apparently was twisted around to the toilet and felt a pop and abrupt thigh discomfort and the EMT was called..." A review of attachment C, which is a part of the facility's fracture investigation report revealed the following written statement by nurse aide #121 on 3/28/2013. "I was trying to take Resident #97 to the bathroom. I had put her in an angle in the bathroom so that both hands would be on the railing. As I stood her up she keeped (sic) on taking her hands off the railing and reaching for the toilet and when I finally got her to keep both hands on the railing, I turned her around and set (sic) her down. I heard a pop. I had looked down and notice (sic) her leg. Her daughter was outside the room and was the one to insist for me to take her to the bathroom. I yeld (sic) for help and ____ (nurse aide assigned to the Resident #97 and who is no longer employed by the facility) went and got help. I never left (Resident # 97). An interview was conducted with the facility administrator (#115) on 6/20/2013 at approximately 4:30 PM. the facility administrator stated that she was familiar with the incident and would provide supporting documentation the next day. The next morning on 6/21/2013 at approximately 8:45 AM the facility administrator provided a timeline of events, but only one entry addressed the fracture that occurred on 3/28/2013. The administrator's note read in part, " Resident grabbed handrails during transfer and resisted turn causing her to turn awkwardly popping the hip out of joint." The timeline note did not address the resident's weight bearing status nor did the timeline address the number of staff required to transfer and toilet resident # 97. The timeline did indicate that the CNA stated that she transferred the resident to the toilet with 2 CNA's. The timeline did not identify the other CNA. An interview was also conducted with Nurse Aide #121 on 6/21/2013 at approximately 9:15 AM. The nurse aide stated that she has been employed at the facility for [AGE] years and voiced that she remembered Resident #97 well. She stated that Resident #97 was normally not in her section, but did work with her occasionally. The nurse aide also recalled the event involving the resident's right hip fracture on 3/28/2013. The aide recalled that the incident occurred just before meal trays were delivered on the floor. She went on to say that the resident's daughter wanted us to take her to the bathroom. The nurse aide stated that both the resident and her daughter were in the hallway at the time of the request. Nurse aide #121 stated that she took the resident to the bathroom by herself. She stated that the resident's daughter was still in the hallway. The nurse aide went on to convey, "I wheeled her into the bathroom. I had her at an angle so that both of her hands would be on the railing. When I stood her up and pulled her pants down she started flailing her hands, I had to do that several times and she kept reaching and bending down with her hand and then finally she caught on to the rail. That's when I helped her pivot and sat her down. I heard the pop when she was sitting down, as she was being sat down. I screamed for help. I never left her." CNA #121 continued and commented that "Nurse #9 came in to the bathroom. I know Nurse #94 (Unit manager) came in for sure. She (Nurse #94) stayed with me and Resident #97 until the ambulance came and got her. Resident #97 was really grabby that day." The nurse aide stated that the resident cried and wanted off the toilet. The nurse aide voiced, "We tried to explain to her that we could not get her off the toilet. She was still grabbing as they were trying to get her off the toilet." The nurse aide continued, "It bothered me, I was just so panicky. It made me sick to my stomach. She had on that black thing. I think it was a brace. It (her leg) was swelling right above the black thing (right knee immobilizer)." The nurse aide conveyed further, "After that, me and ___ (Director of Nursing, DON) went into her office and we had a talk. I had to explain to her what had happened. She was wanting to figure how it happened and what I did wrong. I don't think I did anything wrong. I then went back on the floor. She questioned me about everything." She (DON) gave me an education on how to transfer to make sure that I transferred right. I had to show her what I did. I took her into the bathroom and showed her what I did. I don't remember if she said I should have done anything different." The nurse aide continued, "(the DON) said I should have went from another position a different angle. She said next time have two (two nurse aides)." The nurse aide conveyed further, "I think her index paper (kardex) said I should have had two CNA's. You usually just know how many CNA's to have by just transferring the residents. I used my gait belt that day. I had taken her to the bathroom before, and the same way, but I did not have a problem before, but she wasn't grabby the first time. She seemed really restless that day." The nurse aide continued, "She (Resident # 97) wasn't in my section. I was just in the hallway when her daughter asked me to take her to the bathroom." The nurse aide did not recall referring to the Kardex prior to taking the resident to the bathroom. She just recalled that the family member asked her to take the resident to the bathroom, and she did. The nurse aide believed that she may have referred to the Kardex after meeting with the facility DON. The nurse aide also stated, "I think (named CNA who is no longer employed by the facility) was assigned to her, but she doesn't work here anymore. I knew I needed to write up a statement (Attachment C, as referenced above)." An interview was also conducted on 6/21/2013 at 10:45 AM with a Physical Therapist, (#128) who is also the Therapy Program Manager and who was aware of the resident's condition concerning the hip fracture on 3/28/2013. The physical therapist reviewed the clinical record and conveyed that during the weeks of 3/7/2013 through 3/21/2013, Resident #97 had physician's orders [REDACTED]. The physical therapist also conveyed that after the resident's 3/21/2013 follow-up orthopedic appointment, the physician's orders [REDACTED]. The physical therapist stated that Resident #97 was still non-weight bearing status on 3/28/2013 on the date that the fractured hip occurred. The physical therapist stated that non-weight bearing means that the right leg should not have been touching the floor. She conveyed that a resident can pivot on the left leg, (for which the therapist demonstrated), and still meet non-weight bearing status on the right lower extremity but only if the right leg is not touching the floor. A follow up interview was conducted with nurse aide #121 on 4/21/2013 at 11:05 AM to determine weight bear status at the time of the transfer on 3/28/2013. The nurse aide re-iterated that she was asked by the resident's daughter to take the resident to the bathroom. The aide stated that she was not the aide that was assigned to the resident that day, but was familiar with the resident. The nurse aide voiced that she transferred the resident alone to the bathroom. She voiced that she was not assisted by any other staff or family member. The nurse aide went on to say that while in the bathroom with resident #97, she recalled using her gait belt to stand the resident and to get her to hold onto the railing in the bathroom. The nurse aide stated repeatedly that the resident was "grabby" that day. She voiced that by grabby, she meant that the resident was reaching downward as if trying to reach for the commode seat. The aide voiced also that the resident had both feet firmly planted on the floor. She conveyed that the resident was standing on both feet and was facing the wall that has the railing. The nurse aide then demonstrated the technique that she used to independently transfer the resident from the wheel chair to the commode. She also demonstrated how she stood the resident from the wheel chair, and then assisted her to hold on to the grab bar/railing. The nurse aide stated that she stood the resident with both feet planted on the floor. The nurse aide also demonstrated the manner in which the resident was reaching downward with her arms flailing as she attempted to reach for the commode seat. The nurse aide demonstrated a second time the position of the resident's feet which she stated were both flat on the floor as she stood the resident from the wheel chair with her gait belt. The nurse aide stated that she pivoted the resident onto the commode seat. The nurse aide stated that the resident's right leg did not move with her as she pivoted the resident to the commode seat and then she heard a pop. The nurse aide stated that is when she noticed the swelling above the resident's right leg brace and screamed for help. A review of the Kardex with an admitted ,[DATE]/ 2013 and an assessment reference date of 3/14/2013 revealed a starred entry which was undated for " Non-weight bearing only, Right leg." There was also an entry for the knee immobilizer to right leg at all times. The kardex was unclear as to the amount of support required for transfer and toilet use. The transfer section listed extensive assistance and next to that was an entry "1-2, Two plus, person's physical assist." Under the section for toilet use, the resident was listed as requiring extensive assistance 1-Two plus person's physical assist. The Kardex also indicated that the resident was not steady during transitions when moving from seated to standing, moving on and off toilet, and with surface to surface transfers. An interview was conducted with interview with the unit manager, Nurse # 94 on 6/21/2013 at approximately 1:35 PM. Nurse #94 voiced that she remembered the incident where Resident # 97's hip was fractured while in the bathroom. She voiced that she was pretty sure there were two nurse aide's toileting the resident but was not 100 percent sure. The unit manager stated that she palpated the right hip and you could immediately tell that there was a deformity. She conveyed further that she did not move the resident's leg, but could feel it. She stated that Resident #97 came here with a right hip fracture, and that she had the brace on when she went into the bathroom. She conveyed further that Nurse #9 and she checked it out and called the physician and then sent her to ER. She went on to say that Resident #97 was scared and crying a little bit. She stated that she had gotten a statement from the resident and that she said she heard a popping sound and her leg did not go with her. Nurse #94 was not able to produce any statements from any other nurse aides or from Resident #97. Nurse #94 stated that Resident #97 was "toe touch" then they switched her to non-weight bearing (NWB) status on the right. Nurse # 94 stated, "I'm not sure how many staff were supposed to transfer her." physician's orders [REDACTED]. The unit manager confirmed that the residents weight bearing status was changed from "toe touch" to "non-weight bearing" status on 3/21/2013 and remained as non-weight bearing on the right lower extremity until she was discharged out to the emergency roiagnom on [DATE]. The unit manager stated that even when the resident was re-admitted to the facility on [DATE] she was still non-weight bearing status. No other witness statements from other nurse aides were provided with the fracture investigation. Only nurse aide #121's statement was included in fracture investigation packet that was provided. The investigation did not identify the name of the other CNA that was referenced above. Nurse #9 was scheduled off and was not available for interview regarding the fractured hip investigation that occurred on 3/28/2013. The investigation that was completed by nurse #9 was reviewed and revealed that the resident was being toileted by 2 CNA's; however only one CNA's statement or name was included in the investigation which was the aforementioned statement written by nurse aide #121. The investigation also had a section entitled witnesses. The witness section was left blank. Nowhere in the investigation was another CNA identified. The aforementioned facility's policy regarding lifting and transfer referenced the need for a mechanical lift for residents who are non-weight bearing status. Neither the plan of care nor the resident care kardex referenced the mechanical lift as per policy. .

Based on clinical record review, facility policy review, observations, and staff interview, the facility failed to review and revise the resident's plan of care to prevent avoidable falls resulting in injury. This affected 1 of 4 residents reviewed out of 5 residents with concerns related to accidents (Resident #123). Findings include: Review of resident #123's clinical record revealed an initial admission date of [DATE] and [DIAGNOSES REDACTED]. On the most recent comprehensive Minimum Data Set assessment dated [DATE], Section C, Brief Interview for Mental Status, the resident scored a 1, indicating severely impaired cognition, triggering a Care Area Assessment (CAA) to be completed for cognition. Review of the CAA worksheet revealed the resident had dementia with confusion, short and long term memory loss and poor safety awareness. The resident was assessed to have decreased ability to make self understood or to understand others, and presented with confusion, disorientation, and forgetfulness. Review of Section G, Activities of Daily Living, documented the resident required extensive assistance of one staff member for bed mobility, transfers, and walking. Balance during transitions and walking was assessed as not steady, only able to stabilize with staff assistance. Under Mobility Devices the resident was assessed to use a wheelchair and a walker. Resident #123's care plan dated 12/21/2012, revealed the resident was at risk for falls with injury related to weakness, unsteady gait, impaired balance, dementia with confusion, decreased safety awareness, use of [MEDICAL CONDITION] medications, use of cardiac medication, use of blood thinning medication and the presence of a cardiac pacemaker. The interventions included the use of a clip alarm at all times, check placement and function every shift, remind resident to use call light to prior to ambulating or transfer, reinforce need to call for assistance, place call light within easy reach, encourage resident to transfer and change positions slowly, encourage resident to communicate needs/ask for assistance. The resident received Physical and Occupational therapy from 12/20/2013 through 01/25/2013. Review of a Physical Therapy Evaluation form dated 01/25/2013 revealed the resident was discharged from Physical and Occupational therapy and referred to Restorative Nursing for an ambulation program to maintain current mobility status. Review of Resident 123's fall investigations, revealed that from 01/05/2013 through 05/24/2013, resident #123 experienced 12 falls. The resident's fall investigations were as follows: On 01/5/2013 at 3:30 a.m., the resident attempted to stand from his/her wheelchair with breaks unlocked and fell to the floor. The resident was assessed to have three skin tears to his/her right forearm. A new intervention for the use of a wheelchair alarm was initiated at that time. On 01/05/2013 at 9:15 a.m. the resident was found on the floor beside his/her bed. The resident complained of left hip pain and headache. The resident was sent to the emergency room for evaluation and returned that day with no injury noted. A new intervention for the use of a bed alarm was initiated at that time. On 01/11/2013 at 6:54 a.m., the resident fell from his/her wheelchair. The resident was assessed to have a hematoma to his/her posterior head. The interventions listed were to continue Physical Therapy for strengthening and to encourage the resident to comply with remaining in his/her wheelchair until assistance is available. On 01/17/2013 at 5:33 a.m., the resident's wheelchair alarm sounded and the staff found the resident seated in his/her bathtub, the resident stated he/she lost his/her balance and landed in the bathtub. The resident was assessed to have no injuries at that time. The new intervention at that time was to monitor for signs of toileting needs. Review of a Physical Therapy Evaluation form dated 01/25/2013, revealed the resident was discharged from physical therapy and referred to a restorative nursing program to maintain current mobility status. A physician order [REDACTED]. The clinical record was silent for initiation of the order. Review of physician order [REDACTED]. An interdisciplinary team (IDT) note dated 2/14/2013 at 2:40 p.m., revealed the alarm was discontinued due to the residents multiple attempts to ambulate unassisted. In addition at that time the residents Trazadone dosage was increased to 50 mg and [MEDICATION NAME] 1 mg as needed every 6 hours was initiated. Review of the resident's plan of care for the use of Trazadone indicated side effects including sedation, drowsiness and blurred vision, and for [MEDICATION NAME] side effects included sedation, drowsiness and blurred vision, placing the resident at an increased risk for falls. However, the clinical record was silent for the development of any new fall interventions to prevent further falls at that time. On 02/14/2013 at 1:20 a.m. the resident fell out of his/her wheelchair. The resident was assessed to have a large hematoma above his/her left eye and a skin tear to his/her left elbow. The resident became less alert and was sent to the emergency room for evaluation. The new fall interventions initiated at that time were to encourage resident to sort mail, remove from loud areas and referenced that his/her Trazadone dosage was increased. On 02/16/2013 at 12:30 a.m. the resident was ambulating with a walker, became unsteady and fell backwards. No injury was noted at that time. The new fall intervention was to continue to offer assistance and check the resident frequently. On 02/16/2013 at 3:45 a.m. the resident was found on the floor next to his/her bed. The resident was assessed to have a large hematoma and small abrasion to his/her right eye and was sent to the emergency room for evaluation. The new fall interventions initiated at that time were to encourage assistance, offer snacks, and mail sorting activity. On 02/19/2013 at 12:55 p.m. the resident was found on the floor in the hallway. The resident was assessed to have a small laceration to the left side of his/her head above the eyebrow and complained of left hip and left shoulder pain. The resident was sent to the emergency room where he/she received 4 sutures to close the wound. The new fall interventions initiated at that time were to refer the resident to Physical and Occupational therapy for device use. Review of the clinical record was silent for the aforementioned Physical and Occupational therapy referral and evaluation for device use. On 02/20/2013 a physician order [REDACTED]. On 02/22/2013 at 3:00 p.m., the resident fell out of his/her wheelchair striking his/her head on a door resulting in an abrasion to the top of his/her head. The resident had removed the clip and alarm and placed it in his/her pocket. The new fall intervention initiated at that time was to encourage the resident to ask for assistance and to toilet frequently. On 02/27/2013 at 9:15 p.m. the resident fell out of his/her wheelchair. The resident was not injured. The new fall intervention was to keep the resident in a high traffic area. On 03/11/2013 at 8:10 a.m. the resident was found on the floor in front of his/her toilet. The resident was not injured. The new fall intervention was to have the resident's medications evaluated by his/her physician. On 05/24/2013 at 10:00 p.m. the resident slid out of his/her wheelchair. The resident was not injured. The new fall intervention was to encourage resident to seek assistance with transfers and ambulation. On 06/18/2013 at 3:41 pm the resident was observed in bed asleep with bed alarm in place. On 06/18/2013 4:30 pm the resident was observed up in his/her wheelchair with alarm in place. The resident was wearing non-skid socks. On 06/19/2013 at 8:37 am the resident was observed in bed with personal alarm in place. During interview on 06/20/2013 10:41 a.m., staff member #136 verified the resident received Occupational therapy from 12/20/2013 through 01/25/2013. Stated the resident was re-evaluated 02/07/2013 as a re-admit, however was not picked up for Occupational therapy services at that time. Staff further stated the resident was screened again on 03/12/2013 and was unsure if it was a quarterly screen or hospital readmission screen, however the resident refused to participate in the evaluation at that time. Staff verified no referral was made by nursing on 02/19/2013 as indicated on the fall investigation report dated 02/19/2013 in regards to device use related to falls. During an interview on 06/20/2013 at 3:31 p.m., staff member #59 upon review of the aforementioned incident reports, stated the fall intervention initiated on 01/11/2013, to encourage the resident to comply with remaining in his/her wheelchair until assistance was available, was not an appropriate or effective intervention due to the resident's cognitive status. The staff member stated the resident was very spontaneous and could not follow that type of direction. In regards to initiation of the physician order [REDACTED]. Staff further stated the resident was hospitalized from [DATE] till 02/06/2013 for a psychiatric evaluation and verified the previous recommendation and physician order [REDACTED].#59 stated it was discontinued due to not being an effective fall intervention and verified no new interventions were initiated at that time to prevent another fall. In regards to the fall interventions initiated on 02/16/2013 to continue to offer assistance and check the resident frequently, staff member #59 verified these were not formal interventions and the clinical record was silent for initiation of the interventions. In addition staff member #59 verified the resident was not referred to Physical and Occupational therapy for device use as indicated on the 02/19/2013 incident report. In regards to the fall interventions initiated on 02/22/2013, to encourage the resident to ask for assistance, staff member #59 stated due to the residents cognitive status he/she could not remember to ask for assistance and verified this was not an appropriate intervention to prevent further falls. In regards to the fall intervention initiated on 05/24/2013, to encourage the resident to seek assistance with transfers and ambulation, staff member #59 again verified due to the resident ' s cognitive status this was not an effective or appropriate intervention to prevent further falls. During an interview conducted on 6/21/2013 at 9:39 a.m., staff member #13 verified the plan of care located in the resident's chart was used by the staff to guide the care the resident received. Staff member #13 verified on 02/16/2013, there were no other interventions developed other than what was listed on the fall report. Staff member #13 stated on 02/19/2013 no new interventions were developed to prevent further falls. Staff member #13, verified on 02/13/2013, the resident's alarms were discontinued and stated the resident's Trazadone was increased and [MEDICATION NAME] was initiated and verified known side effects of the psychoactive medications increased the resident's risk for falls, however no new formal interventions to prevent falls were developed at that time. Staff member #13 verified on 02/22/2013, the toileting intervention was in place prior to the resident's fall, and verified no formal intervention was developed at that time. Staff member #13 stated due to the resident's impaired cognitive status, to encourage the resident to ask for assistance was not an appropriate or effective fall intervention. Staff member #13 stated on 2/27/2013 the intervention documented on the fall investigation to place the resident in a high traffic area was not part of the formal care plan to direct resident care in order to prevent further falls. Staff member #13 stated that on 5/24/2013 the intervention to ensure the resident's wheelchair is locked before attempting to stand, was not an appropriate intervention due to the resident's impaired cognitive status. The facility's "Problem Management" policy, noted "Develop a plan of care including general and specific interventions to reduce falls risk" and "Refer to the following tools to develop an individual plan of care which addresses environmental modifications, sensory capacity, functional deficits, orthostatic [MEDICAL CONDITION], medications that affect balance or level of consciousness, and appropriate restorative/rehabilitation services". In addition the policy noted to "Update care plan with new interventions as appropriate". .

Based on record review and staff interviews, the facility failed to provide care and services to prevent the development of avoidable pressure ulcers. This affected 1 of 3 residents reviewed out of 5 residents identified with pressure ulcers (Resident #62). Findings include: Resident #62 was admitted on [DATE]. Admission [DIAGNOSES REDACTED]. The hospital admission record dated 1/20/2013 noted that Resident #62 had a history of [REDACTED]." A care plan dated 02/07/2013 noted that Resident #62 was at risk for self care deficits. An intervention was "Left knee immobilizer at all times, check circulation q (every) shift". No other care plan entries related to care of Resident #62's leg brace were found. On 01/28/2013 at 4:00 PM, Nurse #6 noted that Resident #62 had Stage 2 pressure ulcers to "both sides of coccyx". No open wounds were noted on Resident #62's legs. The Nursing Admission assessment dated [DATE] noted that Resident #62 had an immobilizer on her left leg and no open areas were recorded on the body diagram. A Pain Evaluation form dated 02/20/2013 and signed by Nurse #91 noted Resident #62 had a wound to her calf and a skin tear. The wound was not noted on the diagram and no other description was documented. A Change of Condition Documentation form dated 02/20/2013 at 10:00 AM by Nurse #91 noted that Resident #62 had an "open wound noted to left calf area (after) knee immobilizer removed for therapy. Area noted where metal rod of brace is on calf." A Pressure Ulcer Documentation Form dated 02/20/2013 by Nurse #112 noted that Resident #62 had a Stage 3 pressure ulcer measuring 2 cm (centimeters) by 1.7 cm and 0.3 cm in depth to the left calf. Review of Weekly Progress Summary notes from physical therapy revealed a note dated 02/25/2013 by Therapist #130. Therapist #130 wrote, "While adjusting knee immobilizer on 2/21/2013, observed pressure sore on posterior L (left) lower leg-nursing made aware of pressure area, now covered with dressing. Applied extra padding to rigid backing on immobilizer to decrease amount of pressure." On 06/18/2013 at 3:40 PM, an interview was completed with Therapist #130. "I saw the sore on the 21st. I let the nurse know. I write it down on the weekly note. I could have written the 21st instead of the 20th. (Resident #62) had a knee immobilizer on. She had a left [MEDICAL CONDITION]. The doctor ordered the knee immobilizer to be worn all the time. I would readjust it during therapy. When she walked, it would slide down. I might not have seen it the days before. I think I was adjusting the immobilizer and felt that it was moist behind her leg. I wasn't looking for a sore. The immobilizer is more for weight bearing. When she is in the bed it could be removed for hygiene." Review of facility assignment sheets noted that Nursing Assistant (NA) #105 was assigned to care for Resident #62 on 2/17/2013. On 06/18/2013 4:27 PM, an interview was completed with NA #105. NA #105 stated that she was familiar with Resident #62. "We had to feed her, dress her and bathe her. She could use the bedpan. She had the pillow between her legs. (Resident #62) would take it off and hang her foot off the bed. At one point she had a knee immobilizer on too. She didn't like it either. She had it on all the time. We could take it off long enough to give her a bath. When we bathe a resident we look at the skin. If I see bruises, skin tears, anything different, I report to the nurse. If I had seen anything different on the (February) 17th, I would have told the nurse." An interview was conducted with NA #39 on 6/19/2013 at 8:40 AM. NA #39 stated that she was familiar with Resident #62. "(Resident #62) was total care for dressing and bathing. She had a brace on her leg." NA #39 verified she gave Resident #62 a bed bath on February 18th, 19th and 20th. "(Resident #62) had the brace on all the time. When I gave a bath, I would unfasten it, wash and dry under it and put it back on. I never removed it. If we see anything on the skin we report to the nurse. I saw it after the nurses knew about it. I didn't see it during bathing." On 06/19/13 at 10:24 AM, an interview was completed with Nurse #91. Nurse #91 said that she was familiar with Resident #62. "I was called to therapy by (Therapist #130). He was doing therapy. He told me when he took the brace off he found the place on (Resident #62's) calf. She wore a knee immobilizer that was not to be removed at any time, not even for care. We couldn't wash her leg per (Physician #151). An interview was completed with the Director of Nurse #38 (DON) on 06/19/2013 at 10:35 AM. The DON stated "We were not allowed to remove the brace. The way the brace was made, you could wash most of her leg. It just had straps at the top and the bottom and a reinforcing bar along the back of her leg. The regional director and I do skin sweeps. We decided to look at her leg. When we felt the back of leg, we found the wound. The open area was very small. The measurement was the red area around the open area" An attempt was made to call Physician #151. He was not available for interview during the survey. A follow up interview was completed on 06/19/2013 at 11:15 AM with the DON. "We don't have a written policy on taking care of the braces. It is specific to the orthopedist." On 06/19/2013 at 11:20 AM, a follow up interview was completed with Therapist #130. Therapist #130 said that Resident #62's knee immobilizer did not have just straps at the top and bottom. "The immobilizer has three straps above and three straps below the knee. The material is cut out around the patella (knee cap). There is material that covers most of the leg." An interview was completed with Physician's Assistant #151 (PA) on 06/19/2013 at 11:30 AM. PA #151 stated that he was familiar with Resident #62 and had seen her during the hospital admission on 01/21/2013. "On 01/21(2013) (Resident #62) had the hip arthroplasty (hip replacement). The next day, we found she had dislocated her hip. The knee immobilizer was to keep her from dislocating her hip. The next time we saw her (2/22/2013), I told them (facility staff) it was OK to take it off and to change the dressing. The intent was for her to wear the brace so she didn't dislocate her hip again. They could take it off to clean her leg and put it back on (before the wound was found). They just couldn't leave her with it off." On 06/19/2013 at 12:15 PM, an interview was completed with Nurse #6. Nurse #6 was identified as signing the weekly skin assessment dated [DATE] noted that Resident #62 had intact skin. Nurse #6 said that she was familiar with Resident #62. "When I do a skin assessment, I go in and look. If I remember correctly, there were bars (on the knee immobilizer) you could see in between. There was a doctor ' s order not to take it off. I looked at her leg where I could see it, but didn't take it off. If I see a new area, I do an incident report and call the physician." An interview was completed on 06/19/2013 12:36 PM with Treatment Nurse #60 (TN). TN #60 said, "The wound measurement would have been the size of the open area. There really wasn't any redness. Her legs were generally [MEDICAL CONDITION]." Another interview was completed with the DON on 06/19/2013 at 12:54 PM. "The Nurse Practitioner saw (Resident #62) on 02/20/2013 (after the wound was found). She recommended removing the brace. We contacted the doctor and he said she was to wear the brace until he saw her. (Resident #62) went to the doctor the next day. Her son went with her. He wanted the brace discontinued and the doctor would not stop it for 2 more weeks, but did give an order to remove it for care. She was also on [MEDICATION NAME] (antibiotic) for [MEDICAL CONDITION]. [MEDICATION NAME] started on 02/17 (2013). We were watching her legs for [MEDICAL CONDITION] and we still missed it (the pressure ulcer)." .

Based on medical record review, observation, staff interview, policy review, and resident interview, the facility failed to: (a) accurately assess and record the status of pressure ulcers on admission and thereafter; (b) monitor for and record changes in wound status on a weekly basis per facility policy; (c) administer treatments as ordered by the physician to prevent infection and promote wound healing; and/or (d) failed to implement other interventions (such as to reduce friction / shearing) as ordered by the physician to prevent the development of pressure ulcers. This was true for four (4) of forty-nine (49) Stage II sample residents with pressure ulcers (#109, #106, #72, and #105) and resulted in actual harm to one (1) of these four (4) residents (#109). Resident #109 was readmitted to the facility on [DATE]. According to his minimum data set assessments (MDS) with assessment reference dates (ARDs) of 04/22/11 and 04/28/11, he had two (2) unstageable pressure ulcers present on admission, with the larger of the two (2) wounds measuring 1.4 cm x 1.8 cm, and the most severe tissue type for any pressure ulcer being eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). According to the MDS with an ARD of 05/08/11, he continued to have two (2) unstageable pressure ulcers due to the presence of eschar or slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous), with the larger of the two (2) wounds now measuring 5.4 cm x 4.0 cm, and the most severe tissue type of any pressure ulcer present being slough. The larger of Resident #109's two (2) wounds more than doubled in size between the assessment reference periods ending 04/28/11 and 05/08/11, and the wound subsequently cultured positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) for which antibiotic therapy was initiated on 05/02/11. Review of Resident #109's pressure ulcer documentation forms (PUDFs), on which a facility nurse was to record a description of each wound, found the facility was not accurately assessing / monitoring the status of the wounds on a weekly basis in accordance with facility policy. During Resident #109's previous stay at the facility from 03/14/11 to 03/29/11, the facility failed to accurate assess / monitor the status of his wounds and administer treatments daily as ordered by his physician. Resident identifiers: #109, #106, #72, and #105. Facility census: 108. Findings include: a) Resident #109 1. Medical record review revealed this [AGE] year old male was admitted to the nursing home on 03/14/11 with the following active Diagnoses: [REDACTED]. The admission nursing assessment, completed by a licensed practical nurse (LPN - Employee #120) on 03/14/11 and co-signed as having been reviewed by a registered nurse (RN - Employee #138), noted Resident #109 had an unstageable pressure ulcer on his left foot, an "ulcer" (with no stage noted) on his left lower leg, a Stage I pressure on his left buttock, and a Stage II pressure ulcer on his right buttock. Further record review revealed, per the resident's admission MDS with an ARD of 03/21/11, he had one (1) Stage I pressure ulcer, two (2) Stage II pressure ulcers, and one (1) unstageable pressure ulcer / suspected deep tissue injury in evolution. Although the most severe tissue type for any pressure ulcer was identified as being eschar, the MDS was not encoded to identify the presence of any pressure ulcers that were unstageable due to the presence of eschar or slough, and no measurements were recorded on the MDS for the wound covered with eschar. Review of the admission history and physical examination [REDACTED]. In the section entitled "Skin / Lymph" was recorded: "W&D / (symbol for 'no') (illegible)". This entry was translated by the director of nursing (DON - Employee #55) to mean "warm and dry with no [MEDICAL CONDITION]". On 03/29/11, the resident was discharged to a local hospital, and he subsequently returned to the facility on [DATE]. A re-admission nursing assessment, completed by an LPN (Employee #80) on 04/15/11 and not co-signed to indicate review by an RN, noted Resident #109 had a Stage II pressure ulcer on his left foot, an abraded area just above the pressure ulcer on his left foot, and no pressure areas on his coccyx / buttocks. A nursing note, dated 04/15/11 at 9:00 p.m., documented (quoted as written):"... L ankle outer Stage II decub. L (left) ankle outer Stage III decub. ... No breakdown to coccyx, or peri area. ..." - Review of the facility's "Skin Care and Pressure Ulcer Management Program" policy (dated January 2008 and revised "1/10") revealed the following definitions: - Suspected Deep Tissue Injury (sDTI): "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue." - Stage I pressure ulcer: "Intact skin with non-blanchable redness of a localized area usually over a bony prominence." - Stage II pressure ulcer: "Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. ..." - Stage III pressure ulcer: "Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling." - Stage IV pressure ulcer: "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." - Unstageable: "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." - Observation of Resident #109, during dressing changes on 05/12/11 at 11:00 a.m., found he had a small healing Stage II pressure ulcer on the left ankle and another pressure ulcer on the left lateral foot. When the treatment nurse (Employee #4) removed the dressing from the left lateral foot, this open wound with red edges immediately began to bleed. The treatment nurse placed a protective pad on the bed beneath the foot due to the bleeding. During the treatment, the resident expressed verbal complaints of pain, encouraged the nurse to please hurry, and exhibited facial grimacing and moaning. (See also citation at F309.) - On 05/11/11 at 12:00 p.m., the DON presented various PUDFs and stated this was all the information he had available to reflect evidence of on-going assessment and monitoring of the resident's pressure ulcers. The DON reported the facility had terminated the treatment nurse who had been responsible for completing the PUDFs weekly when they realized this nurse had not been performing her duties. Review of the facility's policy entitled "Skin care and pressure ulcer management program" found on Page 12 under the heading "Investigation Process": "Any new skin issue is an 'incident' which requires an investigation to determine the root cause. ... 3. Complete a Pressure Ulcer Documentation Form to document the status of the pressure ulcer. ..." When subsequently interviewed on 05/12/11 at 1:30 p.m., the DON confirmed the facility had no additional measurements or any other descriptive information available regarding the resident's pressure ulcers upon his re-admission to the nursing facility on 04/15/11. The DON verified that PUDFs should have been completed upon re-admission. - On 04/20/11, five (5) days after the resident's re-admission to the facility, a PUDF was completed for each of the two (2) pressure areas as follows: - PUDF for pressure ulcer on left lateral leg / ankle - Date of onset: 03/14/11. Present on admission: Yes. -- Date: 04/20/11 -- Stage: II -- Wound Measurements: 0.3 cm x 0.3 cm x UTD (unable to determine) -- Undermining Present: (This section was blank.) -- Tunneling Present: (This section was blank.) -- Odor: (This section was blank.) -- Exudate in wound after dressing removed: Moderate amount, bloody -- Wound Bed Tissue Type Equals 100%: Eschar 100%. -- Condition of Surrounding Skin: Indurated -- Evidence of Wound Related Pain: Yes (with no further information given) -- Order Change: No -- Notification of Change: (This section was blank.) -- Nurse signature: (Signature of nurse) - PUDF for pressure ulcer on left lateral foot - Date of onset: 03/14/11. Present on admission: Yes. -- Date: 04/20/11 -- Stage: II -- Wound Measurements: 1.2 cm x 0.4 cm x less than 0.1 cm -- Undermining Present: No -- Tunneling Present: No -- Odor: No -- Exudate in wound after dressing removed: Small serosanguineous -- Wound Bed Tissue Type Equals 100%: Slough 100%. -- Condition of Surrounding Skin: Tender -- Evidence of Wound Related Pain: Yes (with no further information given) -- Order Change: No -- Notification of Change: (This section was blank.) -- Nurse signature: (Signature of nurse) - Further review of the PUDF for the left lateral leg / ankle found the wound continued to be staged and described as a Stage II pressure ulcer each week on the following dates: 04/27/11, 05/04/11, and 05/12/11. From 04/20/11 to 05/12/11, this wound increased in length (from 0.3 cm to 1.0 cm) and width (from 0.3 cm to 0.5 cm), with the depth of the wound recorded as UTD. On 04/20/11, the wound tissue bed was documented as 100% eschar; on 04/27/11, the wound bed tissue was documented as 100% slough; no description of the wound bed tissue was provided on 05/04/11 or 05/12/11. On 04/20/11 and 04/27/11, the condition of the skin surrounding the wound was described as indurated (hardened); no description of the surrounding skin was provided on 05/04/11 and 05/12/11. Exudate in wound after dressing removed was documented as being a moderate amount of bloody drainage on 04/20/11 and 04/27/11. On 04/28/11, the physician ordered a culture of wound to the left lateral foot. The pressure area was found to [MEDICAL CONDITION], and an antibiotic was started 05/02/11. However, there was no documentation describing the presence or characteristics of exudate from the wound on 05/04/11 or 05/12/11. Additionally, the information describing the undermining, tunneling, odor, evidence of wound-related pain, order change, and notification of change was not completed on 05/04/11 and 05/12/11. - Further review of the PUDF for the left lateral foot found this wound continued to be staged and described as a Stage II pressure ulcer each week on the following dates: 04/27/11, 05/04/11, and 05/12/11. From 04/20/11 to 05/12/11, the wound increased in length (from 1.2 cm to 3.0 cm) and width (from 0.4 cm to 2.5 cm). Exudate in wound after dressing removed increased from a small amount of serosanguineous drainage on 04/20/11 to a moderate amount of "yellow" drainage on 05/04/11. The wound bed issue was described as being 100% slough on 04/20/11, 04/27/11, and 05/04/11, with no description of the wound bed tissue provided on 05/12/11. When the pressure ulcer was measured on 05/12/11, the nurse failed to provide documentation on the following: exudate in wound after dressing change, wound bed tissue type, evidence of wound-related pain, order change, and notification of change. - Review of the resident's most recent MDS, a Medicare 30-Day MDS with an ARD of 05/08/11, revealed that, during this assessment reference period, he had two (2) unstageable pressure ulcers which were noted to have been present on admission. The MDS nurse encoded the larger of the two (2) wounds as measuring 5.4 cm in length and 4.0 cm in width. In Item M0700, the MDS nurse noted the most severe tissue type for any pressure ulcer was slough. Review of the Medicare 14-Day MDS with an ARD of 04/28/11 revealed that, during this assessment reference period, the resident had two (2) unstageable pressure ulcers which were noted to have been present on admission. The MDS nurse encoded the larger of the two (2) wounds as measuring 1.4 cm x 1.8 cm, with the most severe tissue type for any pressure ulcer being eschar. Review of the Medicare 5-Day MDS with an ARD of 04/22/11 revealed that, during this assessment reference period, the resident had two (2) unstageable pressure ulcers which were noted to have been present on admission. The MDS nurse encoded the larger of the two (2) wounds as measuring 1.4 cm x 1.8 cm, with the most severe tissue type for any pressure ulcer being eschar. A nursing note, dated 04/22/11 at 2:10 p.m. and recorded by Employee #12 (the RN who completed the MDSs for this resident), stated, "Resident's skin assessed for MDS process. Has Rt (right) hand skin tear /c (with) Opsite, old small scabbed area Lt (left) buttock (appears as old / healing), Left lateral foot unstageable decub - 1.4 x 1.8 cm & Lt ankle unstageable decub 0.5 x 0.5 cm. ..." Employee #12, when interviewed on the afternoon of 05/17/11, stated, "The measurements on the MDS are correct, because I measured it myself." When asked if she was aware of the discrepancies on the MDS versus the PUDF, she stated, "Yes, I am, but I am correct." She stated she also had the MDS nurse (Employee #106) accompany her to the resident's room to complete the measurements. Employee #106, when interviewed, stated, "The wound measurements made by myself and (Employee #12) are correct. I was a former wound nurse, and I know how to measure a wound." - On the afternoon of 05/17/11, the DON was made aware of the discrepancies between the measurements of the wound on the lateral left foot (the larger of the two (2) wounds) found in the PUDFs versus the measurements of the same wound found on the MDSs. He was unable to provide further information on the measurements of the wounds and was unable to verify which of the two (2) sources of measurements (PUDFs versus MDSs) was correct. -- 2. Review of the PUDFs for Resident #109, from his previous admission beginning on 03/14/11, found descriptions of three (3) of the four (4) wounds identified on the admission nursing assessment. - PUDF for pressure ulcer on above left ankle - Date of onset: 03/14/11. Present on admission: Yes. -- Date: 03/14/11 -- Stage: II -- Wound Measurements: 2 cm x 1.2 cm -- Undermining Present: No -- Tunneling Present: No -- Odor: No -- Exudate in wound after dressing removed: (This section was blank.) -- Wound Bed Tissue Type Equals 100%: Eschar 100%. -- Condition of Surrounding Skin: Healthy -- Evidence of Wound Related Pain: No -- Order Change: Yes -- Notification of Change: (This section was blank.) -- Nurse Signature: (Initials of nurse) - PUDF for pressure ulcer on left lateral foot - Date of onset: 03/14/11. Present on admission: Yes. -- Date: 03/14/11 -- Stage: SDTI (suspected deep tissue injury) -- Wound Measurements: 2.8 cm x 1.3 cm -- Undermining Present: No -- Tunneling Present: No -- Odor: No -- Exudate in wound after dressing removed: None -- Wound Bed Tissue Type Equals 100%: Eschar 100% -- Condition of Surrounding Skin: Healthy -- Evidence of Wound Related Pain: No -- Order Change: Yes -- Notification of Change: Resident, Physician, Family -- Nurse Signature: (Signature of nurse) - PUDF for pressure ulcer on left buttock - Date of onset: 03/14/11. Present on admission: Yes. -- Date: 03/14/11 -- Stage: II -- Wound Measurements: 0.8 cm x 0.3 cm -- Undermining Present: No -- Tunneling Present: No -- Odor: No -- Exudate in wound after dressing removed: None -- Wound Bed Tissue Type Equals 100%: Granulation 100% -- Condition of Surrounding Skin: Healthy -- Evidence of Wound Related Pain: No -- Order Change: Yes -- Notification of Change: Resident, Physician, Family -- Nurse Signature: (Signature of nurse) - A comparison of these PUDFs to the admission nursing assessment dated [DATE] (the details of which were mentioned above) revealed the following discrepancies: - On the admission nursing assessment, the wound above the left ankle was described the area as "ulcer" with no stage specified; on the PUDF, the same wound was described as Stage II with 100% eschar. - On the admission nursing assessment, the wound on the left lateral foot was described as "unstageable"; on the PUDF, the same wound was described as a SDTI with 100% eschar. - On the admission nursing assessment, the wound the left buttock was described as a Stage I; on the PUDF, the same wound was described as Stage II with 100% granulation tissue. - On the admission nursing assessment, the wound on the right buttock was described as a Stage II to the right buttock; there was no PUDF initiated for this wound. Additionally, the facility's documentation on the PUDFs of the staging of Resident #109's pressure areas during both of the resident's stays at the facility could not be correct according to their own policy. A pressure area containing any slough or covered by 100% slough or 100% eschar cannot, by definition, be a Stage II pressure ulcer. -- 3. Review of Resident #109's treatment administration records (TARs) found the following treatments for his pressure areas: - "Cleanse Stage II to lower lateral left leg just above the ankle with NSS (normal saline solution), apply [MEDICATION NAME], cover with [MEDICATION NAME] dressing q (every) day. Start date: 3/14/11." Review of the TAR revealed this treatment was not started until 03/15/11, and the TAR was not initialed to indicate completion of these treatments on 03/16/11 or 03/17/11. The TAR contained no explanation as to why the treatments were not provided daily as ordered by the physician. - "Cleanse SDTI to left lateral foot with NSS (normal saline solution), apply Hydrogel and cover with [MEDICATION NAME] dressing q day. Start date: 3/14/11." Review of the TAR revealed this treatment was not started until 03/15/11, and the TAR was not initialed to indicate completion of these treatments on 03/16/11 or 03/17/11. The TAR contained no explanation as to why the treatments were not provided daily as ordered by the physician. - "Apply [MEDICATION NAME] every shift and as needed to the sacral area for prevention. Start date: 3/14/11." The first treatment was not provided until 03/15/11. - "Cleanse Stage II to left buttock with NSS. Apply [MEDICATION NAME] every shift and as needed until resolved. Start date: 3/15/11." The first treatment was not provided until 03/16/11. -- b) Resident #106 1. Resident #106's medical record disclosed this [AGE] year old male was most recently re-admitted to the facility on [DATE], at which time he had no pressure ulcers present. According to his most recent quarterly MDS with an ARD of 01/24/11, he had no pressure ulcers during the assessment reference period, and no pressure ulcers were present on the previous MDS, but he was at risk for developing pressure ulcers. His active [DIAGNOSES REDACTED]. -- 2. Review of Resident #106's medical record disclosed a physician's orders [REDACTED]. This order was transcribed correctly on the TAR for February 2011, blocks were set aside to record the nurses' initials on all three (3) shifts daily, and initials indicated the medicated cream was applied as ordered three (3) times a day during that month, with the exception of one (1) omission on the evening shift of 02/21/11. Review of this resident's TARs for March and April 2011 revealed this order was transcribed correctly for those months; however, blocks were set aside to record the nurses' initials only once daily on day shift. Initials indicated the medicated cream was applied on thirty (30) of ninety-three (93) shifts in March and on five (5) of thirty-nine (39) shifts from 04/01/11 through 04/13/11. On 04/14/11, staff identified that Resident #106 had developed a Stage II pressure ulcer to his right buttock. After the Stage II pressure ulcer was identified on 04/14/11, no change was made to his treatment order; the order to apply [MEDICATION NAME] cream to both buttocks on every shift (three-times-daily) continued. Based on documentation on the April TAR, the [MEDICATION NAME] cream was applied to his buttocks (including to the Stage II pressure ulcer on his right buttock) on only three (3) of nineteen (19) shifts from 04/14/11 through day shift on 04/20/11, when the order to apply [MEDICATION NAME] cream to both buttocks every shift for excoriation was discontinued; three (3) of the sixteen (16) treatment omissions were attributed to the resident sleeping. On 04/20/11, the physician discontinued the [MEDICATION NAME] cream to both buttocks every shift and gave an order to apply [MEDICATION NAME] cream to the right buttock every shift to treat the Stage II pressure ulcer until resolved. Thereafter, the April TAR was initialed to indicate this cream was applied three (3) times daily through the remainder of April and month-to-date in May as of day shift on 05/17/11, with the exception of one (1) omission on the evening shift of 05/03/11 and a refusal by the resident on day shift on 05/01/11. -- 3. The nurse completing the 04/14/11 entry on the PUDF, identifying the presence of the Stage II pressure ulcer on the resident's right buttock, also indicated on this form that an order change occurred. However, after the Stage II pressure ulcer was identified on 04/14/11, no change was made to his treatment order; the order to apply [MEDICATION NAME] cream to both buttocks on every shift (three-times-daily) continued. On 04/20/11, the physician discontinued the [MEDICATION NAME] cream to both buttocks every shift and gave an order to apply [MEDICATION NAME] cream to the right buttock every shift to treat the Stage II pressure ulcer until resolved. The treatment order (the application of [MEDICATION NAME] cream every shift), which had not been effective in preventing the development of the Stage II pressure ulcer, was not altered in any way other than revising the order to apply to cream to the right buttock instead of both buttocks. -- 4. The resident's care plan related to skin breakdown was not revised until six (6) days after the Stage II pressure ulcer was identified, when on 04/20/11 a goal was added for this wound to be healed by 05/22/11. On 04/22/11, the following interventions were added to this care plan (quoted as typed): "Provide treatments per order, assessing areas for effective healing and signs of infection (redness, odor, drainage, warmth)- notify MD if problems. Monitor environent and assure safety- observe for any hazards." One (1) intervention associated with the problem of skin breakdown ("Weekly skin assessment.") had been initiated on 05/04/10 - almost a year before the Stage II pressure ulcer was identified on the resident's right buttock. -- 5. When, on 04/14/11, staff identified that Resident #106 had developed a Stage II pressure ulcer to his right buttock, a pressure ulcer documentation form (PUDF) was started, on which weekly assessments of the ulcer and surrounding tissue were to be recorded. Review of this PUDF found entries dated 04/14/11, 04/21/11, 05/04/11 (thirteen days later), and 05/12/11; these assessments were not being performed weekly. Additionally, the assessments, when performed, were not complete. The assessment dated [DATE], which identified the presence of a Stage II pressure ulcer measuring 0.4 cm x 0.4 cm with no depth, did not address the condition of the surrounding skin, whether there was evidence of wound-related pain, whether any orders were changed, and whether any notifications of changes were made. The assessment dated [DATE], which stated the area was now resolved, did not note whether the resident, physician, or family was notified of this change in status. -- 6. Review of the resident's TAR for May 2011 found the physician's orders [REDACTED]. The blocks for 05/07/11 and 05/14/11 were not initialed to indicate these assessments had been completed as ordered, even though these dates had already come to pass. -- 7. On 05/16/11 at 11:00 a.m., this nurse surveyor questioned the MDS nurse (Employee #106) about weekly skin assessments, and he stated staff kept them on the medication administration records (MARs). When asked to locate the weekly skin assessments for Resident #106, Employee #106 could not find them. (Evidence of weekly skin assessments were found for other residents but not for this resident.) There was no evidence to reflect facility staff was completing weekly skin assessments for Resident #106 on an on-going basis. Review of his physician's orders [REDACTED]. The DON, when questioned about Resident #106's skin assessments on 05/16/11 at 3:00 p.m., was unable to produce evidence to reflect these had been completed weekly as ordered. -- 8. This nurse surveyor observed Resident #106's buttocks on 05/17/11, after permission was obtained to do so. The area on his buttock was resolved, and there was no current skin breakdown. The resident reported, when interviewed on 05/17/11 at 2:00 p.m., that this area on his bottom would re-open at times. He stated that, sometimes, staff did not put his ointment on the area like they were supposed to. -- c) Resident #72 1. Review of Resident #72's medical record revealed this [AGE] year old male was admitted on [DATE]. According to a PUDF, this resident had a Stage II pressure ulcer present on admission on his left buttock measuring 0.4 cm x 0.4 cm with no depth. There was no further information about this wound on admission, such as a description of the wound bed tissue type and the condition of the surrounding skin. This form had spaces for recording weekly assessments for this pressure ulcer for a period of five (5) weeks, but there was no further documentation on this PUDF. There were no further measurements or any description of this wound until 04/20/11, when a second PUDF was started. At the top of this second PUDF, the date of onset for this area was recorded as 03/23/11; this was twenty-eight (28) days after the first PUDF was started. At that time, the wound measured 0.8 cm x 0.5 cm with a depth of < 0.1 cm, the wound bed tissue type was 100% granulation, the surrounding skin was healthy, and there was no undermining, tunneling, odor, or wound-related pain. Subsequent entries on this second PUDF were dated 04/27/11, 05/04/11, and 05/12/11. The DON, when interviewed at 2:00 p.m. on 05/16/11, verified this pressure ulcer was identified on 03/23/11 and that there was no evidence to reflect staff had completed weekly assessments of this wound from 03/23/11 to 04/20/11. He also verified that the facility's policy was to obtain weekly measurements of pressure ulcers. -- 2. Record review revealed a physician's orders [REDACTED]. Observations of Resident #72 in bed in his room on 05/16/11 at 11:00 a.m., 2:00 p.m., and 4:00 p.m. found he did not have heel protectors in place, and his heels were in direct contact with the mattress on each of these observations. In an interview at 4:00 p.m. on 05/16/11, Employee #114 verified she was the nursing assistant assigned to provide care for Resident #72 on this shift. When questioned, Employee #114 stated that she had never known Resident #72 to use heel protectors. She looked through the drawers in his room and could not find any heel protectors. She stated she would check on this. Review of Resident #72's TAR found the order for heel protectors dated 05/04/11; however, each block for each shift was either initiated / circled or blank, and there was no documentation on the reverse side of the TAR to explain why the initials were circled. Employee #101 (a licensed practical nurse), when interviewed at 4:45 p.m. on 05/16/11, verified she was the nurse providing care to this resident on this shift. When questioned about the heel protectors, she stated they did not have any heel protectors for that resident. She verified that circled initials on a TAR meant the ordered treatment was not done, and that nurses were to turn the TAR over and record why the treatment was not done on the back side. Employee #101 stated she would see if she could get him some heel protectors. A follow-up observation, made at 5:15 p.m. on 05/16/11, found the resident had heel protectors in place at that time. -- d) Resident #105 1. Review of Resident #105's closed medical record revealed this [AGE] year old male was admitted on [DATE]. According to documentation on his admission nursing assessment dated [DATE], he had a suspected deep tissue injury (sDTI) to his left buttock at that time. Review of the PUDF for Resident #105 found the wound on his left buttock was identified as a Stage I pressure ulcer measuring 8 cm x 1 cm on 12/30/10 (day of admission), with the wound bed tissue type being described as 100% [MEDICATION NAME]. This entry was recorded by a registered nurse (RN - Employee #70). The next entry on the PUDF, dated 01/02/11, identified the wound as a Stage I pressure ulcer measuring 10 cm x 1 cm, with the wound bed tissue type being described as 100% [MEDICATION NAME]. This entry was recorded by a second nurse whose signature was not legible. The next entry on the PUDF, dated 01/12/11, identified the wound as a Stage II pressure ulcer measuring 2.5 cm x 0.3 cm, with the wound bed tissue type being described as 10% granulation and 90% slough. This assessment was not completed until ten (10) days after the previous assessment. This entry was recorded by a third nurse, the former RN treatment nurse (Employee #138). (As noted above, the presence of slough in a wound is incompatible with the definition of a Stage II pressure ulcer.) A care plan, dated 01/05/11, noted Resident #105 had a Stage I pressure ulcer to his left buttock. The goal was to resolve this area in the next two (2) weeks. The next entry on the PUDF, dated 01/12/11, identified the wound as a Stage II pressure ulcer measuring 2.5 cm x 0.3 cm, with the wound bed tissue type being described as 10% granulation and 90% slough. This assessment was not completed until ten (10) days after the previous assessment. This entry was recorded by a third nurse, the former RN treatment nurse (Employee #138). Additional entries documenting the presence of this pressure ulcer were made by Employee #138 (on 01/19/11 and 01/26/11) and a fourth nurse (whose signature was also not legible) on 02/02/11. There was no evidence this care plan was reviewed / revised when the Stage I pressure ulcer was identified as being a Stage II area on 01/12/11. -- 2. Review of Resident #105's Medicare 5-Day MDS with an ARD of 01/06/11 found there were no pressure ulcers present during that assessment reference period. The next MDS, a Medicare 14-Day MDS with an ARD of 01/11/11, also indicated there were no pressure ulcers during that assessment reference period; this assessment reference period ended only one (1) day before the PUDF entry dated 01/12/11 indicating the Stage I pressure ulcer to the resident's left buttock had declined to Stage II. The MDS nurse who completed the skin condition sections of these assessment (Employee #106), when interviewed on 05/12/11 at 11:00 a.m., stated Resident #105 did not have a pressure ulcer to his left buttock. He stated that, when he examined the resident's skin when completing the MDS, it looked as if he had previously had a scratch that was healed over, but he did not have a pressure ulcer. Employee #106 said he was aware what was recorded on the PUDFs for Resident #105, but he knew there was no pressure ulcer when he looked at this resident's buttocks on the MDS assessment reference dates. He verified that the PUDF and previous care plan stated the resident did have a pressure ulcer, but he s

Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practical physical and psychosocial well-being for two (2) of forty-nine (49) Stage II sample residents (Residents #109 and #190). Resident #109 had pressure ulcers on the left ankle and foot. During a treatment observation of these pressure ulcers at 11:00 a.m. on 05/12/11, the resident exhibited signs of pain with facial grimacing, moaning, and verbal complaints of pain. The resident had been given a routine order for [MEDICATION NAME] ER (extended release) 15 mg at 9:00 a.m. on 05/12/11. Review of current physician orders [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #190 did not receive care for a surgical wound. The wound was red with yellow drainage, and the facility failed to notify the physician and obtain treatment. Resident identifiers: #109 and #190. Facility census: 108. Findings include: a) Resident # 109 Observation of Resident #109, during dressing changes on 05/12/11 at 11:00 a.m., found he had a small healing Stage II pressure ulcer on the left ankle and another pressure ulcer on the left lateral foot. When the treatment nurse (Employee #4) removed the dressing from the left lateral foot, this open wound with red edges immediately began to bleed. The treatment nurse placed a protective pad on the bed beneath the foot due to the bleeding. During the treatment, the resident expressed verbal complaints of pain, encouraged the nurse to please hurry, and exhibited facial grimacing and moaning. Review of the resident's current physician orders, following the treatment, found the resident had a routine order for [MEDICATION NAME] ER (extended release)15 mg to be administered at 9:00 a.m. daily. For review found the resident also had an order to receive [MEDICATION NAME] 5/500 mg every four (4) hours as needed (PRN) for pain prior to the treatment. At 11:25 a.m. on 05/12/11, this nurse surveyor approached the medication nurse (Employee #98) and asked for the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of these documents found the resident had not been given the PRN [MEDICATION NAME] prior to this painful treatment for [REDACTED]. Review of the resident's pressure ulcer documentation forms for both wounds on his left lower extremity found a prompt for the assessing nurse, on a weekly basis, to record whether there was evidence of wound-related pain. On the assessments of both wounds dated 04/20/11 and 04/27/11, the assessing nurse recorded that wound-related pain was present, although no further descriptive information was provided (e.g., whether the pain was continuous, episodic, or occurred during procedures). On the assessments of both wounds dated 05/04/11 and 05/12/11, the assessing nurse did not record any information as to whether there was evidence of wound-related pain. During an interview with the director of nursing (Employee #55) on 05/17/11, at 10:30 a.m., he agreed the resident should have been medicated with the PRN [MEDICATION NAME] prior to the treatment procedure. -- b) Resident #190 Review of Resident #190's medical record revealed a discharge summary dated 05/01/11, on this discharge summary there was mention of a surgical wound with any redness or drainage. The following information was listed on the discharge summary: "Daily Dry dressing changes should be performed to the surgical incision." Review of physician orders [REDACTED]. COVER WITH DRY DRESSING. CHANGE DAILY- Day Shift Everyday." Further review of the medical recorded revealed an assessment dated [DATE], stating the surgical wound had a small amount of yellow drainage. Review of nursing notes dated 05/04/11 also recorded the presence of yellow drainage from surgical wound. A subsequent entry in medical record dated 05/09/11 revealed the resident had an incision wound to left hip that was red, warm to the touch, and with slight yellow drainage noted. On 05/16/11 at 1:40 p.m., an interview with the DON revealed the surgical wound was not addressed in the care plan. The DON agreed this should have been addressed in the care plan. On 05/16/11 at 2:20 p.m., a a subsequent interview with the DON revealed there was no evidence that the physician was notified of changes in the status of the surgical wound. On 05/17/11 at 10:35 a.m., an interview with a registered nurse (Employee #72) confirmed the physician was not contacted when yellow drainage was noted; she further stated it was a small amount of drainage. .